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Posts Tagged ‘prevention of mother to child transmission’

The full-court press is on for Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. With the Global Fund’s replenishment conference set for early October, “this must be an intensive period of advocacy of all of us,” he told a group of D.C.-based global health advocates on Wednesday.

One of the first—and most important—signals on the Global Fund’s prospects for a robust replenishment will come from Washington, when lawmakers in Congress set the U.S. contribution to the Fund in the FY2011 appropriations bills, he said. The Global Fund’s conference is set for Oct. 4 & 5 at the United Nations, and Kazatchkine urged advocates to push for Secretary of State Hillary Clinton to be there in person, instead of a lower-level U.S. representative.

“It would be extremely meaningful if Secretary Clinton could attend and come with a pledge for three years,” he said. “It’s essential for stability and planning,” he said of the three-year pledge, adding that he and others understand such a multi-year commitment would be contingent on congressional approval.

So how much money is he talking about? “Big money … but peanuts if we compare it to what the world could find in three weeks times to rescue the financial markets,” he said. “Money is political choice.”

Kazatchkine said the Global Fund has drafted three different potential funding scenarios, and he focused on the middle one in his talk on Wednesday. Under that scenario, the Global Fund could continue funding all its current programs and expand at the same pace as it did in Rounds 8 & 9. To do that, the Fund will need $17 billion over three years, with a $5.5 billion three-year contribution from the U.S., he said.

He acknowledged that the political climate for making this request is tough, but said advocates must stress that poor countries have been hit even harder by the economic crisis and much is at stake.

“All the gains we have achieved are fragile, and if we slow down on this, it can be very dangerous,” he said. If access to treatment for HIV, TB or malaria becomes more restricted, “we can lose drugs because of resistance,” he noted.

On the other hand, the potential gains are immense. He cited, for example, the Fund’s efforts to improve and expand access to prevention of mother-to-child HIV transmission. “It remains unacceptable that 400,000 children were infected with HIV in Africa last year, when in France it was 4,” he said.

If resources for the Fund are sustained and expanded, he said, the world could see virtual elimination of mother-to-child HIV transmission by 2015. “It would have not only a huge human impact, but also a huge symbolic impact,” he said. “I call it the beginning of the end.”

More broadly, the replenishment conference will go a long way to determining “where the world will be in 2015 in terms of global health,” he said.

In the video clip above, you can hear Kazatchkine’s response to a question about how advocates can answer questions from Capitol Hill about why robust funding is needed for both PEPFAR and the Global Fund, as opposed to one versus the other.

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

Attention turned to HIV among women and children at CROI today, when Elaine Abrams, MD, a senior a professor of pediatrics and epidemiology at the Columbia University College of Physicians & Surgeons and the Mailman School of Public Health, provided an informative  overview of the challenges in protecting children from HIV in developing-world settings.  For starters, she said, we are not doing a very good job in preventing HIV infection in women, with 1 million new infections a year in women. Then there are the 1,000 new pediatric HIV infections every single day. And in most high prevalent developing world settings, there is very poor access to family planning services, leaving women with few tools to prevent unwanted pregnancies.

In the context of antiretroviral therapy scale-up, there has been a failure to identify and prioritize pregnant women for ART who are at risk of transmitting HIV infection to their infants.

There has also been limited scale-up of prevention of mother to child transmission programs, in large part because these programs are layered into the limited infrastructure available in many countries for maternal and child health services. Too often, there has been an over-reliance on short-term ART for pregnant women, rather than a continuum of care and treatment for HIV-infected women and their children.

Until recently, there was no ART intervention for prevention of post-natal transmission, leaving many infants vulnerable to HIV transmission during the breastfeeding period. Current strategies using daily neviripine in infants during breastfeeding reduces the risk of HIV acquisition, but it also confers neviripine resistance on infants who fail prophylaxis at very high levels – some 52 percent.  Drug alternatives to neviripine are not widely available.  The public health approach to ART access in developing-world settings is anchored in neviripine-based regimens.  Lopinivir is the only protease inhibitor available for infants.  In general, there are very few ART options available for children in resource-poor countries, especially in the context of widespread neviripine resistance.

Dr. Abrams also noted that there is very limited capacity for early diagnosis in infants, even though mortality in this population is extremely high.  Thirty-five percent of HIV-infected infants, if untreated, will die in their first year of life, and that number increases to 53 percent by age two.  The World Health Organization recommends that all HIV-positive children under age 1 should receive ART therapy.

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There’s fresh evidence out today that greater access to AIDS treatment for women will help keep their babies healthy.

A new article in Clinical Infectious Diseases reports that a higher maternal viral load during the 30th week of pregnancy significantly increased the risk of HIV transmission to the baby—a finding that provides additional confirmation of the nexus between HIV/AIDS and child & maternal health. The results suggest that pregnant women’s viral loads should be controlled “well before delivery,” the study authors report. Click here to get to CID and here to read a story about the study by aidsmap.

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The case for earlier and wider initiation of antiretroviral therapy just keeps getting stronger.

First, there’s the increasing solid consensus that initiating ART earlier significantly increases an HIV patient’s chances of survival. Then there’s the fact that initiating ART earlier reduces the number of people needing more costly second-line therapy. We also know that the best way to stave off tuberculosis-related deaths in HIV-positive individuals is to put those patients on ART.

Add to all that this latest news: New mothers receiving highly active antiretroviral therapy (HAART) for HIV-1 infection are much less likely than untreated mothers to transmit the virus to their newborns through breastfeeding. Those findings, published online today in the Nov. 15 issue of The Journal of Infectious Diseases, suggest HAART regimens should be initiated “as early as possible in eligible mothers in areas with limited resources, such as Africa, where most infant HIV-1 infections occur, and breastfeeding is common,” according to a news release from JID.

The study, conducted in mother/infant pairs in Malawi and led by Taha E. Taha, MBBS, PhD, of Johns Hopkins University Bloomberg School of Public Health, found that HAART was associated with an 82 percent reduction in postnatal HIV-1 transmission.

“While acknowledging more research is needed to develop safe, effective, and affordable ways to prevent postnatal transmission in settings with few resources, the study’s authors recommend that women presenting late in pregnancy who have low CD4 counts and require antiretroviral treatment start HAART as soon as possible during pregnancy or postpartum,” the JID news release says.

In an accompanying editorial, Grace C. John-Stewart, MD, PhD, of the University of Washington School of Public Health, writes of the need “accelerate many incremental steps” to make PMCTC programs more successful.

“As research informs new PMTCT policy recommendations, it is critical to improve the logistics of CD4 cell count testing and HAART integration to increase the effectiveness of PMTCT and lay the foundation for even more effective programs,” he writes.

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This post is by Center Director Christine Lubinski, reporting from the 2009 IAS conference in Cape Town.

Dramatic scale-up and innovative approaches are critically needed to improve prevention of mother-to-child transmission, Elaine Abrams, of Columbia University’s International Center for AIDS Care and Treatment Programs, said at an IAS conference session on PMTCT today. In a stirring presentation, Abrams noted the urgency of ensuring that HIV-infected women and their children have access to continuity of high-quality health care and other services that are nested in maternal/child health services in the community.  A great deal of work still needs to be done in that arena, said Abrams, who is director of ICAP’s MTCT-Plus Initiative, a care and treatment program for HIV-infected women and their families in resource-constrained settings.

For starters, only 43% of HIV-positive pregnant women receive antiviral therapy, and the percentage of infants who receive ARV interventions is even lower.  Some countries in southern Africa do better than others.  But Abrams called for reconceptualizing this intervention as a component of HIV care and treatment for pregnant women, children and families.  She said program implementers and others need to identify the population of infected women and children across the range of maternal/child health services.  She called for maximizing available biomedical interventions by ensuring that mothers and babies receive potent ART regimens for treatment and prevention prophylaxis.

Abrams said HIV testing should be widely available through maternal/child health services.  She highlighted several successful models, including the implementation of partner testing in Ethiopia and efforts reported upon by Rollins et all to integrate HIV testing, including infant testing, in immunization clinics.  From Abrams’s perspective, HAART should be offered to all women of child-bearing age with CD4 counts under 350 and multiple-drug regimens should be offered to HIV-infected women with higher CD4 counts during pregnancy, coupled with infant prophylaxis to newborns.  The goal of these programs should be enhance HIV-free survival for children and improve maternal health.

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