Curiculum vitae

Dr. Anggraini Alam, dr., SpA(K)

Consultant in Infection & Tropical Diseases,

Child Health Department, Faculty of Medicine
Universitas Padjadjaran/Hasan Sadikin General Hospital

Education:
MD, Pediatrician, and Doctor graduates from Faculty of Medicine Universitas Padjadjaran
Pediatric Consultant of Infection & Tropical Medicine from Indonesian Pediatric College 2011

Organization:
Head of Working Group of Infection & Tropical Diseases of Indonesian Pediatric Society (IPS)
Board Member of Indonesian Pediatric College
Board Member of Asia Society of Pediatric Infectious Diseases (ASPID)
Expert Committee of Diphtheria in Ministry of Health
Expert Committee of HIV/AIDS in Ministry of Health
Secretary of Internal Advisory of IPS West Java Branch
Member of COVID-19, HIV, and Pharmacy Task Force of IPS
Member of Infection Control, AMR, HIV/AIDS, and Outbreak Response (COVID-19) in Hasan
Sadikin GH

Anggraini Alam
Does U equal U in prevention of mother
to child transmission of HIV?

Anggraini Alam
Dep. IK Anak FK Univ. Padjadjaran/RSUP DR. Hasan Sadikin
Satgas HIV IDAI

Anggraini Alam
 UNAIDS data 2019
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 Case: HIV positive (BF 88%)
Control group were HIV negative children with HIV positive mother (BF
52%)
Breastfeeding is an important risk factor in HIV transmission from
mother to child, when mothers had had no ARV therapy.

Anggraini
Anggraini Alam, et al. American Journal of Pediatrics. 2016; 2(4):Alam
15-18
 PMTCT
ART

SC

Mother ARV
Nutrition: EBF/FF
Infant prophylaxis

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Data Indonesia

Data:
- World Bank PLH= 18.000
- Data yang dilaporkan Kemenkes
0-18 tahun = 1203

Anggraini Alam UNAIDS data 2018

World Bank 2019
Perlu effort untuk mencapai
90 90 90 di Indonesia
Anggraini Alam
UNAIDS 2019
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Mengapa WHO memberikan
alternatif pemberian ASI?

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 Penelitian yang
digunakan untuk
menyusun
Guideline WHO

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 Hasil Systematic Review 2009

• Resource-rich countries:
– mothers with HIV infection are counseled not to breastfeed their children, and
there are feasible and affordable alternatives to breastfeeding
• However, in parts of the world where the vast majority of mothers with
HIV infection live, complete avoidance of breastfeeding is often not
feasible (for example, because of the lack of availability of clean water
and of affordable replacement feeding).
– interventions to prevent transmission of HIV infection through breast milk are
urgently needed by EBF instead of mixed feeding (feeding the baby other
liquids or solids)

Anggraini Alam
Horvath T, et al. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006734.
Anggraini Alam
 Pemberian ART pada seluruh Ibu Hamil
• use of zidovudine (AZT) from 14 weeks’ gestation, single-dose nevirapine
(NVP) at birth, and 7 days of AZT/ lamivudine (3TC) postpartum for the
mother; and daily NVP for the infant until the cessation of breastfeeding or

Opt A until 4 - 6 weeks of age if the mother is receiving antiretroviral therapy (ART)
or is not breastfeeding

• ART for the mother from 14 weeks’ gestation until birth or the
cessation of breastfeeding, and the use of NVP for the infant until 4 -
Opt B 6 weeks of age.

• a prevention of vertical transmission approach for expectant

mothers living with HIV in which women are immediately offered
treatment for life regardless of their CD4 count (lifelong ART),
Op B+ and the use of ARV for the infant until 6 weeks of age.

Anggraini Alam
Studies of Breastfed Infants whose
Mothers were on ART

Studi
di Afrika dan India

Chikhungu L, Bispo S, Newell ML

Anggraini Alam Mallampati D, MacLean R, Ciaranello A.
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 Hasil Penelitian: tetap ada bayi yang terinfeksi
walaupun Ibu HIV telah dipersiapkan dengan baik
Anggraini Alam
 Mother on ARV
+ breastfeeding

When baby become HIV+

Drug Resistance (ARV) in the Baby
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 Alasan Pemberian ASI
Qualitative study of mothers with HIV in Canada
(negara maju):
– Social,
– Cultural
– Emotional factors
– Concerns about HIV-related stigma. 4

• Some women, especially those from a country or cultural

background where breastfeeding is the norm, fear that not
breastfeeding will lead to disclosure of their HIV status.

Ibu disiplin minum ART à Undetectable pada plasma

Anggraini Alam
 U = U is sometimes wrongly
interpreted as covering all ways
that HIV can be transmitted.

Note:
U = undetectable
U - untransmittable
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Why U = U does not cover
breastfeeding?

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 Possible reasons for risk not becoming zero
• High lifetime exposure volume
compared to sexual fluid: 3-4
cups of milk a day is 150 litres
over six months.
• Breast milk is likely to include 1
million immune cells/day and 150
million over six months
• Breast milk induces immune
activation and HIV replication is
10-fold higher in milk vs blood.
• Cell-associated HIV DNA persists
on ART and latently infected
resting cells are transmitted (and
then activated) in milk.
• Breast inflammation can activate
HIV (mastitis, abscess,
engorgement etc).
• Great immune vulnerability in
infant GI tissue.
• Adherence difficulties
postpartum (erratic sleep,
depression, support) are well
documented in all settings,
including high-income countries

Breastfeeding starts off with a much higher risk of transmission because the infant is
exposed to far higher amounts of infectious fluid.
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• Characteristics of breast milk lymphocytes: human milk content highly immunologically
active components designed to protect the mother-infant from potential pathogens.
• Nevertheless, some of the same cells that provide these functions are ideal targets for
HIV-1 infection and transmission
Anggraini Alam
P. Van de Perre, et al. Sci. Transl. Med. 4, 143sr3 (2012)
• HIV-1–secreting CD4 T cells in breast milk, which can be detected in
+

vitro by their HIV-1 antigen or HIV-1 RNA production

– are source of HIV-1 transmission by breast-feeding from women
successfully treated with ARV regimens
Anggraini Alam
P. Van de Perre, et al. Sci. Transl. Med. 4, 143sr3 (2012).
 a positive correlation between breastmilk HIV-1 RNA and DNA and
maternal antenatal plasma viral load

Anggraini Alam
Ndirangu J, et al. PLoS ONE 2012. 7(12): e51493. doi:10.1371/journal.pone.0051493
• Virologic status in breast milk correlated strongly with plasma
• Transmission risk to be 3.8 times higher among women with
detectable (>40 copies/mL) compared to non-detectable levels
of HIV RNA in breast milk
• But, recommended target threshold for virologic suppression
in breast milk has not yet been established.

Anggraini Alam
Chan M, et al. PLoS ONE. 2019, 14(5): e0216252.
 Cell-associated virus levels have been consistently
detected in breastmilk despite antiretroviral therapy

this highlights a potential challenge for

resource-limited settings to achieve the
UNAIDS goal for 2015 of eliminating vertical
transmission.

Anggraini Alam
 Mengapa WHO
menganjurkan
pemberian ASI?

Anggraini Alam
 Context: low- vs high-income settings
In low-income settings
• with limited access to clean
water, formula feed and
medical care the
recommendation to
breastfeed on ART means:
– the positive benefits from
breast milk in fighting
malnutrition, diarrhoea and
pneumonia outweigh the low
risk of HIV transmission.
In high-income settings
• the rates of infant mortality
from background health
risks are much lower:
– the recommendation to use
formula feed has the best
outcome in terms of infant
health and the higher risk
comes from HIV via
breastfeeding.

The US recommendations on perinatal HIV transmission emphatically state

that women with HIV should avoid breastfeeding to prevent mother-to-child
transmission of HIV because
Anggraini Alam the risk is not zero
 AS minta Organisasi Perdagangan Dunia (WTO)
untuk mencabut Indonesia dari daftar negara berkembang

Albania; Argentina; Armenia; Brazil; Bulgaria; Tiongkok; Kolumbia; Kosta Rika; Georgia; Hongkong; India;
Kazakhstan; Republik Kyrgyzstan; Malaysia; Moldova; Montenegro; Makedonia Utara; Rumania;
Anggraini Alam
Singapura; Afrika Selatan; Korea Selatan; Thailand; Ukraina; dan Vietnam.
 Linkage to HIV treatment and care services was
poor in several countries, particularly Afghanistan
and Indonesia, where more than half of the people who knew
they were living with HIV were not accessing antiretroviral
therapy in 2018

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 Data Indonesia
Coverage of early infant diagnosis is similarly uneven,
ranging from more than 90% in Malaysia, Singapore and
Thailand to extremely low levels in Afghanistan,
Indonesia, Pakistan and the Philippines

Anggraini Alam UNAIDS data 2018

World Bank 2019
 the first countries validated for EMTCT – Cuba, Thailand, Belarus,
Republic of Moldova (syphilis only) and Armenia (HIV only), as well as
the next six countries and territories
of Anguilla, Montserrat, Cayman Islands, Bermuda, Antigua and
Barbuda, and StAnggraini
Christopher
Alam and Nevis
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Systematic reviews used to develop the guidelines

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Malaysia

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 Pemberian PASI
kepada bayi
dari Ibu HIV+

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