Prévention de la transmission mère-enfant du VIH L’apport des recherches en sciences sociales dans les pays du Sud Paris, 14 janvier 2011

… et si on partait quand même de l’approche biomédicale ? 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 même de l’approche biomédicale ? François Dabis Avec 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 needing and 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)

New HIV recommendations to improve health, reduce infections and save lives 2009 - 2010 Antiretroviral therapy for HIV infection in adults and adolescents Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants WHO principles and recommendations on infant feeding in the context of HIV Antiretroviral therapy for HIV infection in children 2009 PMTCT ARV Guidelines

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

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 2010 PMTCT ART / ARV Guidelines

ART for eligible mothers and prophylaxis for exposed infants AZT + 3TC + NVP or AZT + 3TC + EFV or TDF + XTC + NVP or TDF + XTC + EFV (note: XTC = 3TC or FTC) Strong recommendation Infant Breastfeeding population Daily NVP from birth to 6 weeks Non-breastfeeding population AZT for 6 weeks OR NVP for 6 weeks Strong recommendation Strong recommendation 20010 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 2010 PMTCT ART / ARV guidelines

What ARV prophylaxis to give to non-eligible pregnant women? 2 possible options: Maternal AZT mono-prophylaxis 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* 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 Infant Breastfeeding 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 Daily NVP from birth to 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 2009 PMTCT ARV Guidelines

Le défi du passage à large échelle des interventions de PTME Femmes en âge de procréer Prévention primaire Seules 35% des femmes enceintes ont été testées pour le VIH en Afrique en 2009 Femmes infectées par le VIH Accès au dépistage et aux interventions de PTME La couverture des interventions de PTME déjà existantes reste faible en Afrique (54% en 2009) Taux de PTME : 40% Taux de PTME : 5% à 12% 11

Projet PEARL, Côte d’Ivoire 570 femmes VIH+ (9650 cordon ombilical) 98% 59% 52% 40% Centre PTME : 40% des femmes VIH connaissent leur statut

Prise effective de nevirapine Etude menée chez 29,103 couples mère-enfant VIH+ dans 4 pays 51% 75% Cam 59% Zam 54% SA 16% CI 19

Improve along both axes Two Dimensions Needed to Improve PMTCT (courtesy of A. Ciaranello and K. Freedberg) No PMTCT Option A Option B “Option B+” sdNVP Improve 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 ? …