Option B+

{Photo credit: Mark Tuschman, Kenya.}Photo credit: Mark Tuschman, Kenya.

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?

[Scott Kellerman]Scott KellermanSK: 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”.

{Photo credit: Reavis/MSH, Malawi}Photo credit: Reavis/MSH, Malawi

The World Health Organization (WHO) made waves at the International AIDS Society conference in Kuala Lumpur when it issued revised guidelines for HIV treatment. The new guidelines—WHO’s first major update since 2010—recommend an earlier start to treatment, from a CD4 threshold of 350 cells/mm3 to 500 cells/mm3. While most patients don’t show symptoms of disease at these higher CD4 counts (a measure of immune system strength), the new guidelines responded to evidence that an earlier start improves long-term clinical outcomes and that ARV treatment dramatically reduces patients’ likelihood of transmitting the virus to sexual partners.

This week’s Lancet returns the spotlight to Option B+, an innovative strategy for preventing mother-to-child transmission of HIV which was first developed in Malawi with technical assistance from MSH. Four letters respond to the concern that international organizations have too quickly endorsed the Option B+ approach of providing lifelong triple antiretroviral therapy (ART), irrespective of CD4 count, to pregnant women with HIV in high-burden countries.

MSH experts Scott Kellerman, Jonathan Jay and Jonathan Quick argue that “a strong case exists for expanding research on Option B+, but not for impeding countries that pursue it on the basis of available evidence and programmatic experience:”

Uganda. {Photo credit: Paydos/MSH.}Photo credit: Paydos/MSH.

The Ugandan government launched a new prevention of mother-to-child HIV transmission (PMTCT) strategy on September 12.

Uganda will transition from an approach based on the World Health Organization's (WHO) Option A --- which is contingent on an HIV-positive pregnant woman’s CD4 count --- to WHO's newest PMTCT strategy, Option B+.

Option B+ — whereby HIV-positive pregnant women receive lifelong treatment, regardless of their CD4 levels — originated in 2010 when the Malawian government decided to combine antiretroviral therapy (ART) with PMTCT in response to the challenges of providing reliable CD4 testing in remote settings.

The WHO updated its PMTCT guidelines with Option B+ in April of this year.

Frieda Komba, a licensed drug dispenser in Tanzania. {Photo credit: MSH.}Photo credit: MSH.

Each year over 10 million men, women, and children in developing countries die as a result of our collective failure to deliver available safe, affordable, and proven prevention and treatment. A recent analysis of innovations in products and practices for global health, from the Hepatitis B vaccine to use of skilled birth attendants, revealed virtually none of these life-saving interventions reaches much more than half their target population—even after as many as 28 years of availability. This reflects a vast gap between knowledge and action in global health.

Successful Health Systems Innovations

Low- and middle-income countries (LMIC) benefit from continued innovations in health products and health practices, such as use of misoprostol to prevent post-partum hemorrhage, and technologies such as internet-based mHealth applications to protect the poor from catastrophic health expenditures.  To ensure such innovations achieve large-scale, widespread coverage, they must be accompanied by much more effective health systems innovations.

President William Clinton at Closing Session of AIDS 2012. {Photo credit: © IAS/Steve Shapiro - Commercialimage.net.}Photo credit: © IAS/Steve Shapiro - Commercialimage.net.

It's been nearly two weeks since former President William J. Clinton closed the last session of the XIX International AIDS Conference (AIDS 2012) and delegates returned home.

This year's conference featured commitment and calls for an AIDS-free generation, a growing interest in Option B+, and new research towards a cure.  Here are some reflections from what we learned at AIDS 2012, where we truly started "turning the tide together".

Clinton calls for a blueprint toward an AIDS-free generation

Secretary Hilary Rodham Clinton announced significant funding towards preventing mother-to-child transmission (PMTCT) of HIV, South Africa’s plan for voluntary medical male circumcision, and money for “implementation research,” civil society, and country-led plans. Sec. Clinton also called on Ambassador Eric Goosby to provide a blueprint for achieving an AIDS-free generation during her plenary address. Numerous other stakeholders echoed her commitment. But, if we really want to achieve an AIDS-free generation, the $7 billion funding gap that stands between where we are now, and where we should be, will need to be erased

{Photo credit: MSH, South Africa.}Photo credit: MSH, South Africa.

The prospect that we may see the end of AIDS in our lifetime has never been greater. Over the last decade, the global HIV & AIDS community has achieved stunning successes, including a steady decrease in new HIV cases, a massive scale-up of antiretroviral therapy (ART), and proof that treatment is prevention. As we begin the XIX International AIDS Conference, we are also excited by new scientific advances in prevention and treatment, such as Option B+  for prevention of maternal-to-child transmission (PMTCT). As new possibilities develop, we must also build on the successes of the last decade. Only by "turning the tide together" through the simultaneous pursuit of new possibilities, leveraging of proven interventions for scale and sustainability, and strengthening of health systems overall, can we hope to reach our goal of ending the HIV & AIDS epidemic.

AIDSChat 2012AIDSChat 2012

USAID and partners are hosting a Twitter chat in preparation for the 19th International AIDS Conference. The began at 10 am EDT and continues throughout the day.

Management Sciences for Health (MSH) will be co-hosting from 2:00 - 2:30 pm on the topic of prevention of mother-to-child transmission (PMTCT) of HIV with Scott Kellerman, MD, MPH, tweeting from .

Scott Kellerman, around age 5. {Photo courtesy of S. Kellerman.}Photo courtesy of S. Kellerman.

The prevention of mother-to-child transmission (PMTCT) of HIV is taking center stage this week during USAID’s 5th Birthday campaign -- and rightly so.  Preventing mother to child transmission of HIV is one of the most critical, effective tools to helping kids reach their fifth birthdays.

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