Progress, challenges, and new opportunities for the prevention of mother-to-child transmission of HIV under the US President's Emergency Plan for AIDS Relief

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality--all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.     

Antiretroviral Drug Regimens to Prevent Mother-To-Child Transmission of HIV: A Review of Scientific, Program, and Policy Advances for Sub-Saharan Africa

Considerable advances have been made in the effort to prevent mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Clinical trials have demonstrated the efficacy of antiretroviral regimens to interrupt HIV transmission through the antenatal, intrapartum, and postnatal periods. Scientific discoveries have been rapidly translated into health policy, bolstered by substantial investment in health infrastructure capable of delivering increasingly complex services. A new scientific agenda is also emerging, one that is focused on the challenges of effective and sustainable program implementation. Finally, global campaigns to “virtually eliminate” pediatric HIV and dramatically reduce HIV-related maternal mortality have mobilized new resources and renewed political will. Each of these developments marks a major step in regional PMTCT efforts; their convergence signals a time of rapid progress in the field, characterized by an increased interdependency between clinical research, program implementation, and policy. In this review, we take stock of recent advances across each of these areas, highlighting the challenges—and opportunities—of improving health services for HIV-infected mothers and their children across the region.     

Male Involvement for the Prevention of Mother-to-Child HIV Transmission: A Brief Review of Initiatives in East,West, and Central Africa

Current trends in HIV/AIDS research in sub-Saharan Africa (SSA) highlight socially and culturally sensitive interventions that mobilize community members and resources for universal access to HIV prevention, treatment, and care services. These factors are particularly important when addressing the complex social and cultural nature of implementing services for prevention of mother-to-child transmission of HIV (PMTCT). Across the globe approximately 34 % fewer children were infected with HIV through the perinatal or breastfeeding route in 2011 (est. 330,000) than in 2001 (est. 500,000), but ongoing mother-to-child HIV transmission is concentrated in sub-Saharan Africa, where fully 90 % of 2011 cases are estimated to have occurred. Recent literature suggests that PMTCT in Africa is optimized when interventions engage and empower community members, including male partners, to support program implementation and confront the social, cultural and economic barriers that facilitate continued vertical transmission of HIV. In resource-limited settings the feasibility and sustainability of PMTCT programs require innovative approaches to strengthening male engagement by leveraging lessons learned from successful initiatives in SSA. This review presents an overview of studies assessing barriers and facilitators of male participation in PMTCT and new interventions designed to increase male engagement in East, West, and Central Africa from 2000–2013, and examines the inclusion of men in PMTCT programs through the lens of community and facility activities that promote the engagement and involvement of both men and women in transformative PMTCT initiatives.     

Social consequences of HIV-positive women's participation in prevention of mother-to-child transmission programmes

Approximately two-third of the worlds HIV/AIDS cases are found in sub-Saharan Africa. The rate of mother-to-child-transmission (MTCT) has been found to lie between 15 and 40%. The aim of this study was to explore the social consequences affecting the experience HIV-positive women have when taking part in a prevention of mother-to-child-transmission programme (PMTCT). Few studies have investigated this earlier. A cross section of 52 participating women enrolled into a PMTCT programme were randomly selected and interviewed, using a structured questionnaire. There were three main findings. The most important consequence of participating was the difficulty associated with the breast-feeding issue. For the women who because of a wish to prevent MTCT are employing formula feeding, this causes suspicion and prejudice amongst people in the local community. Few people influence a woman's decision to take part, as they tend to keep their HIV status to themselves. More information to the general public about HIV and PMTCT programmes will enhance acceptance to HIV, and generate an environment conducive towards participation in PMTCT programmes.     

Global impact of human immunodeficiency virus and AIDS

This review provides information on the epidemiology, economic impact, and intervention strategies for the human immunodeficiency virus (HIV)/AIDS pandemic in developing countries. According to the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) at the end of 1999, an estimated 34.3 million people were living with HIV/AIDS. Most of the people living with HIV, 95% of the global total, live in developing countries. Examples of the impact of HIV/AIDS in Africa, Asia, Latin America, the Caribbean, and the Newly Independent States provide insight into the demographics, modes of exposure, treatment and prevention options, and the economic effect of the epidemic on the global community. The epidemic in each region of the world is influenced by the specific risk factors that are associated with the spread of HIV/AIDS and the responses that have evolved to address it. These influences are important in developing HIV/AIDS policies and programs to effectively address the global pandemic.     

Treatment and care for HIV / AIDS: is there hope for the developing world?

Although 92% of the estimated 21 million adults and children infected with human immunodeficiency virus (HIV) live in developing countries, only 8% of global spending on acquired immunodeficiency syndrome (AIDS) supports programs in resource-poor countries in Africa, Asia, and Latin America. AIDS treatment and care in the developing world were addressed at a meeting held in Washington, D.C., on October 7, 1996, sponsored by the National Council for International Health's AIDS Program and the Global Network of People with AIDS. It was noted that most people with AIDS in the Third World lack access to treatment for opportunistic infections, let alone the new combination drug therapies that have led those in developed countries to declare a "near victory" over AIDS. Since the international donor community has been slow to discern its role in AIDS treatment, private individuals and groups have taken the initiative to send medical supplies and unused or expired drugs to Asia and Latin America. Although such medication banks fulfill a short-term need, they do not address the overall problem of inequitable access to care and treatment. The Global Network seeks to gain support from donor organizations for training programs in treatment and care skills building, including training for physicians in developing countries, improved information sharing, counseling to people with AIDS, programs for treatment advocates, and global strategies to improve access to medications. Also envisioned was the formation of medical cooperatives that work in coordination with recipient countries and operate within the context of legal parameters.     

Africa's children and AIDS -- a continent in crisis. The devastation of the HIV / AIDS pandemic

AIDS is having a major impact upon child health. By mid-1996, UNAIDS estimated that worldwide there were 3 million HIV infections in children. Accordingly, infant mortality rates (IMRs) have increased due to AIDS, reversing declines which had been occurring in many countries over the last few decades. The IMR in 1996 would have been 51.7 per 1000 without AIDS; it is instead 72.8 with AIDS, 40% higher than expected. IMR is 30% higher than expected in Zambia and almost 20% higher in Kenya and Uganda. IMRs should grow considerably during the next decade as the epidemic spreads. Two-thirds of AIDS deaths among children occur among those aged 1-4 years, with countries in southern Africa being the most affected. With regard to life expectancy, many years of life will be lost due to the AIDS epidemic. AIDS has already led to widespread and marked reductions in life expectancy, with life expectancy for females being lower than that for males because women are infected with HIV and die at younger ages than men. Lower life expectancy will lead to an increase in the proportion of orphaned children. It is likely that at least 30 million children are living with HIV-positive parents, at risk of being orphaned in the next few years. The implications of the growing proportions of orphans and challenges in child health are considered.     

Trends and determinants of Comprehensive HIV and AIDS knowledge among urban young women in Kenya

Background  

Sub-Saharan Africa remains the region most heavily affected by HIV. In 2008, the region accounted for 67% of HIV infections worldwide, the region also accounted for 72% of the world's AIDS-related deaths in 2008. Young people aged 15-24 years accounted for an estimated 45% of the new HIV infections. In sub-Saharan Africa, Kenya is among countries affected by the HIV and AIDS pandemic which led to the declaration of AIDS as a national disaster in 1999. Given these scenario the study was undertaken to examine trends in HIV and AIDS comprehensive knowledge and identify the main correlates of comprehensive HIV and AIDS knowledge among Kenyan urban young women.     

Pediatric HIV/AIDS in sub-Saharan Africa: emerging issues and way forward

Background

Sub-Saharan Africa has the largest burden of pediatric HIV in the world. Global target has been set for eradication of pediatric HIV by 2015 but there are still so many complex issues facing HIV infected and affected children in the sub-continent.

Objective

To review the current and emerging challenges facing pediatric HIV care in sub-Saharan Africa; and proffer solutions that could help in tackling these challenges.

Method

A Medline literature search of recent publications was performed to identify articles on “pediatric HIV”, “HIV and children”, “HIV and infants”, “HIV and adolescents” in sub-Saharan Africa.

Result

There are a number of challenges and emerging complex issues facing children infected and affected by HIV in sub-Saharan Africa. These include late presentation, limited access to pediatric HIV services, delayed diagnosis, infant feeding choices, malnutrition, limited and complex drug regimen, disclosure, treatment failure and reproductive health concerns. A holistic cost effective preventive, diagnostic and treatment strategies are required in order to eliminate pediatric HIV in SSA.

Conclusion

HIV infected children and their families in sub-Saharan Africa face myriad of complex medical and psychosocial issues. A holistic health promotional approach is being advocated as the required step for eradication of pediatric HIV in Africa.     

Mandela calls for greater commitment and leadership in fighting AIDS. The World Economic Forum -- Policy and business in a world of HIV / AIDS

The 27th annual meeting of the World Economic Forum in Davos, Switzerland, on February 3, 1997, was attended by 2000 political and financial leaders of countries and businesses around the world. The forum is the world's largest annual gathering of economic and political dignitaries. In his address to the forum, Nelson Mandela, president of South Africa, called for a global effort against AIDS and a strengthening of the world's political and business leaders' commitment against HIV/AIDS. The disease is creating global economic problems by affecting people in their prime productive and reproductive years. Mandela criticized political leaders for their limited actions in addressing the AIDS pandemic and called upon the world's business community to support government AIDS programs and help people affected by AIDS. All sectors and all spheres of society must be involved as equal partners in the war against HIV/AIDS, for neither the health sector nor government can meet the challenge on its own. If current HIV/AIDS trends continue in South Africa, AIDS will cost the country 1% of its domestic gross product by the year 2005, and up to 75% of the country's budget will be consumed by direct health costs related to HIV/AIDS. At a panel discussion preceding President Mandela's address, Dr. Peter Piot, executive director of UNAIDS, argued that the AIDS pandemic could have a devastating effect upon the global economy and urged business leaders to take strong action against the disease.     

Reducing HIV and AIDS in Adolescents: Opportunities and Challenges

Adolescents are critical to efforts to end the AIDS epidemic. Few national AIDS strategies explicitly program for children in their second decade of life. Adolescents (aged 10–19 years) are therefore largely invisible in global, regional, and country HIV and AIDS reports making it difficult to assess progress in this population. We have unprecedented knowledge to guide investment towards greater impact on HIV prevention, treatment, and care in adolescents, but it has not been applied to reach those most vulnerable and optimize efficiency and scale. The cost of this is increasing AIDS-related deaths and largely unchanged levels of new HIV infections in adolescents. An AIDS-free generation will remain out of reach if the global community does not prioritize adolescents. National AIDS responses must be accountable to adolescents, invest in strengthening and monitoring protective and supportive laws and policies and access for adolescents to high impact HIV interventions.     

DNA vaccines for HIV: challenges and opportunities

In December 2005, the UNAIDS and WHO reported that the global epidemic known as acquired immunodeficiency syndrome (AIDS) has claimed the lives of more than 25 million adults and children over the past 26 years. These figures included an estimated 3.1 million AIDS-related deaths in 2005. Despite enormous efforts to control the spread of human immunodeficiency virus (HIV) new infection rates are on the rise. An estimated 40.3 million people are now living with HIV, including 4.9 million new infections this past year. Nearly half of new HIV infections are in young people between the ages of 15 and 24. While drug therapies have helped sustain the lives of infected individuals in wealthy regions, they are relatively unavailable to the poorest global regions. This includes sub-Saharan Africa which has ∼25.8 million infected individuals, more than triple the number of infections of any other region in the world. It is widely believed that the greatest hope for controlling this devastating pandemic is a vaccine. In this review, we will discuss the current state of DNA-based vaccines and how they compare to other vaccination methods currently under investigation. We will also discuss innovative ideas for enhancing DNA vaccine efficacy and the progress being made toward developing an effective vaccine.     

Responding to the HIV pandemic: the power of an academic medical partnership.

Partnerships between academic medical center (AMCs) in North America and the developing world are uniquely capable of fulfilling the tripartite needs of care, training, and research required to address health care crises in the developing world. Moreover, the institutional resources and credibility of AMCs can provide the foundation to build systems of care with long-term sustainability, even in resource-poor settings. The authors describe a partnership between Indiana University School of Medicine and Moi University and Moi Teaching and Referral Hospital in Kenya that demonstrates the power of an academic medical partnership in its response to the HIV/AIDS pandemic in sub-Saharan Africa. Through the Academic Model for the Prevention and Treatment of HIV/AIDS, the partnership currently treats over 40,000 HIV-positive patients at 19 urban and rural sites in western Kenya, now enrolls nearly 2,000 new HIV positive patients every month, feeds up to 30,000 people weekly, enables economic security, fosters HIV prevention, tests more than 25,000 pregnant women annually for HIV, engages communities, and is developing a robust electronic information system.The partnership evolved from a program of limited size and a focus on general internal medicine into one of the largest and most comprehensive HIV/AIDS-control systems in sub-Saharan Africa. The partnership's rapid increase in scale, combined with the comprehensive and long-term approach to the region's health care needs, provides a twinning model that can and should be replicated to address the shameful fact that millions are dying of preventable and treatable diseases in the developing world.     

AIDS/HIV crisis in developing countries: the need for greater understanding and innovative health promotion approaches.

Epidemiologic data on morbidity and mortality have shown that the acquired immunodeficiency syndrome/human immunodeficiency virus (AIDS/HIV) epidemic is relatively widespread in the developing countries of the world, especially in the already economically deprived regions of Sub-Saharan Africa. Africa is estimated to have approximately 5 million seropositive individuals, and by the year 2000, this number is expected to include 10 million HIV-infected children. Improved control over this epidemic can only come through a greater understanding of the specifics of the disease and, eventually, the introduction of more effective and innovative health promotion campaigns targeted at medical personnel, traditional healers, families, and persons with AIDS. Comprehensive health promotion campaigns, carefully using mass media strategies in addition to more community-based programs, all operating under "decentralized" AIDS control programs, are reasoned to be the most efficacious approach that African and other developing countries can use to successfully contain the AIDS/HIV epidemic. Given the reality of the following factors: Pattern II (ie, transmission of AIDS via heterosexual sexual activity) is the main mode of HIV transmission in Africa, the traditional dominant roles males have in sexual relations, and the positive relationship between sexually transmitted diseases and AIDS, health promotion campaigns must focus specifically on addressing at-risk culturally related sexual values and behaviors in African communities. Failure to address these and other related factors will certainly lead to an escalation of the AIDS/HIV epidemic in Africa and, therefore, concomitant devastation in the human and societal realms of the region.     

Saving lives for a lifetime: supporting orphans and vulnerable children impacted by HIV/AIDS

President's Emergency Plan for AIDS Relief (PEPFAR's) response to the millions of children impacted by HIV/AIDS was to designate 10% of its budget to securing their futures, making it the leading supporter of programs reaching orphan and vulnerable children (OVC) programs globally. This article describes the evolution of PEPFAR's OVC response based on programmatic lessons learned and an evergrowing understanding of the impacts of HIV/AIDS. In launching this international emergency effort and transitioning it toward sustainable local systems, PEPFAR helped establish both the technical content and the central importance of care and support for OVC as a necessary complement to biomedical efforts to end the HIV/AIDS epidemic. Critical services are reaching millions of HIV-affected children and families through vast networks of community-based responders and strengthened national systems of care. But rapid program scale-up has at times resulted in inconsistent responses, failure to match resources to properly assessed needs, and a dearth of rigorous program evaluations. Key investments should continue to be directed toward more sustainable and effective responses. These include greater attention to children's most significant developmental stages, a focus on building the resilience of families and communities, a proper balance of government and civil society investments, and more rigorous evaluation and research to ensure evidence-based programming. Even as HIV prevalence declines and medical treatment improves and expands, the impacts of HIV/AIDS on children, families, communities, economies, and societies will continue to accumulate for generations. Protecting the full potential of children-and thus of societies-requires sustained and strategic global investments aligned with experience and science.     

Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroon's 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.     

The HIV Epidemic in Southern Africa – Is an AIDS-Free Generation Possible?

Southern Africa, home to about 20 % of the global burden of infection continues to experience high rates of new HIV infection despite substantial programmatic scale-up of treatment and prevention interventions. While several countries in the region have had substantial reductions in HIV infection, almost half a million new infections occurred in this region in 2012. Sexual transmission remains the dominant mode of transmission. A recent national household survey in Swaziland revealed an HIV prevalence of 14.3 % among 18–19 year old girls, compared to 0.8 % among their male peers. Expanded ART programmes in Southern Africa have resulted in dramatically decreased HIV incidence and HIV mortality rates. In South Africa alone, it is estimated that more than 2.1 million of the 6.1 million HIV-positive people were receiving ART by the end of 2012, and that this resulted in more than 2.7 million life-years saved, and hundreds of thousands of HIV infections averted. Biological, behavioural and structural factors all contribute to the ongoing high rates of new HIV infection; however, as the epidemic matures and mortality is reduced from increased ART coverage, epidemiological trends become hard to quantify. What is clear is that a key driver of the Southern African epidemic is the high incidence rate of infection in young women, a vulnerable population with limited prevention options. Moreover, whilst ongoing trials of combination prevention, microbicides and behavioural economics hold promise for further epidemic control, an AIDS-free generation will not be realised unless incident infections in key populations are reduced.     

Lessons from Africa

Delayed access to HIV care and treatment in sub-Saharan Africa meant that the early years of HIV scale-up were characterized by a largely North-to-South transfer of knowledge and resources. Clinicians from wealthy countries were among the first to gain experience with antiretroviral treatment and care of people living with HIV and shared key lessons with their colleagues in sub-Saharan Africa. Ten years later, lessons from Africa learned from the remarkable achievements of HIV programs now have the potential to inform the response to the US domestic epidemic.     

Autopsy causes of death in HIV-positive individuals in sub-Saharan Africa and correlation with clinical diagnoses

Despite the persistently high HIV-related mortality in sub-Saharan Africa, limited information on the causes of death is available. Pathological autopsies are the gold standard to establish causes of death. In this review we describe the autopsy series performed among HIV-infected individuals in sub-Saharan Africa over the last two decades. We identified nine complete and 11 partial or minimally invasive autopsy series. Complete autopsies were performed in 593 HIV-positive adults and 177 HIV-positive children. Postmortem diagnoses were mainly infectious diseases. Tuberculosis was the most frequent, present in 21-54% of HIV-positive adults and was considered the cause of death in 32-45%. Overall, pulmonary infections accounted for approximately 66% of pathology and central nervous system infections for approximately 20%. A high discordance between clinical and postmortem diagnoses was observed. This review emphasizes the need for reliable information on causes of death in order to improve HIV patient care, guide further research, and inform health policy.