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41 Cards in this Set
- Front
- Back
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Stages In HIV Infection
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a) Acute infection (acute retroviral syndrome)
b) A strong cell-mediated and humoral anti-HIV immune defense c) Clinical latency – due to the strong immune response, virus suppressed; can vary from 1 year to 15 years or more d) Loss of CD4+ cells and suppression of the immune response. e) Onset of AIDS. |
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Vertical Transmission (Mother to child – MTCT)
Factors that ↑ risk of MTCT |
Labor and delivery factors: (increased transmission during delivery 3X)
- PROM, premature birth, episiotomy laceration, scalp electrodes, CHORIOAMNIONITIS Maternal: Advanced HIV disease High maternal HIV-1 RNA levels Low maternal CD4+ lymphocyte counts Acute maternal HIV infection during pregnancy |
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Vertical Transmission
What did the ACTG 076 study show? |
ACTG 076
66% reduction in MTCT Mother - AZT during pregnancy (14 - 34 wks), labor and delivery Baby - 1st 6 weeks of life The zidovudine regimen included antepartum zidovudine (100 mg orally five times daily), intrapartum zidovudine (2 mg per kilogram of body weight given intravenously over a one-hour period, then 1 mg per kilogram per hour until delivery), and zidovudine for the newborn (2 mg per kilogram orally every six hours for six weeks). Infants with at least one positive HIV culture of peripheral-blood mononuclear cells were classified as HIV-infected. In pregnant women with mildly symptomatic HIV disease and no prior treatment with antiretroviral drugs during the pregnancy, a regimen consisting of zidovudine given ante partum and intra partum to the mother and to the newborn for six weeks reduced the risk of maternal-infant HIV transmission by approximately two thirds. |
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Vertical Transmission
What did the HIVNET 012 study show? |
HIVNET 012
Uganda; single dose nevirapine during delivery and to newborn within 72 hours – better than AZT; sustained response at 18 months. Problem of drug resistance Single-dose oral nevirapine administered at the onset of labour to HIV-1 infected women and to babies within 72 h of birth, significantly lowered the risk of HIV-1 perinatal transmission and was associated with significantly longer HIV-1-free survival than treatment with short-course zidovudine administered over a similar time period. |
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Pregnancy & HIV - guidelines for developING countries
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Developing countries (risk of MTCT 25 to 40%)
Breastfeeding recommended Preventive therapy/techniques not feasible |
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Pregnancy & HIV - guidelines for developED countries
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Developed countries (risk of MTCT <1%)
Avoid breast-feeding Use of ARVs in pregnancy, labor and baby Avoid invasive techniques Offer HIV testing to all pregnant women Offer Cesarean section to all pregnant women |
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Kesho Bora - ‘a better future’ (Swahili), 2005-’08 - WHAT did it find?
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Kenya, South Africa and Burkina Faso
ARV treatment for mothers started during pregnancy and continued throughout the breastfeeding period resulted in a significantly lower rate of MTCT when compared with the standard short-course regimen (Standard antiretroviral therapy (ART) consists of the use of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease.) International AIDS Society conference, Capetown, July 2009: WHO may change ARV guidelines for pregnant mothers: HAART reduces HIV transmission while breastfeeding a stronger drug cocktail administered over a longer period reduced the risk of mother-to-child HIV transmission compared with the current WHO-recommended short-course ARV regimen. - - triple ARV regimen started in last trimester and upto six months into breastfeeding; women with CD4 counts between 200 – 500 - almost two-fold reduction in the risk of HIV transmission during the breastfeeding period - biggest effect in in mothers with CD4 counts between 200 and 350 |
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WHO, July 2010 - Recs for MTCT
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Approximately 400 000 infants acquire HIV infection each year as a result of MTCT
WHO recommends that all women with HIV should receive antiretroviral drugs to protect against HIV transmission during pregnancy, delivery or breastfeeding. Mothers may safely breastfeed provided that they or their infants receive ARV drugs during the breastfeeding period. |
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HIV testing - general principles
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Long “window period” for antibodies to appear
Principles of testing - screening & confirmation by 2 different tests Screening tests should have high sensitivity; confirmatory tests should have high specificity. Newborn - maternal antibodies can persist for 18 months (PCR, IgA are specific) Rapid tests esp. for single visits (Oraquick, Reveal) – point of care testing Issues of confidentiality, acceptability, stigma etc |
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Why is there a continued rise of HIV in the developing world?
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Poverty - insufficient money for control programs
Limited access to health care Lack of diagnostic facilities High prevalence of STDs High risk behavior, conflict, mobile populations High prevalence of endemic diseases like TB and diarrhea increase the demands on health system Societal norms and lack of education |
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HIV - Africa - issues
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60% HIV+ are female; higher in teenagers
> 90% of children born HIV+ were born in Africa HIV prevalence in general population as high as 50% or more in some areas Of the 3.1m deaths in 2002, 2.4m were in Africa With 3.5 million new infections in 2000, the total PLWHA increased to 28.5 m; however, < 1% of these received any antiretroviral treatment (PLWHA - prevalence living with HIV or AIDS) |
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Why is there a continued rise of HIV in the developing world?
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Poverty - insufficient money for control programs
Limited access to health care Lack of diagnostic facilities High prevalence of STDs High risk behavior, conflict, mobile populations High prevalence of endemic diseases like TB and diarrhea increase the demands on health system Societal norms and lack of education |
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HIV - Reasons for gender imbalance
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HIV - Reasons for gender imbalance
SOCIAL/CULTURAL – younger women having sex with older men – “sugar daddies”, exchanging sex for money for school fees, being kept by older men who buy them soaps, perfumes etc, young girls “given” to village chieftain who has many wives etc Lack of information or power to negotiate condom use BIOLOGICAL- the risk is 3 to 4 times higher in women; more so in younger age groups |
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HIV - Reasons for gender imbalance - what are the biological factors?
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BIOLOGICAL- the risk is 3 to 4 times higher in women; more so in younger age groups
Immature reproductive tracts Menstruation Small tears in tissue during intercourse |
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Prevention Programs - HIV Control - short-term measures
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Community-based programmes - involving community leaders, PLWHA
Public education for prevention and to dispel stigma Social policy reform - eg; empowerment of women; street children; drug addicts; CSWs Focus on high risk groups - truck drivers, CSWs, IDUs etc. (people livingwith HIV or AIDS) |
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Prevention Programs - HIV Control - long-term measures
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Changing societal norms
Addressing poverty Improving access to healthcare Education -starting at school level Continued surveillance Change focus from groups to national coverage Budget commitment International responses |
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Prevention - specific measures
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Control/ treatment of STDs
Promotion of barrier methods Preventing vertical transmission Blood bank screening Needle exchange programs High risk group counseling & testing Contact tracing/ partner notification |
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What is the ABC Model of HIV Prevention
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A- abstinence/deferred sexual inception
B- Be faithful or partner reduction C- Condoms “B” is often neglected |
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Prevention - Barrier methods
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The condom is the single most effective and cheapest means of prevention of HIV & STD transmission
Problems: Male condom: 2% breakage rate Female: 26% annual failure rate (MMWR, 1993, 42) Not used or when used, improperly used Women-controlled more successful |
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Prevention – vaginal microbicides
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More control for females
Two basic types being tested – contraceptive and non-contraceptive Over 60 products in testing/trials Protective effect on transmission of HIV, STIs Preserve lactobacilli |
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What is the CAPRISA trial?
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The Centre for the AIDS Program of Research in South Africa (CAPRISA) 004 trial assessed the effectiveness and safety of a 1% vaginal gel formulation of tenofovir, a nucleotide reverse transcriptase inhibitor, for the prevention of HIV acquisition in women.
HIV serostatus, safety, sexual behavior, and gel and condom use were assessed at monthly follow-up visits for 30 months. HIV incidence in the tenofovir gel arm was 5.6 per 100 women-years (person time of study observation) (38 out of 680.6 women-years) compared with 9.1 per 100 women-years (60 out of 660.7 women-years) in the placebo gel arm (incidence rate ratio = 0.61; P = 0.017). Tenofovir gel reduced HIV acquisition by an estimated 39% overall, and by 54% in women with high gel adherence. |
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Control Policies & Programs
National responses to the epidemic - what works |
Political commitment & leadership
Societal openness and fight against stigma National strategic response involving govt., medical sector, society leaders, NGOs, private sector & donors |
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Control Policies & Programs - Cost Issues
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Recent move towards making drugs cheaper to developing countries - WTO agreement
But costs include not only treatment, but diagnosis, counseling, program costs etc. International commitment More resources required. |
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Control Policies & Programs - Prevention Vs. Treatment - Why prevention alone is insufficient:
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Why prevention alone is insufficient:
Many of those at greatest risk already know that HIV is sexually transmitted and condoms can reduce transmission The risk of HIV in vulnerable populations stems less from ignorance than from the precarious situations in which they live Gender inequality adds a further dimension to women living in poverty *Prevention programs ignore the 40 million already infected.* |
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Control Policies & Programs -
Increasing Access to ARVs |
Even an intervention as effective as MTCT is not being implemented in areas where most needed
Less than 1% of antenatal HIV+ women in SS Africa receiving prophylaxis in 2006(exceptions – Botswana, Uganda and Namibia) 75% of those receiving ARVs in Africa were men in 2005 *An estimated 5.2 million people in low and middle-income countries were receiving life-saving HIV treatment at the end of 2009* |
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Prevention vs. Treatment:Is this the issue?
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Controversial topic until recently – is providing ARVs in control programs worthwhile?
Debate has changed now to general agreement that ARVs should be part of control programs. The debate now is how best to achieve this? Brazil – has been a pioneer in the developing world. Mandated universal access by presidential decree in 1996. Using a mix of brand names from the US and locally-produced generics, significant results have been achieved. The survival of AIDS patients in Brazil now is the same as in the US. |
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President’s Emergency Plan for AIDS Relief (PEPFAR)
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Office of the Coordinator for US Govt.
Announced in 2003 – 15 billion to 15 countries in Africa, Caribbean (+ Vietnam) 1st round of grants awarded in April 2004 www.state.gov/s/gac/ First year’s funding fully obligated only by September 2004 Days before the International AIDS Conference, August 2008, President Bush signed legislation to increase funding to 48 billion over the next 5 years. |
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President’s Emergency Plan for AIDS Relief (PEPFAR) - what are the 5 year goals?
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By 5 years:
Prevent 7 million infections ARV therapy to 2 million people Care for 10 million affected, including orphans and vulnerable children |
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PEPFAR re-authorization, 2008
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On December 1, PEPFAR announced that the United States has fulfilled its commitment early to support treatment for 2 million people
Why? Treatment has become much cheaper As of September 30, 2008, nearly 9.7 million people in PEPFAR focus countries had received compassionate care, including nearly 4 million orphans and vulnerable children. Senate members were pushing for 55% allocation for treatment; among objections raised were that the money could be used for abortion referrals and needle exchange. |
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What are the PEPFAR Controversies?
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Clause - “Agencies promoting the practice of prostitution”
US – Increasing incidence in MSM and African Americans – several leaders are calling for a domestic PEPFAR Removed the clause that one-third of money allocated to prevention programs should be spent on abstinence and fidelity programs Removed the ban on HIV-infected persons entering the US International AIDS Conference will be able to return to the US (first one was in Atlanta, 1985) |
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PEPFAR II Funding Priorities (1)
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The total legislation is $50 Billion ($48 B for PEPFAR and $2 B for American Indian issues.)
The bill includes an amendment intended to INCREASE OVERSITE of GFATM The bill ENCOURAGES COST-SHARING and transition strategies as part of agreements with countries that receive PEPFAR aid. The bill does not mention family planning programs. The bill OVERTURNS an existing law that requires one-third of prevention funds be spent on ABSTINENCE AND FIDELITY PROGRAMS. Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) |
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PEPFAR II Funding Priorities (2)
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The legislation contains an existing requirement that organizations receiving PEPFAR aid have a POLICY THAT OPOSES SEX WORK
The bill creates links between HIV/AIDS and nutrition programs and sets a target of recruiting 140,000 HEALTHCARE WORKERS. The bill eases U.S. HIV/AIDS TRAVEL RESTRICTIONS |
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PEPFAR’s controversial policies
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Nearly a quarter of all funding goes to FBOs (faith based orgs) (American and international)
“Conscience clause” “Sex worker clause” OVC (orphans and vulnerable children) as a target group Neglect of MSM as a Most at Risk Populations (MARP) Lack of advocacy for needle exchange programs Should have channeled the money through the U.N. Too much emphasis on faith-based groups and abstinence / be faithful Shunned anything associated with abortions and the negative impact on women’s health Emphasis on treatment: Concentrated on AIDS treatment at the expense of prevention Has diverted attention away from bigger killers like pneumonia and diarrhea |
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HIV & TB: a dual challenge - why?
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TB is the leading cause of death in HIV-infected
Responsible for 1 in 3 deaths worldwide 14 million currently co-infected |
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How does HIV fuel the TB epidemic?
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HIV promotes progression of both recent and latent TB infection to active disease
HIV increases the rate of recurrent TB Increased numbers of co-infected people pose an increased risk of transmission in the community Increased numbers of susceptible persons also increase transmission |
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Principles of TB/HIV Collaboration
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“Two diseases, one patient”
Patient-focused delivery of care for both diseases No separate programme Collaborative activities add to existing TB and HIV/AIDS control strategies TB is part of the problem, but TB is also part of the solution But policy needs to be global |
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WHO Three I's for HIV/TB strategy 2010 guidelines
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The Three I's
All children & adults living with HIV, including pregnant women and those receivingART, should receive IPT. (Isoniazid Preventive Therapy ) Isoniazid should be provided for 6 to 36 months, or life-long in settings with high HIV &TB prevalence. People living with HIV who may have TB symptoms should be screened for active TB or other conditions so that they are able to access the appropriate treatments. |
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WHO Three I's for HIV/TB strategy 2010 guidelines
The Three I's are: |
The Three I's are:
Isoniazid Preventive Therapy Intensified TB screening Infection control for TB. |
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HIV & Male Circumcision
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Orange Farm, 2005 – 60% protection by
intent-to-treat analysis; 75% otherwise The protective effects of circumcision: HIV target cells in foreskin (Langerhan cells) Epithelium of the glans is thinner if not circumcised Prepuce is more vulnerable to trauma during intercourse Micro-environment conducive to viral survival Circumcision may decrease risk of genital ulcer disease and STDs known to affect HIV transmission |
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HIV UNAIDS 2010 UPDATE
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Between 2001 and 2009, the rate of new infections in 33 countries (incl 22 in SSA) fell by at least 25%
By end-2010, more than 6 million people were on treatment Global MTCT coverage exceeded 50% for the first time. |
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How did Uganda reverses the tide of HIV/AIDS ?
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Success in reducing the prevalence of HIV in Uganda is the result of a
broad-based national effort backed up by firm political commitment, including the personal involvement of the head of state, President Yoweri Museveni Same day Voluntary counselling and testing (VCT) Sex education in schools Social Marketing Condom use STI self-treatment kit |
