Prevention of Vertical
Transmission: The role of
families
Elaine J. Abrams, MD
Harlem Hospital and the
International Center for AIDS Care
and Treatment Programs
Columbia University
Prevention of vertical transmission:
Spectrum of care for mother & child
Effective ‘PMTCT’ is a long term
intervention for women
Antepartum:
PMTCT
Non-pregnant:
Family planning
(FP) counseling
Preconception Care
Partner HIV testing
PITC in ANC
CD4 Testing
ART treatment or
prophylaxis
Adherence support
Infant feeding (IF)
counseling
Safe Motherhood
Birth Preparedness
Maternal
Care
Intrapartum:
PITC in L&D
CD4 testing
ARV prophylaxis
Safe Delivery
IF counseling
FP counseling
Adherence support
Spectrum
from Pregnancy to 18 months Post Partum
1-8 Weeks Post
Partum:
Maternal postpartum
follow-up
Enrollment into HIV
care
ART treatment or
prophylaxis during BF
FP counseling
IF counseling
Adherence support
2-6 Months Post
Partum:
Repeat CD4 (6
months pp)
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence support
6-9 Months Post
Partum:
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence support
9-12 Months Post
Partum:
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence support
Effective PMTCT includes a series of biomedical and psychosocial
interventions administered throughout the reproductive live of the
woman living with HIV
The images in this were created by University Research Co., LLC with funding from
the United States Agency for International Development.
12-18 Months
Post Partum:
ART treatment
FP counseling
Adherence
support
Repeat CD4
Effective ‘PMTCT’ is a long term
intervention for infants & children
1-8 Weeks :
Birth:
ART
prophylaxis
FU appt at 6
weeks
Infant
prophylaxis
during BF
PCR testing at
4-6weeks
Growth &
developmental
monitoring
CTX initiation at
6 weeks
The images in this were created by University Research Co., LLC with
funding from the United States Agency for International Development.
2-6 Months:
6-9 Months:
9-12 Months :
Infant
prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Infant prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Repeat HIV test
6weeks post BF
cessation
IF support
HIV infected infants:
HAART initiation
CD4 testing
Infant prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Repeat HIV test
6weeks post BF
cessation
IF support
HIV infected
infants:
HAART initiation
CD4 testing
HIV infected infants:
HAART initiation
CD4 testing
12-18
Months:
IF support
Determine final
infection status:
antibody testing at
>12-18mos
Child discharged
from PMTCT
program
HIV infected infants:
HAART initiation
CD4 testing
Illustrations by Petra Rohr-Rouendaal, 2010
Antepartum:
Non-pregnant:
Family planning
(FP) counseling
Preconception
Care
Partner HIV
testing
PITC in ANC
CD4 Testing
ART treatment
or prophylaxis
Adherence
support
Infant feeding
(IF) counseling
Safe
Motherhood
Birth
Preparedness
Intrapartum:
PITC in L&D
CD4 testing
ARV prophylaxis
Safe Delivery
IF counseling
FP counseling
Adherence
support
1-8 Weeks Post
Partum:
Maternal
postpartum followup
Enrollment into HIV
care
ART treatment or
prophylaxis during
BF
FP counseling
IF counseling
Adherence support
2-6 Months Post
Partum:
Repeat CD4 (6
months pp)
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence
support
6-9 Months Post
Partum:
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence
support
9-12 Months
Post Partum:
12-18 Months
Post Partum:
ART treatment or
BF prophylaxis
FP counseling
IF counseling
Adherence
support
ART treatment
FP counseling
Adherence
support
Repeat CD4
Happy
Healthy
Family
PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum
PMTCT Spectrum of Care
1-8 Weeks :
Birth:
ART
prophylaxis
FU appt at 6
weeks
The images in this were created by
University Research Co., LLC with funding
from the United States Agency for
International Development.
Infant
prophylaxis
during BF
PCR testing at
4-6weeks
Growth &
developmental
monitoring
CTX initiation at
6 weeks
2-6 Months:
6-9 Months:
Infant
prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Infant prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Repeat HIV test
6weeks post BF
cessation
IF support
HIV infected
infants:
HAART initiation
CD4 testing
HIV infected infants:
HAART initiation
CD4 testing
9-12 Months :
Infant prophylaxis
during BF
Growth &
developmental
monitoring
CTX continuation
Repeat HIV test
6weeks post BF
cessation
IF support
HIV infected infants:
HAART initiation
CD4 testing
12-18
Months:
IF support
Determine final
infection status:
antibody testing at
>12-18mos
Child discharged
from PMTCT
program
HIV infected infants:
HAART initiation
CD4 testing
Discharged
from PMTCT
Program
Engaged in
familyfocused HIV
care services
Prevention of vertical transmission is a
family-centered intervention
• Addresses the health of the maternal-child dyad
• Provides an unparalleled opportunity to engage
other family members in HIV and other health
and social services
– Partner, husband, children, extended family members
– HIV services include testing, prevention, care and
treatment
• Offers a platform to initiate other health services
– TB screening, diagnosis, treatment
– Early infant interventions
• Effective PMTCT prevents orphanhood
Family involvement enhances
prevention of vertical transmission
• Partner testing in PMTCT programs has been associated
with
– greater use of antiretrovirals for prophylaxis
– higher acceptance of post-test counseling
– increased spousal communication about HIV and sexual risk
• Using PMTCT services as an entry point into HIV care and
treatment for women, partners and family members has
been associated with high rates of retention and ART
adherence
• Family-focused home based HIV testing, care and
treatment services can improve health outcomes for HIV
positive and negative family members
• Disclosure of HIV status has been associated with better
pediatric outcomes
The MTCT-Plus Initiative
• A multi-country HIV care and treatment program
(2003-2010)
– PMTCT entry point for pregnant & postpartum
women to engage in HIV care and treatment
– PMTCT as an entry point to identify HIV-infected partners,
children and family members and engage in HIV care and
treatment
• Reframes PMTCT in the context of the reproductive
lives of women living with HIV
– Recognizes that pregnancy is a normal and expected
aspect of a woman’s life and aims to support and maximize
the health of the woman, her child and her family
• Model for Family-Focused HIV services
The MTCT-Plus Initiative
MTCT-Plus
MTCT-Plus approach
approach to
HIV
care
&&
treatment
HIV
care
treatment
Factors shaping the MTCT-Plus
model of care
• HIV is a multi-generational family
disease: multiple family members living
with HIV
• All family members are affected when
any individual within the family has HIV
• Most HIV care occurs within households
and families
• Women and children have multiple
needs that may impact on adherence to
care & treatment
• Families can be important sources of
support for successful treatment
• Cultural and community factors impact
access and adherence
•
•
•
•
•
•
Comprehensive HIV primary care
inclusive of antiretroviral therapy to
all family members
Family-centered care
– Inclusive of infants and children
Attention to psychosocial, behavioral,
structural, and environmental issues
Care provided by multidisciplinary
teams of health providers
Involvement of person living with HIV
and outreach to community resources
HIV care and treatment for staff living
with HIV
MTCT-Plus Sites
Uganda:
St. Francis Hospital Nysambya, Kampala
Mulago Hospital, Kampala
Kenya:
Moi University College of
Health Sciences, Eldoret
Nyanza Provincial General
Hospital, Kisumu
Cote d’Ivoire:
Formation Sanitaire Urban de
Yopougon-Attié
Formation Sanitaire Urban
d’Abobo-Attié
Thailand:
Police Hospital Clinic
Chulalongkorn Hospital Clinic
Thammasat University
Hospital Sriracha Hospital
Sirikit Hospital
Nigeria:
Ogoja (Cross River State)
Kafanchan (Kaduna State)
Rwanda:
Cameroon:
Nkwen clinic
M’bingo Hospital Clinic
Mboppi Hospital Clinic
Banso Hospital Clinic
Mutengene Hospital Clinic
South Africa:
Cato Manor Clinic, Durban
Perinatal HIV Research Unit,
University of Witswatersrand,
Johannesburg
Langa Health Clinic, Cape Town
Treatment and Research AIDS Center, Kigali
Zambia:
Mtendere Health Clinic, Lusaka
Chelstone Clinic, Lusaka
Mozambique:
Beira Hospital Clinic
Chimoio Hospital Clinic
Enrollment into PMTCT programs
Enrollment into
MTCT-Plus
Long-term HIV care services:
• Family-centered services
• Clinical & CD4 monitoring
• Antiretroviral therapy
• Screening and treatment for OI, TB
• Psychological & social support
• Nutritional counseling & support
• Outreach activities
MTCT-Plus
HIV-infected
partners
and children
PMTCT programs
Women attending ANC clinics
Enrollment in the MTCT-Plus Initiative
Total Adults and Children Receiving HIV Care
Adults Receiving HIV Care
16,457
9,718 (59%)
Adults on ART
3,933 (40%)
Women Enrolled During Pregnancy
4,275 (44%)
Male Partners Enrolled
1,569 (16%)
Children Enrolled
Children Enrolled Before 18 Months of Age
6,739
6,164 (91%)
Other Children in the Household Enrolled (sibling/other)
419 (6%)
Children on ART
512 (8%)
Health Care Workers or their Family Members
306
Partner enrollment varied by country
and site in the MTCT-Plus Initiative
% women enrolling a partner
35%
30%
25%
20%
15%
10%
5%
0%
Other Adult
Male Partner
Findings from the MTCT-Plus Initiative
• The majority of women enrolled during
pregnancy received multi-drug ART regimens:
– 47% received short course ARV prophylaxis
– 20% initiated HAART
– 30% received single-dose nevirapine
• Women initiating HAART during pregnancy
exhibited excellent immunologic response
with an average increase of 451 cells/mm3
after 30 months on treatment
• Retention in care for those initiating ART was
high: 82% for pregnant women, 86% for men,
and 87% of non-pregnant women at 30
months of follow-up
• Women receiving HAART were almost twice
as likely to become pregnant compared with
those in care, likely reflecting improved
health and future outlook
• Photo – old M+ or
cameroon
Conclusions
• HIV infection affects the health and well being of families as
well as individuals
• Most HIV prevention, care and treatment programs have been
established to address the needs of the individual, neglecting
the family
• Prevention of vertical transmission services offer an
unequaled opportunity to
– Address the comprehensive health needs of the mother and child
– Engage partners, children and other family members in HIV testing,
care and treatment services
– Enhance PMTCT outcomes by engaging family members
• To date, few models of family-focused PMTCT have been
trialed or evaluated
• Renewed global attention and commitment to health needs of
women and children provides an opportunity to focus
attention on the importance of families as a means to keep
families healthy and children free of HIV infection
Special thanks to Patricia Toro, Chloe
Teasdale, Wafaa El-Sadr, Fatima Tsiouris,
Theresa S. Betancourt, Ryan McBain,
Mary C. Smith Fawzi
Film Credits:
By Gideon Mendel
Editor Mo Stoebe
Field Producer Patricia Toro
Text Editor Katie Boot
Composer Geoffrey Kigundu
Music by MU-JHU Cares MDD Group and
Florence Kaweesa
Add’l Sound Design Adam Lieber
MTCT-Plus Initiative
Bill and Melinda Gates Foundation
William and Flora Hewlett Foundation
Robert Wood Johnson Foundation
Henry J. Kaiser Family Foundation
John D. and Catherine T. MacArthur
Foundation
David and Lucile Packard Foundation
Rockefeller Foundation
Starr Foundation
U.S. Agency for International Development
(USAID)