“No baby has been born HIV-positive in Washington, DC since 2009”, District of Columbia Mayor Vincent Gray's words drew great applause during the opening session of the 19th International AIDS Conference. While making his opening remarks, Mayor Gray told of the success of the city's interventions for prevention of mother-to-child transmission (PMTCT). Held in the USA for the first time in 22 years, the AIDS Conference was an important opportunity to set the tone for the coming years. Huge progress has been made in prevention and treatment of HIV infection worldwide, but important steps are needed to improve care in low-income and middle-income countries. The elimination of new infections was the focus of many speeches. US Secretary of State, Hillary Clinton, announced tens of millions of dollars in new funding for tackling HIV and AIDS, including US$80 million to ensure that pregnant women with HIV infection get the treatment they need to protect themselves, their children, and their partners. “The United States is committed and will remain committed to achieving an AIDS-free generation”, Clinton said.
In fact, the Global Plan Towards the Elimination of New HIV infections among Children by 2015 and Keeping their Mothers Alivewas frequently discussed during the conference. The global plan provides an unprecedented opportunity not only to scale-up PMTCT in the most affected regions of the world—such as sub-Saharan Africa—but also to address the burden of paediatric HIV. Thanks to the plan, pregnant women with HIV infection are gaining attention worldwide. As a result, more women with HIV infection are receiving treatment during pregnancy and while they are nursing—57% percent of those who needed it in 2011, according to UNAIDS—and the number of children born with HIV infection has been decreasing steadily in recent years.
Full-size image (34K) IIAS/Steve Shapiro—Commercialimage.net
Vincent Gray addresses the 19th International AIDS conference
UNICEF Senior Advisor on AIDS scale-up, Chewe Luo, recognises that much has been accomplished in the past decade, but reminded delegates that the “decline in new HIV infections falls short of what we need to achieve to eliminate new HIV infections among children”. To meet global HIV targets, Luo called for transformation of PMTCT programmes into antiretroviral treatment programmes, which means initiation of lifelong antiretroviral treatment (ART) in pregnant women with HIV infection, irrespective of their CD4 count, in line with the programmatic update to the WHO 2010 guidelines issued in April, 2012 (also known as option B+). This promising approach has been pioneered in Malawi since July, 2011, and has resulted in important increases in the proportion of pregnant women with HIV infection initiating ART for PMTCT or for their own good. The 2010 WHO guidelinesdelineated two different PMTCT prophylactic regimens: option A, use of one antiretroviral drug, and option B, use of a combination of three antiretroviral drugs, equivalent to the regimens used for ART. When Malawi started implementing option B+ as part of new national HIV treatment guidelines, ART and PMTCT programmes were integrated, with major gains in coordination, logistics, and supply-chain management. A year has passed and available data show that, since the implementation of option B+, Malawi has quickly expanded access to ART for pregnant women in hard-to-reach areas all over the country.
With the achievement of ambitious PMTCT-related targets in mind, UNICEF wants to speed up progress and is strongly encouraging countries to switch to option B+. However, some researchers note the absence of long-term data for implementation of option B+. Speaking at the fourth International Workshop on HIV Paediatrics, held in Washington shortly before the International AIDS Conference, PMTCT expert James McIntyre from the Anova Health Institute and University of Cape Town said: “it's important in this wave of optimism to stay grounded in science”. In a recent interview, Robert J Simonds, Vice President of Innovation and Policy at the Elizabeth Glaser Paediatric AIDS Foundation, agreed with the need to have additional information about adherence in women with high CD4 counts, and also about their retention in care.
Key challenges in PMTCT remain. WHO guidelines recommend that all infants and children with HIV infection diagnosed in the first 2 years of life should initiate ART, irrespective of CD4 count or clinical stage. Strong evidence shows 30% of children living with HIV infection die before the age of 1 year, and 50% die before the age of 2 years. In resource-limited countries, early diagnosis of infants is a huge operational challenge, and that is why only an estimated 15% of HIV-exposed infants worldwide benefit from early diagnosis.
Treatment coverage for children still lags behind that for adults. Even though substantial progress has been made in increasing the number of children who receive ART, coverage is still only 28% among children in need of paediatric ART, according to UNAIDS; at only 21%, coverage is especially low in sub-Saharan Africa, a region that accounts for about 91% of global need for paediatric treatment.
These disparities increase concerns among the paediatric HIV care community that the push towards elimination of new paediatric HIV infections will result in treatment and care being overlooked for the children who do become infected. Furthermore, treatment for children already infected might be neglected. Despite the big efforts and investment in PMTCT, “each day close to 1000 children are newly infected with HIV worldwide. What about them?” says Shaffiq Essajee, Senior Adviser in HIV at the Clinton Health Access Initiative. “This is a moral and ethical issue: we have to address the need of the most vulnerable.”
But treatment for children is complex. Nandita Sugandhi, Clinical Advisor at the Clinton Health Access Initiative, explains that although guidelines for which regimen should be given to patients exist, guidelines for what formulations should be prescribed to children are absent. Furthermore, even though new formulations for children have been introduced in recent years, the paediatric antiretroviral marketplace is fragmented and vulnerable to supply disruption. Rationalisation of formulations is therefore crucial to ensure all children benefit from new treatment formulations.
“Case finding also needs to be improved so we can reach the children in need of antiretroviral treatment”, Sugandhi notes. With the knowledge that with ART started at 6 weeks of age, about 95% of children can survive the first year of life, the importance of early infant diagnosis is clear. However, reaching children, testing them, transporting blood samples to an equipped laboratory, returning the results, and eventually initiating ART is a complex process in resource-limited settings. And, after initiating ART, children need to be retained in the treatment programme. Long-term retention must be improved and both Essajee and Sugandhi agree that this issue must be considered in the upcoming years if the ambitious targets of an AIDS-free generation are to be met.
What can be done to raise global awareness of the HIV burden in children? Essajee thinks the call will come from the community: “mothers need to demand care for their children and remind the decision makers of the moral imperative”. In Africa, women have the least agency. “Only seconded by children”, notes Sugandhi, “they have no voice at all.” Hillary Clinton also highlighted the particular part that women play: “in sub-Saharan Africa today, women account for 60% of those living with HIV. Women want to protect themselves from HIV and they want access to adequate health care. And we need to answer their call.” To change women's power, their right to access education, quality treatment, and reproductive and sexual health services, and their right to demand treatment and protection for their children, is essential in the fight against HIV and AIDS.
Adolescents should also not be forgotten. During her presentation at the AIDS Conference, Luo emphasised that adolescents and young people must be included in the global HIV response. In fact, this challenging period raises key questions about how to optimise treatment and ensure adherence. Thanks to early diagnosis, care, and treatment of HIV infection, more and more children with HIV are surviving into adolescence. During this period, psychosocial issues need to be be addressed, namely those related to sexual debut, stigma, and discrimination.
One final issue must be considered: even though investment in HIV research for new and effective treatments has been huge, paediatric HIV is not included in the HIV research agenda. Because paediatric HIV is all but eliminated in wealthy countries, big pharmaceutical companies have little incentive to develop innovative formulations for children. Children who are poor have no voice and they are not lucrative for pharmaceutical companies. In 2010, the International AIDS society sought to raise awareness of gaps in clinical and operational research for women and children by releasing the Consensus Statement on HIV Research Agenda for Women and Children. But improved, appropriate, and affordable treatment is not yet available to most children with HIV infection.
Reference:
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70211-6/fulltext?rss=yes
Random fact for you, in terms of new HIV and AIDS infections in the US, the large majority of new cases are in the African American population, especially amongst African American women.
ReplyDeleteParent to child transmission of HIV is a very important topic to bring awareness to. Nearly 34 million people are infected worldwide with a majority of 22.4 million people infected in Sub-Saharan Africa. Since people carry the knowledge that HIV is transmitted mostly through sexual contact, people fail to see the maternal transmission of the HIV virus to a fetus from transplacental infection. HIV transmission can also occur from an infected mother to an infant via breast milk in nursing. It’s alarming how 50% of infected children die within two years. Low income areas such as Sub-Saharan Africa where the majority of HIV infection occurs don’t have the monetary resources to facilitate in aiding pediatric HIV prevention. It probably isn’t educated well in this area that child transmission is also possible. Sub-Saharan Africa should be the leading area to raise awareness of HIV transmission and provide women there with the healthcare access they need for children who have been infected.
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ReplyDeleteEither a vaccination or a treatment would be ideal for such a disease however a preventive medication, Truvada has recently been approved by the FDA. Truvada is to be taken one daily and is composed of two drugs tenofovir and emtricitabine. These drugs in combination have been shown to be effective reverse transcriptase inhibitors of the HIV virus. Additionally by inhibiting the HIV1 protease newly synthesized HIV polyproteins cannot be cleaved making HIV unable to replicate. Although Truvada has been shown to be an effective drug it is only approved for HIV prevention not treatment. However a once a day HIV prevention drug seems unpractical. I would imagine that an individual that is taking a daily pill to prevent HIV would also have the same logic to not engage in unprotected safe. It is definitely much more cost effective and with less side effects to use contraceptives. I am interested to see if the research conducted in production for of Truvada will lead to a cure or vaccine for HIV.Either a vaccination or a treatment would be ideal for such a disease however a preventive medication, Truvada has recently been approved by the FDA. Truvada is to be taken one daily and is composed of two drugs tenofovir and emtricitabine. These drugs in combination have been shown to be effective reverse transcriptase inhibitors of the HIV virus. Additionally by inhibiting the HIV1 protease newly synthesized HIV polyproteins cannot be cleaved making HIV unable to replicate. Although Truvada has been shown to be an effective drug it is only approved for HIV prevention not treatment. However a once a day HIV prevention drug seems unpractical. I would imagine that an individual that is taking a daily pill to prevent HIV would also have the same logic to not engage in unprotected safe. It is definitely much more cost effective and with less side effects to use contraceptives. I am interested to see if the research conducted in production for of Truvada will lead to a cure or vaccine for HIV.
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