What We Are Doing: Bravely Facing Hiv Diagnosis Together
The Global Access Program is the Roche Groups proactive response to an enormous humanitarian challenge. Since its inception in 2014, the programme has increased access to HIV viral load tests at substantially reduced prices in sub-Saharan Africa and countries where the disease burden is highest. The Global Access Program focuses on the complete continuum of care, from sample collection and transportation, testing, result delivery to monitoring and education, and works to optimise efforts on a regional basisTo help overcome the hurdles preventing babies from getting diagnosed, was one of the reasons we started the Global Access Program. We developed new diagnostics methods for gathering and transporting blood samples in order to test as many as possible.
For example, blood samples can be taken at a local healthcare centre and dried on a card. Because there is no need for refrigeration, and a small amount of blood is enough, they can be sent through the post for HIV testing.
We also introduced text message technology, making it easier to send test results back to rural healthcare facilities. Secondly, we have developed a mobile application to harness the adoption of mobile technology to deliver results directly back to the infants care giver.
Testing To Determine The Infants Hiv Infection Status
Identification of the infant born to a mother with HIV infection and early determination of the presence or absence of HIV infection in the infant are critical to allow early initiation of prophylaxis or presumptive HIV therapy and provision of needed care. Appropriate HIV diagnostic testing for infants and children younger than 18 months differs from that for older children, adolescents, and adults. Passively transferred maternal HIV antibodies may be detectable in an exposed but uninfected infants bloodstream until approximately 18 months of age. Therefore, routine serological testing of infants exposed to HIV and children before the age of 18 months is generally only informative if the test result is negative.
Clinical Indications For Hiv Testing
Individuals requesting an HIV test.
Individuals with symptoms and signs of HIV infection.
Individuals with illnesses associated with a weakened immune system or a diagnosis of tuberculosis.
Unprotected anal or vaginal intercourse or use of shared drug equipment with a partner whose HIV status is known to be positive.
Pregnant or planning a pregnancy and their partners as appropriate.
Victims of sexual assault.
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How Is Hiv Transmitted From Mother To Child During Pregnancy
If you are a pregnant woman living with HIV there are a number of ways that HIV might be passed on to your baby. HIV in your blood could pass into your babys body. This is most likely to happen in the last few weeks of pregnancy, during labour, or delivery. Breastfeeding your baby can also transmit HIV, because HIV is in your breastmilk.
There is a 15 to 45% chance of passing HIV on to your baby if neither of you take HIV treatment.
However, taking the correct treatment during your pregnancy and while you breastfeed can virtually eliminate this risk.
Chimeric Antigen Receptor T Cell And Lentiviral
Chimeric antigen receptor T-cell immunotherapy is a major advancement in cancer therapeutics, including for pediatric B-cell acute lymphoblastic leukemia . Reprogramming of T cells is achieved by using gammaretroviral or lentiviral vectors. Recent reports indicate that these vectors may interfere with long terminal repeat genomes in HIV NAT tests and, thus, produce false-positive results. As CAR T- cell therapy becomes more widely available for multiple indications, it will be important for clinicians to recognize that routine HIV-1 NAT tests may give rise to false results. In addition, lentiviral vector-based gene therapy as treatment for severe combined immunodeficiency can give rise to false-positive HIV NAT tests. Laboratories should, therefore, have appropriate alternate HIV-1 NAT testing platforms made available for this emerging patient population.7882
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New Research Shows How To Help Hiv
Treating HIV in the tiniest babies could have huge positive implications for their future.
Princess had a rough start in life. She was born HIV-infected. Her mother was often sick, and there was little family support for her own struggles with HIV. But Princess mother had recently started HIV treatment and planned to stay on it. She wanted to do everything possible for her daughter, so she made a decision that ultimately helped save Princess life: she enrolled her in a study to treat HIV infection just a few days after being born.
HIV progresses rapidly in the first year of life, wreaking havoc on an infants developing immune system. Although treating HIV-infected women with three active drugs in pregnancy can prevent most transmission to babies, Princess is one of almost 500 children born each day in sub-Saharan Africa who still become infected with HIV. The World Health Organization recommends starting three-drug antiretroviral treatment in infected children as early as possible, yet this goal has proved elusive in most pediatric HIV treatment programs globally.
Accurately diagnosing HIV in newborns
Limited drugs and misperceptions about treatment
Cost
The final barrier to initiating testing and treatment at birth is cost.
Knocking down barriers
We do not have a cure for HIV yet, but immediate testing and treatment of newborns offers a pathway forward so children like Princess can survive until we do.
New York Public Health Law 2500
New York accounts for roughly one-fourth of the countrys pediatric HIV infections, with more than 87 percent of those infections in New York City . In the 1980s, New York was among a group of states that enacted blind newborn testing under the CDCs guidance. While names and test results were not connected, other demographic data from the mother were recorded and tracked. Blind newborn testing caused controversy because the practice released HIV-positive newborns to their mothers, who may or may not have known of their infants status, so there was not an opportunity to allow the newborns to receive treatment that may have prolonged their lives. This concern led New York to pass the AIDS Baby Bill .
As the commissioner of the New York State Health Department has explained, this essentially means that women in labor who were not tested during prenatal care will learn their HIV status during or immediately after delivery . The stated purposes of the regulations are to achieve the goal of universal prenatal counseling and testing, and to ensure that newborns who are born exposed to HIV receive prompt and immediate care and treatment that can enhance, prolong, and possibly save their lives .
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Protecting Your Baby During Childbirth
If you take your treatment correctly, it will lower the amount of HIV in your body. In some people, the amount of HIV in their body can be reduced to such low levels that it is said to be undetectable .
This means that you can plan to have a vaginal delivery because the risk of passing on HIV to your baby during childbirth will be extremely small.
If you dont have an undetectable viral load, you may be offered a caesarean section, as this carries a smaller risk of passing HIV to your baby than a vaginal delivery.
If your HIV test result comes back positive, there are a number of things you can do to reduce the risk of passing HIV to your baby.
I was diagnosed with HIV. After a few years I entered a relationship and we decided to have children. My HIV consultant assured me that it was fine since my viral load was undetectable. I had my twins through C-section, which was planned.
Other Factors Influencing Hiv Transmission Risk
Within each route of transmission, estimates of the risk of transmission vary widely, likely due to the role of behavioural and biological co-factors. Viral load appears to be an important predictor of transmission, regardless of route of transmission. However, the evidence indicates that viral load is not the only determinant, and other co-factors, such as the presence of co-infections, play a role in increasing or decreasing the risk of transmission.
Viral Load
The strongest predictor of sexual transmission of HIV is plasma viral load . A dose-response relationship has been observed, where each ten-fold increase in plasma VL resulted in an increased relative risk of transmission of 2.5 to 2.9 per sexual contact. The concentration of HIV in genital secretions also plays a major role in sexual transmission. While there is a strong correlation between HIV concentrations in plasma and in genital secretions, some studies have found genital tract HIV shedding in 20% to 30% of men and women without detectable plasma viral load. Much of what is known about the impact of viral load on the sexual transmission of HIV is derived from studies of heterosexual populations. Very little is known about the relationship between HIV viral load and rate of transmission through anal intercourse.
Co-infections
Circumcision
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Pneumocystis Carinii Pneumonia Prophylaxis
Pneumocystis carinii pneumonia in infants can have an acute onset and a high mortality rate. It is often the first indicator of perinatal HIV infection.24 In HIV-infected infants, the peak incidence of P. carinii pneumonia is at three to six months of age. This pneumonia can occur in HIV-infected children younger than one year, regardless of the CD4+ lymphocyte count . Therefore, all newborns of HIV-infected mothers should receive P. carinii pneumonia prophylaxis starting at six weeks of age and continuing until HIV infection is excluded.25
The recommended agent for P. carinii pneumonia prophylaxis is trimethoprim-sulfamethoxazole .26 Dapsone and atovaquone are possible alternatives .25 Because of the side effects of these medications, the complete blood count should be evaluated at the initiation of therapy and monthly thereafter.16
Regimens for Pneumocystis carinii Pneumonia Prophylaxis in Infants
Recommended drug: trimethoprim-sulfamethoxazole suspension .
*Only if trimethoprim-sulfamethoxazole is not tolerated.
Adapted with permission from 1995 revised guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with or perinatally exposed to human immunodeficiency virus. MMWR Morb Mortal Wkly Rep 1995 :111.
Regimens for Pneumocystis carinii Pneumonia Prophylaxis in Infants
Recommended drug: trimethoprim-sulfamethoxazole suspension .
*Only if trimethoprim-sulfamethoxazole is not tolerated.
The Impact Of Our Work: Sustainable Treatment
In 2014 we collaborated with a number of international organisations to launch the Global Access Program . aimed at strengthening local healthcare capacity and increasing access to affordable diagnostic tools in resource-limited settings. Since its inception, the program has expanded substantially in menu and geographic footprint to provide increased access to diagnostics for other high burden diseases – MTB, HBV/HCV and HPV/ cervical cancer – to meet the challenges facing healthcare systems. Through the Global Access Program, more than 100 lab technicians across Sub-Saharan Africa are trained every year at our Roche Scientific Campus and partner training facilities in South Africa. We have also added more programmes to train healthcare workers in all areas of laboratory medicine.
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What Is The Treatment For Hiv
Individuals who are HIV positive will likely need to see a specialist. As with many other conditions, early detection offers more options for treatment. Today, there are medical treatments that can slow down the rate at which HIV weakens the immune system. However, there are other treatments that can prevent or cure the conditions associated with HIV. Anti-retroviral drug therapy may be given to a pregnant woman, which has proven to greatly reduce the chance of an infant developing HIV. A cesarean section may be recommended to reduce infant transmission from the birth canal. In the U.S., where other feeding options are available, an infected mother should be discouraged from breastfeeding her infant. Consult your child’s doctor for more information regarding various drug therapies.
Reevaluating Newborn Hiv Screening Policy
In light of evolving HIV diagnostic technology and medical therapy, it is clear that current recommendations regarding newborn HIV screening should be periodically reevaluated. In anticipation of such a need, the committee considered several possible developments that might lead to modification of its present conclusions.
If safe, effective antiretroviral therapy or prophylactic treatment for opportunistic infection and a definitive diagnostic screening tool for newborns were available, the argument for voluntary newborn HIV screening with “fight of refusal,” to ensure that all infants who would benefit from early intervention were identified and treated, would be compelling. In such circumstances, the parent or legal guardian would be informed that, unless he or she expressly refused, the newborn would be tested effective treatment for the infant would also be offered. This scenario is consistent with the long tradition of voluntary screening with ”right of refusal” for devastating neonatal conditions for which effective therapy is available .
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Antiretroviral Management For The Infant Exposed To Hiv
When making decisions to use combination antiretroviral drugs, consultation with a pediatrician experienced in the care of children with HIV infection or the National Clinician Consultation Center is beneficial. Monitoring for hematologic toxicity is necessary for any combination of ZDV and lamivudine compared to ZDV alone. Long-lasting resistance is possible if the infant is already infected when prophylaxis is given this was most evident when nevirapine was used as a single agent for prophylaxis. The HHS Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission and Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV each publish an extensive discussion of considerations for infant antiretroviral prophylaxis regimens for different clinical scenarios and provide specific neonatal antiretroviral dosing recommendations.
The administration of ZDV to the infant should be initiated as soon as possible after birth and certainly within 6 to 12 hours after delivery. If the infants HIV exposure is first recognized between 12 and 48 hours after delivery, presumptive HIV therapy should be initiated in that time period. Data from animal studies indicate that the longer the delay in institution of prophylaxis, the less likely that infection will be prevented. In most animal studies, antiretroviral prophylaxis initiated 24 to 36 hours after exposure is not as effective for preventing infection.
Canadian Paediatric Society Infectious Diseases And Immunization Committee
Members: Michelle Barton-Forbes MD Sean Bitnun MD Natalie A Bridger MD Shalini Desai MD Michael Forrester MD Ruth Grimes MD Nicole Le Saux MD Laura Sauve MD Karina Top MDLiaisons: Upton D. Allen MBBS, Canadian Pediatric & Perinatal HIV/AIDS Research Group Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel , Public Health Agency of Canada Carrie Byington MD, Yvonne Maldonado MD, Committee on Infectious Diseases, American Academy of Pediatrics Marc Lebel MD, IMPACT Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada Dorothy L. Moore MD, National Advisory Committee on Immunization Howard Njoo MD, Public Health Agency of CanadaConsultant: Noni E. MacDonald MDPrincipal authors: Dorothy L. Moore MD, Upton D. Allen MBBS
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Where To Access Testing Services
Standard HIV testing can generally be accessed through any health provider across the country. Each province is responsible for licensing the laboratories that provide HIV screening and confirmatory testing in its jurisdiction. In general, all provincial Public Health Laboratories provide both screening and confirmatory testing. Reference and specialized services, when required, are provided by the National HIV Reference Serology Laboratory after consultation with the provincial laboratory. It is advisable to contact your testing laboratory to confirm the specimen collection details.
Anonymous or POC testing locations can be found by calling a local HIV/AIDS hotline .