Prévention de la transmission mère-enfant du VIH

L’apport des recherches en sciences sociales dans les pays du Sud

Paris, 14 janvier 2011

Prévention de la transmission mère-enfant du VIH

L’apport des recherches en sciences sociales dans les pays du Sud

… et si on partait quand mêmede l’approche biomédicale ?

François DabisAvec le concours de Renaud Becquet et Didier Ekouevi

INSERM U 897, ISPED, Bordeaux

Percentage of pregnant women who received an HIV test in low- and middle-income countries by region

2005, 2008 and 2009

Estimated number of women living with HIV needingand receiving antiretrovirals for PMTCT

in low- and middle-income countries, 2009

Percentage of pregnant women living with HIV receiving antiretrovirals to prevent mother-to-child transmission of HIV

in 25 countries with the highest HIV burden, 2009

Percentage distribution of various antiretroviral regimens provided to pregnant women in low- and middle-income countries in 2007 (59 countries) and 2009 (86 countries)

2009 PMTCT ARV Guidelines

New HIV recommendations to improve health, New HIV recommendations to improve health, reduce infections and save livesreduce infections and save lives

2009 - 2010

1. Antiretroviral therapy for HIV infection in adults and adolescents

2. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants

3. WHO principles and recommendations on infant feeding in the context of HIV

4. Antiretroviral therapy for HIV infection in children

2009 PMTCT ARV Guidelines

2010 PMTCT guiding principles

• Women (including pregnant women) in need of ARV for their own health should get life-long ART

• Antenatal CD4 is critical for decision-making about ART eligibility

• Interventions should aim to maximize reduction of vertical transmission, minimize side effects for mothers and infants, and preserve future HIV treatment options

• Effective postpartum ARV-based interventions for all women will allow safer breastfeeding practices

• Simple, unifying principles needed for different country settings

ART and ARV prophylaxis

2010 PMTCT ART / ARV Guidelines

Antiretroviral therapy (ART)

• Women with CD4 <350 regardless of clinical stage

• Women with clinical stage 3 or 4 (symptomatic) regardless of CD4

• Start ART as soon as feasible regardless of gestational age and continue for life

Strong recommendation

20010 PMTCT ART/ARV Guidelines

ART for eligible mothersand prophylaxis for exposed

infants

InfantBreastfeeding population• Daily NVP from birth to 6 weeksNon-breastfeeding population• AZT for 6 weeks OR• NVP for 6 weeks

Strong recommendation

Mother• AZT + 3TC + NVP or• AZT + 3TC + EFV or• TDF + XTC + NVP or• TDF + XTC + EFV

(note: XTC = 3TC or FTC)

Strong recommendation

Strong recommendation

2010 PMTCT ART / ARV guidelines

ARV prophylaxis to prevent MTCT

For women not eligible for ART or unknown eligibility

• Beginning as early as 14 weeks of gestation (2nd trimester) or as soon as possible thereafter

Strong recommendation

2009 PMTCT ARV Guidelines

What ARV prophylaxis to giveto non-eligible pregnant

women?

2 possible options:

A) Maternal AZT mono-prophylaxis

B) Maternal triple ARV prophylaxis(NVP-based regimens are not recommended)

Strong recommendation

2009 PMTCT ARV Guidelines

ARV Prophylaxis options for women and infants Option A Option B

Mother• Antepartum AZT (from 14 weeks)• sd-NVP at onset of labour*• AZT + 3TC during labour & delivery*• AZT + 3TC for 7 days postpartum*

Mother• Triple ARV (from 14 wks until one wk after all exposure to breast milk has ended)

• AZT + 3TC + LPV-r

• AZT + 3TC + ABC

• AZT + 3TC + EFV

• TDF + XTC + EFV

InfantBreastfeeding population• Daily NVP (from birth until one wk

after all exposure to breast milk had ended)

Non-breastfeeding population• AZT for 6 weeks OR• NVP for 6 weeks

InfantBreastfeeding population• Daily NVP from birth to 6 weeks

Non-breastfeeding population• AZT for 6 weeks OR• NVP for 6 weeks*sd-NVP and AZT+3TC can be omitted if mother receives > 4 wks AZT antepartum

2009 PMTCT ARV Guidelines

New 2009 key recommendation

Le défi du passage à large échelle des interventions de PTMELe défi du passage à large échelle des interventions de PTME

11

Femmes infectées par le VIH

Taux de PTME : 40% Taux de PTME : 5% à 12%

Femmes en âge de procréer

Prévention primaire

Accès au dépistage et aux interventions de PTME

Seules 35% des femmes enceintes

ont été testées pour le VIH en

Afrique en 2009

La couverture des interventions de

PTME déjà existantes reste faible en Afrique (54% en 2009)

Projet PEARL, Côte d’Ivoire570 femmes VIH+ (9650 cordon ombilical)

Centre PTME : 40% des femmes VIH connaissent leur statut

98%

59%52%

40%

Prise effective de nevirapine Etude menée chez 29,103 couples mère-enfant VIH+

dans 4 pays

51%

75% Cam

59% Zam54% SA16% CI

20

Two Dimensions Needed to Improve PMTCT (courtesy of A. Ciaranello and K. Freedberg)

No PMTCT

Option A

Option B

“Option B+”

sdNVPImprove PMTCT Uptake (95%?)

Improve along both axes

Prévention de la transmission mère-enfant du VIH

L’apport des recherches en sciences sociales dans les pays du Sud

- Comment dépister toutes les femmes enceintes et qui accouchent ?

- Comment révéler leur statut VIH à toutes les femmes dépistées ?

- Comment lier services de SMI, interventions ARV de PTME, promotion de l’allaitement maternel et

services de prise en charge VIH adultes et enfants ?

-Comment porter un diagnostic d’infection pédiatrique à temps pour tous les enfants à risque

?…