Turning the Tide on HIV/AIDS in
Children and Youth
Dr Chewe Luo, MD(Paed), MTropPaed, PhD
Senior Programme Adviser
HIV Section, UNICEF Programme Division
New York
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Outline
What does turning the tide mean?
•Eliminating new HIV
infections in children
•Early diagnosis and
treatment of HIV infected
children
•Adolescent Prevention and
Treatment
•Call to Action
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Key concepts in vertical transmission
TRANSMISSION TIMELINE
• Transmission can occur during pregnancy, labor &
delivery, and postpartum during breast feeding
• Not all infants born to women living with HIV will
acquire HIV infection
– Estimated risk 25-45% without any intervention
Source: DeCock et al. JAMA.2000; 283:1175-1182.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
67% Reduction in Perinatal Transmission with
PACTG 076 AZT Regimen
DSMB halted trial early in Feb 1994
Incidence of Perinatally-Acquired AIDS
United States, 1985-2000
Source: www.cdc.gov/hiv/perinatal/resources
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Overall Target 1: Reduce the Number of New
HIV Infections among children by 90% by 2015
Estimated new Pediatric Infections in
Low and Middle Income Countries
(LMICs)
450,000
Country Contribution to 390,000
Paediatric HIV Infections in LMICs in
2010
430,000
Nigeria
390,000
400,000
10%
DRC
350,000
330,000
29%
300,000
13%
Malawi
250,000
Kenya
2%
200,000
Mozambique
3%
150,000
India
5%
100,000
7%
43,000
50,000
New
Infections
2009
New
Infections
2010
New
New
Infections Infections
2011
2015 (Goal)
6%
6%
6%
Zimbabwe
Ethiopia
Other Priority
Countries
Other LMICs
Source: 1. UNAIDS. Together we will end AIDS. 2012
2 . HIV/AIDS Response – Epidemic Update and Health Sector Progress Towards Universal Access 2011
www.aids2012.org
Tanzania
6%
7%
0
Uganda
Washington D.C., USA, 22-27 July 2012
Overall Target 2: Reduce the Number of HIVassociated maternal deaths to women during
pregnancy, delivery and puerperium by 50% by 2015
Women dying from AIDS-related causes during
pregnancy or within 42 days of the end of
pregnancy in the 22 priority countries
45,000
42,000
22 priority countries contribution to 33,000
HIV-associated maternal deaths in 2011
1%
1%
40,000
30,000
25,000
21,000
1%
.500%
1%
.500%
1%
2%
3%
3%
3%
33,000
35,000
1%
20%
5%
20,000
12%
5%
15,000
5%
10,000
9%
5%
5,000
7%
7%
0
2005
2010
2015 (Goal)
Source: UNAIDS. Together we will end AIDS. 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
7%
Nigeria
South Africa
Tanzania
Mozambique
Uganda
Kenya
Malawi
India
Zimbabwe
Zambia
DRC
Cameroon
Cote D'Ivoire
Ethiopia
Ghana
Angola
Chad
Lesotho
Burundi
Swaziland
Namibia
Botswana
Prevention of mother-to-child transmission of
HIV: Body of scientific research
1994
2010
1994 U.S. AZT Trial ACTG 076
1998 Thai Bangkok short AP/IP AZT trial
1999 PETRA AZT+3TC trial (partly breastfeeding)
1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012)
2000 Thailand PHPT-1 Long vs short AZT regimens
2002 Cote d’Ivoire DITRAME Plus 1201.0 AZT & IP/PP NVP
2003 DITRAME Plus 1201.1 AZT+3TC & IP/PP NVP
2004 Thailand PHPT-2 AZT & IP/PP NVP
2008 PEPI NVP + short vs long AZT for infant (breastfeeding)
2009 Mma Bana comparative trial for CD4<200 (breastfeeding)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Source: McIntyre J, Perinatal HIV Clinical Trials
1998 Cote d‘Ivoire short AP/IP AZT trials (breastfeeding)
Coverage of antiretroviral medicine for preventing
mother-to-child transmission: most effective regimens,
low- and middle-income countries, by region, 2011
90%
80%
79%
Percentage (%)
70%
60%
79%
72%
67%
61%
63%
57%
50%
40%
30%
20%
27%
19%
6%
10%
0%
Sub-Saharan Eastern and Western and Latin America Latin America
Africa
Southern Central Africa
and the
Africa
Caribbean
Caribbean
East, South
and SouthEast Asia
Source: UNAIDS. Together we will end AIDS 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Eastern
Europe and
Central Asia
North Africa
and the
Middle East
All low- and
middleincome
countries
The decline in new HIV infections in children
was roughly 10.8% from 2010 to 2011
Source: 1. UNAIDS 2012 estimates
2. UNICEF/BLC Discussion Paper and Methodology - Business
Case for Options B/B+ , 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Global Plan Targets
Source: Countdown to zero: Global Plan towards the elimination of new infections among children by 2015 and keeping their mothers alive 2011-2015
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
WHO guidelines for PMTCT and infant feeding
(2010 and 2012 Update)
Source: : 1. WHO 2010 PMTCT Guidelines
2. WHO Programmatic Update 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
PMTCT Prophylaxis Options Used by
Selected Countries in Africa & Asia, 2012
Option A
Option B
Option B+
Malawi
Cameroon
India*
Bangladesh
Lesotho
Zimbabwe
Afghanistan
DRC
Myanmar
Bhutan
Ethiopia
Malaysia
Maldives
Kenya*
Vietnam
Nepal
Mozambique
Swaziland
Pakistan
South Africa*
Tanzania
Sri Lanka
Uganda*
Zambia*
Chad
Nigeria
Angola
Burundi
Botswana
Namibia*
Cote D’Ivoire
Ghana
Rwanda
* Countries considering
switch to option B/B+
Source: www.aidsdatahub.org based on WHO, UNAIDS, & UNICEF (2011). Towards
Universal Access Health Sector Response Country Reports 2011 (preliminary data)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of
the 2009 PMTCT Guidelines – 15 Focus Countries, 2010
Scenario “2006”
(95% CI)
Scenario “A”
(95% CI)
Scenario “B”
(95% CI)
Infant HIV Infections
(thousands)
345 (328-361)
242 (231-252)
258 (247-270)
Infections Averted
(thousands)
66 (50-82)
169 (159-180)
152 (141-163)
Life-Years Gained
(LYG millions)
1.3 (0.7-2.0)
3.2 (2.7-3.6)
2.9 (2.4-3.4)
Additional LYG
(millions)
-
1.9 (0.8-2.9)
1.6 (0.4-2.7)
Cost (US $ millions)
64 (55-73)
235 (223-247)
343 (325-362)
Additional Cost
(millions)
-
171 (150-192)
288 (252-307)
ICER
(US $/LYG)
-
92 (81-107)
Equally Effective
More Expensive
Model Outcome
Source: Auld AF et al. XVIII IAS Conf, Vienna, July 2010 Abs
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Bottlenecks in the implementation of Option A
Source: UNICEF/BLC Discussion Paper and Methodology
- Business Case for Options B/B+ , 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Women Eligible for ART Are At Highest Risk for
Mother-to-Child HIV Transmission and Mortality
Eligible
for ART
Not eligible
for ART
MTCT by 6 wk
16.7%
5.0%
Proportion of MTCT
by 6 wks
87.5%
12.5%
MTCT after 6 wks
17.0%
4.2%
Proportion of MTCT
after 6 wks
87.5%
12.5%
Maternal mortality
24 mo post delivery
92%
8%
• Cohort 1,025 pregnant women in Zambia prior to HAART availability
• Analyzed MTCT/mortality by eligibility for ART with current WHO criteria
(CD4 <350 or WHO Stage 3 or 4)
Source: Kuhn L et al. AIDS 2010;24:1374-7
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Mortality risk in HIV-positive postpartum
women with high CD4
Data: Hargrove AIDS 2010; Model: Williams JID 2006.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Double Orphaning is projected to increase by
2016…
Estimates of double orphans for 2010 and 2016
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
.00%
Double orphan prevalence 2010
Double orphan prevalence 2016
Source: Belsey, M. A., L. Sherr. An International Interdisciplinary Journal for Research, Policy and Care; 6 (3):185-200.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Malawi: Proposed “Option B+”
Life-Long ART
Rationale:
• Without CD4, women who need treatment for their own health will not
receive appropriate ART with Option A
• Obtaining CD4 has been a barrier to PMTCT implementation in countries
with heavily constrained health systems
• Prolonged breastfeeding up to 2 years
• High fertility rates with an average of 5.6
• New potential benefit to uninfected sexual partners
Lancet 2011;378:282-4
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Malawi: “Option B+” Scale Up
Number of pregnant and breastfeeding women starting ART
40000
35000
New patients
starting ART
30000
25000
Breastfeeding
women starting
ART
20000
15000
Pregnant women
starting ART
10000
5000
0
Q4
2011 Q1
Q2
Q3
Q4
Six-fold increase in number of pregnant & breastfeeding women starting ART
(from 1200 in Q2 to 15,000 in Q4)
Source: Courtesy of Dr Erik Schouten, unpublished data, Malawi
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Malawi: Progress on key indicators for the Global
Plan for eliminating mother-to-child transmission
Malawi: Percent of women provided
antiretrovirals to reduce transmission
during pregnancy and delivery (excl
sdNVP)
Malawi: Percent of pregnant women
receiving antiretroviral therapy for their
own health
60%
60%
50%
50%
40%
40%
30%
30%
51%
53%
20%
20%
10%
24%
10%
12%
0%
0%
2009*
2011
2009
2011
* 2009 value is not directly comparable to data from 2010 and later because single-dose nevirapine was excluded from the calculation
starting in 2010.
Source: . 2012 UNAIDS estimates for Malawi: ARV/ART coverage among HIV+ pregnant women (Progress in 22 priority countries on key indicators for the
Global Plan for eliminating mother-to-child transmission)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Option B+ Benefits
Source: UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Comprehensive MCH Services
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Acute Infection in Mothers
Associated with MTCT
•
Risk of MTCT in infants of mothers with acute infection during pregnancy
or lactation is increased ~3-fold over mothers with chronic HIV.
Acute/recent
HIV infection
Author
Population
Moodley D
(JID 2011;
203:1231-4)
1,396 HIVwomen/48
Taha TE
(AIDS 2011
May 21
epub)
2,561
HIV+ women
(PP)
2.9% had recent
infection
Humphrey
(BMJ
2010;341:
c6580)
11,240
HIV- women
3.0%
seroconverted
postpartum
3.4%
seroconverted
pregnancy or
by 12 mo PP
HIV Transmission to Infant
• 2.3-fold higher risk of MTCT
(Overall MTCT
20.5% acute vs 9.0% chronic HIV)
• 2.5-fold higher risk in utero MTCT
(In utero MTCT
17.8% acute vs 6.7% chronic HIV)
www.aids2012.org
• 2.8-fold higher risk postnatal MTCT
(Postnatal MTCT
23.6% acute vs 8.5% chronic HIV)
Washington D.C., USA, 22-27 July 2012
Unmet Need for Family Planning
Unmet need for family planning by HIV serostatus based on data
from Demographic and Health Surveys in six countries
Unmet need
among women
living with HIV
Unmet need
among HIVnegative women
Change in unmet need over time
among all women
21%
21%
25% (2003) to 26% (2008)
16%
18%
31% (2004) to 23% (2009)
Malawi 2010
18%
21%
28% (2004) to 26% (2010)
Swaziland 2007
12%
14%
No comparison available
Zambia 2007*
14%
20%
27% (2002) to 27% (2007)
Zimbabwe 2006
14%
8%
13% (1999) to 12% (2006)
Country and year
of survey
Kenya 2008
Lesotho 2009
Sources: UNAIDS calculations of data from Demographic and Health Surveys (MEASURE DHS:
all surveys by country [web site] (25)) and Millennium Development Goals indicators [web site] (36).
aThe difference between women living with HIV and HIV-negative women is statistically significant.
Millenium Development Goals Indicators ( http://mdgs.un.org/unsd/mdg/data.aspx)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Percentage of children living with HIV receiving
antiretroviral therapy in low- and middleincome countries, 2005, 2009, 2010, and 2011
2005
2009
2010
2011
% of children younger than 15 years living with HIV
receiving antiretroviral therapy
70%
65%
61%
60%
56%
55%
50%
46%
42% 42%
40% 39%
40%
34%
30%
21%
20%
32%
31%
28%
26%
23%
17%
20%
10%
6%
5%
23%
21%
12%
10% 9%
6%
4%
0%
1%
5% 6%
0%
Sub-Saharan
Africa
Eastern and
Western and
Southern Africa Central Africa
Latin America
and the
Caribbean
Latin America
Caribbean
East, South and
South-East Asia
Source: WHO, UNAIDS and UNICEF. Global HIV/AIDS Response: Epidemic Update and Health Sector
Progress Towards Universal Access Progress Report 2011
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Europe and
Central Asia
North Africa and Total low- and
the Middle East middle-income
countries
Children Initiating Treatment Immediately
have better chance of survival
Violari et al.NEJM 2008
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Trends in pediatric age distribution at
ART initiation (2005-2010)
Source: McNairy M. et al. Retention of HIV+ Children on ART in ICAP-supported HIV Care and Treatment
Programs. Paper # 959, 19th CROI, Seattle, USA 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Follow up of infants testing positive
via EID at Review Sites
Source: UNICEF. EID Review Country Reports 2009
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Viral Load and EID Product Pipeline
Source: UNITAID HIV/AIDS Diagnostic Landscape 2nd Edition 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Paediatric Antiretrovirals: simplified dosing
formats and analysing their adverse events
CHAPAS-1 trial
PK sub-study 2007
FDA licensing
CHAPAS-2
LPV/r liquid vs tablets
vs sprinkles PK study
3TC/ZDV/N
VP Baby
CHAPAS-3
Looking at specific
toxicities in children
d4T vs
AZT vs
ABC
3TC/ABC Baby and
Junior
Efavirenz
600mg
2 x 300mg
3 x 200mg
Source: Dr Gibb for the Chapas Trials
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
In 2011, 36% of new HIV infections worldwide
occurred in young people (ages 15-24)
Source: UNAIDS., updated 2012 estimates.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Increasing HIV Prevalence in
Adolescents
South Africa: HIV Prevalence Among
Adolescents and Young People
20
25
20
15
Prevalence
Prevalence
Mozambique: HIV Prevalence Among
Adolescents and Young People
15
10
10
5
5
0
0
2-14
Male Prev
15-19
Age
20-24
Female Prev
12-14
Male Prev
15-19
Age
20-24
Female Prev
Source: 1. National Institute of Health (INS), National Institute of Statistics (INE) and ICF Macro. 2010. National Enquiry on HIV/AIDS Prevalence, Behavior Risks and
Information in Mozambique 2009. 2 . Shisana O et al. South African national HIV prevalence, incidence, behaviour and communication survey 2008: A turning tide among
teenagers?
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Prevention and Treatment
Interventions for Adolescents
DECREASING VULNERABILITY
1. Enrollment and retention of girls
in School
2. Skill-based health education
3. Decreasing gender-based violence
4. Increasing age of marriage
5. Ensuring that health services
respond to the needs of
adolescents
6. Social protection
7. Protection, legislation,
enforcement
Interventions that should be
supported whether or not there was
and HIV epidemic for rights or equity
DECREASING RISK
1. Testing
2. Treatment
3. Harm Reduction
I. Condoms
II. Needle Exchange
4. Male Circumcision
1. For today: Adolescents
2. For the future: Neonatal
Specific evidence-based
interventions that decrease the risk
of HIV among young people for HIV,
rights and equity
Source: UNICEF Making the Case for Adolescents, unpublished data , 2012
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Call to Action
•
•
•
•
•
Simplify our programmatic approaches to allow integration of
PMTCT/ART in maternal child health services at the lowest levels of
care – to optimize treatment access, adherence and retention
Introduce innovative approaches to expand provider initiated HIV
testing to adolescents, pregnant women and their partners
Expand early infant diagnosis and integrate paediatric HIV
treatment and care at lower level facilities and child survival
programs
Collaborate with community groups, including women living with
HIV, to enhance support to women and their families to maintain
good adherence and retention in care and treatment
Focus on how to effectively deliver high impact interventions to
adolescent to achieve the best prevention and treatment benefits
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Acknowledgments
•
•
•
•
•
•
Dr Elaine Abrams
Dr Wafaa El-Sadr
Dr Diana Gibb
Dr Priscilla Idele
Dr Susan Kasedde
Malawi Ministry of
Health
www.aids2012.org
•
•
•
•
•
Mr Craig McClure
Dr Lynne Mofenson
Mr Tyler Porth
Dr Juliana Silva
UNICEF Regional
and Country Advisors
• Dr Rachel Yates
Washington D.C., USA, 22-27 July 2012
Thanks to all women and children that
inspire and guide the work we do!!
Thank you!!
www.aids2012.org
Washington D.C., USA, 22-27 July 2012