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PMTCT HIV and syphilis Implementation

PMTCT HIV and syphilis Implementation. Dr John Kinuthia, MBChB , MMED, MPH Consultant Obstetrician & Gynaecologist Honorary Lecturer, Department of Obstetrics & Gynaecology, UoN Head, Research & Programs, Kenyatta National Hospital

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PMTCT HIV and syphilis Implementation

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  1. PMTCT HIV and syphilis Implementation Dr John Kinuthia, MBChB, MMED, MPH Consultant Obstetrician & Gynaecologist Honorary Lecturer, Department of Obstetrics & Gynaecology, UoN Head, Research & Programs, Kenyatta National Hospital 20th International AIDS Conference , July 20th 2014, Melbourne, Australia.

  2. Background • ~1.6M Kenyans living with HIV • 10% children <14 years • 57% women • 11000 new infections among children in 2012 • PMTCT program in Kenya implemented in 2000 • In 2012, >9,000 health facilities offering PMTCT services Men = 4.4% Women = 6.9% Pregnant = 6.5% HIV prevalence among adults and adolescents aged 15–64 years by region* *KAIS 2012

  3. Trends in HIV screening during pregnancy in Kenya KDHS 2003; #KAIS 2008-9; *Kinuthia 2010; **Kiarie 2011;***KAIS 2012

  4. New HIV infections among children reducing Estimated number of new infections in children aged (0-14): Global trends and projections 2001-20015 • PMTCT programs focus on women with chronic HIV infection • Women in window period & those infected after HIV after after HIV testing go unrecognized • Increased HIV incidence during pregnancy reported** • Increased MTCT risk*** • Increased HIV • testing* • Increased availability • & use of ARVs* *UNAIDS, 2013;NASCOP, 2011;**Drake 2014; Kinuthia 2010;Gray 2005;*** Kourtis, 2010; Ioannidis, 1999; Pitt ,1997; Garcia,1999; Mofenson,1999

  5. Ahero Hospital HIV prevalence at ANC 22% HIV-1 incidence during pregnancy and postpartum Kinuthia CROI 2014 • Prospective cohort • Study population • HIV-1 rapid antibody test negative • Day of enrolment or within 3 months • Resident until 9 months postpartum • RPR as part of ANC • HIV testing • Pooled nucleic acid amplification test (NAAT) • 10 samples -ve Serial NAAT +ve Bondo Hospital HIV prevalence at ANC 26% Rapid test ≤3 months NAAT test Pooled Individual NAAT -ve

  6. Antenatal care services & enrolment _ Clinical ANC • Palpation • Hematinic • IPT and ITN • TT injection • Infant feeding coundeling • ARVs Registration • 4245 women • May 2011-June 2013 HTC • 38 (0.9%) Declined • 799(18.8%) HIV-1+ve • 3408 (80.3%) HIV-1-ve Review Nurse/clinician MCH Clinic Antenatal profile • Hemoglobin • RPR • Blood group • Urinalysis Laboratory Laboratory Study clinic • 1304 (56%) enrolled* • RPR 1020 (78.2%) Home *2351 women met eligibility criteria

  7. Baseline characteristics (n=1304) * Years older

  8. HIV-1 incidence Pre-enrollment Enrollment Follow up -ve Serial NAAT Incidence rate 95% CI +ve Rapid test ≤3 months NAAT test pooled + ve repeat rapid antibody test Individual NAAT - ve repeat rapid antibody test + ve NAAT test

  9. Correlates of acute HIV-1 infection

  10. Baseline STIs/genital tract Infections

  11. Challenge of incident maternal HIV infections to eMTCT • High HIV viral load* • Mother not known to be HIV infected • No HIV PMTCT intervention • No maternal ARV • No infant ARV • Obstetrical interventions • Enhanced counseling on exclusive breastfeeding • Infant infection due to • Maternal infection after • ANC testing • 26% (2008) to 34% (2014) in South Africa** • 43% of infant infections iBotswana in 2007*** J Acquir Immune Defic Syndr. 2012 ;59(4):417-25. The contribution of maternal HIV seroconversion during late pregnancy and breastfeeding to mother-to-child transmission of HIV** 16th CROI 2009. Montreal. Abstract 91 HIV Incidence in Pregnancy and the First Post-partum Year and Implications for PMTCT Programs, Francistown, Botswana, 2008 “In this mature and successful PMTCT programme, new and undetected maternal infections may be causing nearly half of infant infections.” Lul et al *Kourtis 2010; Ioannidis 1999; Pitt 1997; Garcia1999; Mofenson 1999; **Johnson 2012; ***Lul CROI 2009

  12. HIV retesting in pregnancy • High acceptability* • Cost effective ** • Limitation • Increased workload • Overstretched workforce • Late initiation of ANC • Miss infection during window period • Role of more sensitive assays*** Obstet Gynecol. 2003 Oct;102(4):782-90. Human immunodeficiency virus retesting during pregnancy: costs and effectiveness in preventing perinatal transmission** • 6.2 per 1000 person-years HIV incidence • 192 infections in women detected • 37 infant infections prevented • 655 infant life-years saved per 100,000 women tested • 5.2 million US$ net saving “Second test would result in net savings in populations with HIV incidence of 1.2 per 1000 person-years or higher” Sansom *Willams 2013; Kinuthia2010; **Soorapanth 2006;Sansom 2003; ***Busch1997;Morandi 1998;Quinn 2000; Hecht 2002

  13. HAART for HIV infected pregnant and breast feeding women irrespective of CD4 count, WHO stage • Option A and B is being phased out

  14. Syphilis in pregnancy PLoS Med. 2013;10(2) Global estimates of syphilis in pregnancy and associated adverse outcomes: analysis of multinational antenatal surveillance data Bull World Health Organ. 2013 Mar 1;91(3):217-26 Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis . *Newman;**Gomez

  15. Syphilis increase risk of HIV Int J Gynaecol Obstet. 1998 Dec;63(3):247-52. Maternal syphilis and vertical perinatal transmission of human immunodeficiency virus type-1 infection AIDS. 2006 Sep 11;20(14):1869-77. Maternal syphilis infection is associated with increased risk of mother-to-child transmission of HIV in Malawi Concurrent maternal syphilis infection associated vertical HIV transmission compared with only history of treated syphilis 100% vs. 21%, P = 0.01 or 100% vs. 14% ,p = 0.0015 for women with no history of syphilis Non-Zidovudineexposed women with concurrent syphilis transmitted HIV to their infants compared to those with only a history of syphilis 100% vs. 0% (P = 0.006) • Maternal syphilis associated with Intrauterine HIV MTCT, after adjusting for maternal log10 HIV-1 viral load and low birth weight ARR, 2.77; 95% CI, 1.40–5.46] • Maternal syphilis associated with Intrapartum/postpartun MTCT after adjusting for recent fever, breast infection, LBW and maternal log10 HIV-1 viral load ARR, 2.74; 95% CI, 1.58–4.74) Mwapasa 2006 Lee 1998

  16. Prevalence of syphilis and HIV among pregnant women - Kenya KAIS 2012 KAIS 2007

  17. Screening for syphilis during pregnancy • Routine test in antenatal care • 1st ANC visit • CDC recommends repeat in 3rd trimester* • Non-treponomal tests • RPR/RPR • Barriers to screening • Cost • ANC non-attendance • Stock out of test kits • Wait time for results *CDC 2002;** KAIS 2012

  18. Correlates of Syphilis infection (n=1020) *yrs=years

  19. X

  20. Dual eliminations strategies supports attainment of MDGs • Prevent Congenital syphilis • Fewer spontaneous abortions • Fewer still births • Reduced risk of HIV acquisition • Reduced HIV shedding • Reduce risk of MTCT of HIV

  21. Why combine efforts towards elimination of MTCT of HIV and syphilis • Sexually transmitted infections that can affect foetus/infant • ANC entry point for care • Point of care testing possible • Effective interventions available • Syphilis treatable • PMTCT of HIV reduce risk to <2% • Combined services more efficient

  22. Acknowledgements • Mama SalamaStudy participants • Ahero and Bondo study staff • Research team • KNH/UoN • John Kinuthia • Daniel Matemo • James Kiarie • UW • Grace John-Stewart • Alison Drake • Katherine Odem-Davis • Barbara Lohman Payne • Barbra Richardson • Jennifer Slyker • Jennifer Unger • Julie Overbaugh • Scott McClelland • Carey Farquhar • Anjuli Wagner • Gwen Ambler • CDC/KEMRI • Clement Zeh • Lisa Mills • Funding • NIH (P01 HSD 064915) • CFAR (P30 AI27757) :

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