Prevention of Vertical Transmission: The role of families

1. 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

2. Prevention of vertical transmission: Spectrum of care for mother & child

3. Effective ‘PMTCT’ is a long term intervention for women PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum 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.

4. Effective ‘PMTCT’ is a long term intervention for infants & children The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development. Illustrations by Petra Rohr-Rouendaal, 2010

5. Discharged from PMTCT Program Engaged in family-focused HIV care services Happy Healthy Family PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum PMTCT Spectrum of Care The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

6. 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

7. 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

8. 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

9. The MTCT-Plus Initiative MTCT-Plus approach to HIV care & treatment MTCT-Plus approach to HIV care & treatment 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 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

10. 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: Treatment and Research AIDS Center, Kigali Cameroon: Nkwen clinic M’bingo Hospital Clinic Mboppi Hospital Clinic Banso Hospital Clinic Mutengene Hospital Clinic Zambia: Mtendere Health Clinic, Lusaka Chelstone Clinic, Lusaka South Africa: Cato Manor Clinic, Durban Perinatal HIV Research Unit, University of Witswatersrand, Johannesburg Langa Health Clinic, Cape Town Mozambique: BeiraHospital Clinic Chimoio Hospital Clinic

11. Women attending ANC clinics Enrollment into PMTCT programs PMTCT programs Enrollment into MTCT-Plus HIV-infected partners and children • 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

12. Enrollment in the MTCT-Plus Initiative

13. Partner enrollment varied by country and site in the MTCT-Plus Initiative % women enrolling a partner

14. 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/mm3after 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

16. 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

17. 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 MendelEditor Mo StoebeField Producer Patricia ToroText Editor Katie BootComposer Geoffrey KigunduMusic by MU-JHU Cares MDD Group and Florence KaweesaAdd’l Sound Design Adam Lieber • MTCT-Plus Initiative • Bill and Melinda Gates FoundationWilliam and Flora Hewlett FoundationRobert Wood Johnson FoundationHenry J. Kaiser Family FoundationJohn D. and Catherine T. MacArthur Foundation • David and Lucile Packard Foundation • Rockefeller FoundationStarr Foundation U.S. Agency for International Development (USAID)