On the eve of the 20th International AIDS Conference (AIDS 2014), Rachel Hassinger, editor of MSH’s Global Health Impact Blog, spoke with Dr. Scott Kellerman, global technical lead on HIV & AIDS, to discuss his latest research on prevention of mother-to-child transmission (PMTCT) of HIV and pediatric HIV & AIDS. Kellerman and colleagues will be attending AIDS 2014, July 20-25, in Melbourne, Australia. (Read more about the conference.)
RH: What is the state of HIV & AIDS globally?
SK: We are at the threshold of a sea change. In the beginning, our HIV prevention tool box was sparse. We could offer extended counseling and condoms, and impart information, but not much else. Behavioral change was the cornerstone of tackling the epidemic. It worked sometimes, but, not consistently.
Now biomedical advances are propelling treatment as prevention—even what I call “treatment IS prevention”.
Where we used to see mothers unable to access treatment and die, now, more often than not, we see mothers, even in remote communities, survive. We also see infants of HIV-positive women born HIV-free.
RH: That’s inspiring—a decade or two ago, that wasn’t the case.
SK: Yes, overall, our global response to HIV & AIDS is maturing and recent advances are extremely exciting—but not fast enough. We still fall far short of our treatment and, by extension, our prevention goals.
As I think about previous AIDS conferences, I recall a palpable tension between the “prevention” camps who were advocating for more prevention funding and the “treatment” camps who saw the future of control of the epidemic in more treatment funding. Cries of “you can’t treat your way out of this epidemic!” rang out in conference halls. Perhaps the most striking thing about the maturation of our response is that our community is coming to the conclusion that treatment IS prevention.
Take PMTCT and Option B+.
Option B+ is an approach to preventing mother-to-child transmission [MTCT] that offers all HIV-infected pregnant and breastfeeding women antiretroviral therapy [ART] for life, regardless of CD4 count.
PMTCT has long been “treatment is prevention.” By treating the mother during pregnancy and breastfeeding with ART, we are preventing her infant from acquiring the virus from her. That much isn’t new—both Options A and B use treatment of the mother to prevent mother-to-child transmission.
Option B+, developed in 2011, takes this a step further. The government of Malawi, with technical support from MSH—including my colleague, Dr. Erik Schouten—developed Option B+ out of necessity. Fertility rates are high in Malawi, and CD4 testing capabilities are minimal—and slow, at best. By offering treatment for life to an HIV-positive pregnant or breastfeeding woman regardless of CD4 count, it has raised the standard for other countries to follow.
We now see many countries in Africa and elsewhere adopting this strategy.
Option B+ also says: the country understands that the woman’s life is critical for the well-being of the children and commits to treating the mother for her HIV infection, as well as providing prophylaxis for the infant. It really raises the emphasis on the health of women as key to the health of the family, the community, and the nation. It’s the right thing to do.
RH: At the AIDS 2012 conference two years ago, Option B+ was the talk of the conference! What’s happening now?
SK: Global support for Option B+ is building—but only recently. The WHO [World Health Organization] included B+ in the 2013 treatment guidelines.
RH: So, how close are we to reaching an AIDS-free generation?
SK: Honestly, I feel that we are close to an AIDS-free generation—it is within our human reach—if the international community addresses the epidemic together from every angle, and thinks outside the box.
The end is in sight for eliminating maternal to child transmission [MTCT] and pediatric HIV. But even if we reach this lofty goal, how will we know?
RH: That’s what you and colleagues are testing now, correct?
SK: Exactly. There’s several promising approaches to measure the effectiveness of PMTCT—and Option B+, in particular—that MSH and colleagues are pursuing. In one study, published in PLOS ONE last month, we show the potential for routine testing at immunization clinics to monitor mother-to-child transmission (MTCT) of HIV in Malawi.
The study also shows the potential of regular data collection as a surveillance tool to assess changes in effectiveness of prevention of MTCT (PMTCT) as Option B+ is scaled-up across the country.
RH: Is this a new method for monitoring transmission?
SK: Yes, it is. We [MSH and colleagues] derived population-based estimates of the HIV vertical transmission rate (VTR) by testing a sample of infants less than 3 months old at their first immunization visit at 53 randomly chosen clinics in four Malawian districts. Comparing the population-based estimate of VTR to the results of subsequent evaluations of the national program will allow Malawi to assess trends in the effectiveness of the national PMTCT program, and by extension, the effectiveness of Option B+.
The approach can be expanded to track programming effectiveness for young infants over time in Malawi, and in other countries adopting Option B+. You can read more about the study in the press release or directly in PLOS ONE where it’s downloadable for free.
We’re also partnering with the CDC [US Centers for Disease Control and Prevention] on a four-year research evaluation to determine HIV-free child survival following Malawi’s initiation of Option B+. The study will follow 37,000 Malawian mother-infant pairs and measure the rates of mother-to-child transmission in HIV-exposed infants at 4 to 12 weeks, 12 months, and 24 months of age, and HIV-free survival at 6 to 12 weeks, 12 months, and 24 months of age. In addition to supporting this research evaluation of Option B+, we support district-level health systems strengthening and country efforts to provide HIV testing, counseling, and treatment to the prison population.
We’re supporting the Governments of Ethiopia and Uganda to scale-up their roll-out of Option B+, too. In Ethiopia, for example, we’ve supported implementation of Option B+ in 276 health centers.
RH: So, we’re supporting progress on implementation and research of Option B+ for PMTCT.
SK: Yes, but reaching an AIDS-free generation is not just about PMTCT.
Even with an absolutely perfect PMTCT system—that identifies and treats every infected mother presenting for antenatal care—there are many women who never make it into antenatal care, are never seen by a health worker during their pregnancy, and never get a chance to be tested or understand how to protect their children from being born with HIV.
The AIDS Journal featured a series of papers on pediatric HIV, written by an amazing array of researchers and thinkers. In the set of articles, we show, among other things, that the infrastructure and health systems that are responsible for caring for kids are really suffering. It comes down to health systems strengthening, not only for adults but also for pediatric care systems—which are separate from those for adults, and are often much less resourced. I guest edited the supplement last fall—and its downloadable for free.
Until now, the primary response to pediatric HIV has been to further strengthen PMTCT programming, which is a critical intervention, and one that is close to my heart. But a lot of kids are missed by PMTCT.
There’s no PMTCT without antenatal care and HIV testing. There’s no PMTCT without stronger health systems.
RH: Can you give an example?
SK: Our HIV work is part of our whole systems approach in many countries. In Ethiopia, for example, about 790,000 Ethiopians are living with HIV. Through one of our projects [ENHAT-CS], we’re supporting the government’s efforts to scale-up comprehensive HIV & AIDS services at health centers and integrate them with other health services, such as maternal, newborn, and child health. ENHAT-CS supports mother support groups in over 80 health centers. HIV-positive women—“mother mentors”—lead the groups. Data show a beneficial effect of mother mentors and mother support groups on uptake of and adherence to HIV care and support and reduced vertical transmission rates among HIV-positive women. And four of the mother mentors in Ethiopia received international recognition for their life-saving work.
Through the SIAPS program, [Systems for Improved Access to Pharmaceuticals and Services Program], we’re partnering with the Ethiopian Government to improve information systems at hundreds of ART clinic pharmacies to improve HIV patient care and adherence to treatment.
We’ve actually been working in partnership with Ethiopia saving lives for 10 years.
RH: The state of global funding is shifting. Since the creation of PEPFAR [the US President’s Emergency Plan for AIDS Relief], the US and global communities have concentrated a lot of money into reducing the HIV & AIDS epidemic, more than for any other area of global health. This year, newly appointed Ambassador Deborah Birx, MD, US Global AIDS Coordinator, reiterated this shift, noting that PEPFAR’s congressional mandate calls for half of funds to go directly to treatment.
If there is a continued push toward treatment, what happens to the other parts of the whole?
SK: We’ve built an incredible system around fighting AIDS: structures of concentric programming circles with HIV prevention and treatment programs aimed at the individual in the middle, but with considerable resources directed at the myriad societal structures that often inhibit people in need of basic care and treatment.
With flat lined or diminishing resources, there’s a renewed focus on increasing the efficiency and getting back to basics—putting pills into people’s mouths, focusing on key populations: men who have sex with men, sex workers, IV-drug users; and eliminating pediatric HIV. It is time that we shift our thinking from a vertical siloes approach, to a cross-cutting, diagonal whole. When it comes down to it, HIV is an infectious disease and we know how to treat it. We can’t keep funding everything.
The question is: How do we increase the efficiency of the AIDS response? And how can we leverage these structures to improve other health areas—the whole person?
We can integrate HIV & AIDS services with other health services—like maternal and child health, tuberculosis, and family planning. Instead of building three separate clinics–a reproductive health clinic next to a tuberculosis (TB) clinic next to an HIV & AIDS clinic–build a clinic that provides quality, integrated services for all of these essential needs. Train community drug shop owners, so that a person living with HIV in a rural community, can pick up pills safely. We’re not the only ones who are doing this well. Many of my colleagues in other organizations are working hard to integrate services and increase efficiencies, too. We can work together to leverage these systems to provide services for multiple health areas, MNCH, TB, family planning, and chronic diseases.
The cost of AIDS medicines has decreased, and coverage for treatment is the norm in many low- and middle-income countries. And, we still have more to do to ensure access for the poor and most vulnerable. Programs like the Malawi prison effort, and the Ethiopian religious leaders and mother mentors are helping to ensure that more and more, people are testing voluntarily for HIV, and getting treatment. But stigma and discrimination are still major issues.
RH: What about HIV & UHC?
SK: We’ll be talking a lot with partners and colleague about universal health coverage (UHC) in the post-2015 development framework at the AIDS 2014 conference. There’s a breakfast on Tuesday [July 22] on building UHC on lessons learned from the AIDS response. You can learn more about the UHC breakfast, and other MSH AIDS2014 events.
RH: What else will you and colleagues be talking about at AIDS 2014?
SK: We’re co-sponsoring three evening sessions [6:30 pm] on Monday, Wednesday, and Thursday. On Monday [July 21], the conversation will focus on women, HIV & AIDS, and non-communicable diseases; on Wednesday [July 23], supply chain for HIV & AIDS medicines and commodities; and on Thursday [July 24], HIV & TB.
And, before the conference begins, I’ll be speaking at an event about PMTCT and pediatric HIV—and on the importance of research and development for stepping up the pace. Our data systems are still primarily designed to count the number of things done, not measure progress toward goals.
We need more research on pediatric HIV, like the article in PLOS ONE outlining a design to measure population-based vertical transmission rates; the AIDS journal supplement focused on PMTCT and pediatric HIV; and the ongoing CDC-supported evaluation to measure the efficacy of Option B+.
As we get closer to our goals of eliminating mother-to-child transmission, these studies could help numerous sub-Saharan Africa countries measure progress toward keeping infants HIV-free.