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
?…
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