This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.
Attention turned to HIV among women and children at CROI today, when Elaine Abrams, MD, a senior a professor of pediatrics and epidemiology at the Columbia University College of Physicians & Surgeons and the Mailman School of Public Health, provided an informative overview of the challenges in protecting children from HIV in developing-world settings. For starters, she said, we are not doing a very good job in preventing HIV infection in women, with 1 million new infections a year in women. Then there are the 1,000 new pediatric HIV infections every single day. And in most high prevalent developing world settings, there is very poor access to family planning services, leaving women with few tools to prevent unwanted pregnancies.
In the context of antiretroviral therapy scale-up, there has been a failure to identify and prioritize pregnant women for ART who are at risk of transmitting HIV infection to their infants.
There has also been limited scale-up of prevention of mother to child transmission programs, in large part because these programs are layered into the limited infrastructure available in many countries for maternal and child health services. Too often, there has been an over-reliance on short-term ART for pregnant women, rather than a continuum of care and treatment for HIV-infected women and their children.
Until recently, there was no ART intervention for prevention of post-natal transmission, leaving many infants vulnerable to HIV transmission during the breastfeeding period. Current strategies using daily neviripine in infants during breastfeeding reduces the risk of HIV acquisition, but it also confers neviripine resistance on infants who fail prophylaxis at very high levels – some 52 percent. Drug alternatives to neviripine are not widely available. The public health approach to ART access in developing-world settings is anchored in neviripine-based regimens. Lopinivir is the only protease inhibitor available for infants. In general, there are very few ART options available for children in resource-poor countries, especially in the context of widespread neviripine resistance.
Dr. Abrams also noted that there is very limited capacity for early diagnosis in infants, even though mortality in this population is extremely high. Thirty-five percent of HIV-infected infants, if untreated, will die in their first year of life, and that number increases to 53 percent by age two. The World Health Organization recommends that all HIV-positive children under age 1 should receive ART therapy.