HIV Exposed Infant feeding recom

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					                              Infant Feeding and
                               HIV transmission

Dr Jagdish Chandra, MD,FIAP
Prof of Pediatrics
LHMC & KSCH, New Delhi
90-95 % new infections in children
        result from PTCT
        Perinatal transmission
  Estimated 2.4 million HIV infected mothers give
     birth annually

  1600 HIV infected babies are born every day

  > 80% of them in resource constrained countries

       No/ limited availability of HAART

       No effective PTCT prevention programs in place

Delhi : 150,000 deliveries annually, 0.3 % HIV rates would mean 4500
      HIV exposed babies annually; 30 % transmission means
                           1350 HIV infected
            Timing of PTCT

    7        9        7                    6
                     early                Late
Pregnancy   Labour
                          Postnatal /
Factors affecting transmission through BF

       Status of maternal disease
       Duration of breast feeding
       Exclusive vs mixed feeding
       Breast conditions
       Breast milk characteristics
       Infant conditions
Factors affecting breastfeeding

     Maternal factors:
        Advanced disease - low CD 4+counts - increased
         viral load in breast milk
        Recent infection
        Breast abscess/ Mastitis / Subclinical mastitis
            Ingestion of inflammatory cells
            Increased viral load
        Nipple lesions: sores and cracks
     Infant:
        Oral candidiasis < 6 months
        Male gender ?
Iliff et al AIDS 2005
Factors affecting breastfeeding

 Characteristics of breast milk:
    Lower conc. of lactoferrin, lysozymes, epidermal
     growth factor, IgM, IgA increase the risk
 Duration of breast feeding
      0.7 % / mo for 1-6 mo
      0.6 % / mo for 6-12 mo
      0.3 % / mo for 12-18 mo
      0.2 % / mo for 18-24 mo
Iliff et al AIDS 2005
What to do regarding feeding of
infants of HIV + ve mothers ?
HIV infected infant

  HIV infected infant should
   receive breastfeeding
Infants status not known (HIV exposed)
or non-infected

 To have HIV free and healthy child
  Not giving breastfeeding at all
       Giving exclusive replacement feeding (ERF)
  Giving exclusive breastfeeding (EBF) and
   making it safer:
   Giving breastfeeding for shorter duration
   Giving EBF and ART
         • To infant
         • To mothers and infants both
   Expressed heat treated breast milk feeding
   Wet nursing

 In developed countries
  Recommendations are to avoid all breastfeeding by HIV
    +ve mothers

 For developing countries ??
1990s: WHO
    Advantages of breastfeeding far outweigh the
     increased risk of HIV transmission through
    HIV +ve women in resource constraint countries
     should continue breastfeeding their infants
2000: WHO
    Exclusive replacement feeding (ERF) is
     recommended if AFASS,
    If ERF is not AFASS, EBF is recommended for initial
     6 months or less
NACO Recommendations :Nov 2006

 Where exclusive replacement feeding is AFASS-
  acceptable, feasible, affordable, sustainable and
  safe, avoidance of all breast feeding is
 In case replacement feeding is not possible,
  exclusive breast-feeding for first six months of
  life is recommended (not longer than 6 mo)
 Acceptable : Mother perceives no problem in accepting
  replacement feeding, even taking into consideration the stigma

 Feasible : Mother has adequate time, knowledge, skills, resources,
  and support to prepare milk and feed up to 12 times/ day

 Affordable : Mother and family, with community support can bear
  the costs without harming the health and nutrition of family

 Sustainable : Availability of a continuous supply of all ingredients
  needed for safe replacement feeding for up to one year or more

 Safe : Replacement feeds are correctly and hygienically prepared
NACO Recommendations :Nov 2006

 When the child is six months or earlier, breast-feeding
  should be stopped within two weeks while ensuring
  comfort level of both mother and infant
 At the same time good quality complementary food
  should be introduced ensuring adequate amount of
  energy, proteins and micronutrients
New relevant literature:
 Suryavanshi N et al. J Nutr 2003;133:1326-31. (Pune)
    101 HIV +ve women interviewed 2 wks postpartum
    Intended to breastfeed 44%
    Intended to give exclusive replacement feeding (ERF) 44%
    Mixed feeding actually occurred 29% (75 % till 3 days
    Time immediately post delivery most critical for counseling
    Reasons for breast feeding:
        Lack of funds
        Poor hygienic conditions
        Risk of social repercussions
New relevant literature:
 Replacement fed infants born to HIV +ve mothers
  have high early postpartum rates of hospitalization
  Phadke et al. J Nutr 2003;133: 3153-57.
   148 mother infant pairs
   42 % EBF
   58 % ERF, primarily diluted cow’s milk
   21 (14.2%) required hospitalization within first six
    months, all from ERF group
   Comparative rates of hospitalization
     ERF 21/ 86 (24 %)
     EBF 0/62 (0 %)
Phadke et al. J Nutr 2003;133: 3153-57.

Indications for hospitalization
      GE                 48.1 %
      Pneumonia          18.5 %
      Septicemia         11.1 %

 Conclusion: in settings like India, where access to safe
  replacement feeding is limited, interventions “making
  EBF safer” are needed
HIV exposed infants: KSCH data
 61 exposed infants, median age 8.5 mo
      Ex replacement Feeding            50
      Ex breast-feeding                 06
      Mixed feeding                     05
  Hospitalization:         20 infants needed 29
      EBF                               10 (166.6%)
      ERF/ mixed feeding                19 (34.5%)
  HIV inf rate:
      EBF                               5 (85 %)
      ERF/ mixed                        1/16 (7%)
 New relevant literature:
 Mashi study (Botswana):
  Thior et al JAMA 2006;296:794-805.
    All mothers received ZDV from 34 wks gestation
    Infants randomized to receive SD-NVP or placebo
    Further randomized to
       6 months BF + ZDV, or
       FF + 1 month ZDV
    Evaluated at 7 and 18 months
    Results:
       Infants evaluated       1179
       7 mo HIV inf rate       9% BF gp vs 5.6 % FF gp (p =.04)
Exclusive breast-feeding vs mixed
 Coovadia et al, Lancet 2007;369:1107-16.
     n=1132 infants born to HIV +ve mothers
     By 6 mo, 19.5% babies were infected
     More chance:
          • When CD 4+ counts < 200/ mm3 (HR 3.79, 2.35-6.12)
          • If babies also recd. formula (HR 1.82, 0.98-3.36)
          • If babies also recd. solids (HR 10.87, 1.51-78.00)

   Presence of complex proteins causing mucosal damage resulting in
    increased permeability to virus
Decreasing duration of breastfeeding:
Is it feasible?
Early cessation of breast feeding:

Increased risk of diarrhea related
 hospitalizations if BF stopped at 6 mo vs
 continued BF
       • KiBS study 2007, PEPI study 2007
Increased overall and diarrhea related
       • PEPI study 2007
Doubling of GE hospitalizations in 3 mo
 following cessation of BF
       • HIVIGLOB study 2007
New relevant literature: summary
 EBF carries a lower risk of HIV transmission than
  mixed feeding
 The risk with mixed feeding with formula milk or solids
  is substantially more than risk from adding water or other
  non-food fluids
 Duration of six months EBF also applies to HIV infected
  women who chose this option as RF is not AFASS
 Benefits of shortening EBF period in terms of HIV
  transmission are unlikely to overcome the risk of
  increased morbidity and mortality
New WHO (IATT) recommendations:
based on 2000, and 2006 technical consultations

Based on:
  2000 guidelines
  Information on increased morbidity on RF from
   India, Africa and other countries
  Information on increased diarrhea morbidity in
   the months following stopping BF
  Information on impact of early cessation of BF
   on nutritional status of infant
New WHO (IATT) recommendations:
based on 2000, and 2006 technical consultations

Most appropriate infant feeding option
 depends on individual circumstances
  Mothers health
  Local situations
  Health services available
  Counseling and support available
New WHO (IATT) recommendations:
based on 2000, and 2006 technical consultations

EBF is recommended for the first six
 months of life unless RF is AFASS before

•Earlier recommendation:
Where exclusive replacement feeding is
AFASS-avoidance of all breast
feeding is recommended
New WHO (IATT) recommendations:
based on 2000, and 2006 technical consultations

 When replacement feeding is AFASS
  avoidance of all breast feeding is recommended
 At six months if RF is still not AFASS, continuation of BF
  with additional complementary foods is recommended,
  while mother and baby continue to be regularly
  assessed. All BF should stop once a nutritionally
  adequate and safe diet without breast milk can be
Making breastfeeding safer:
 Mothers who chose to breastfeed their infants should be
  advised for exclusive breastfeeding
 Mixed feeding must be avoided under all
 Mother should practice good breastfeeding techniques
  and should have access to counselor skilled in infant
 Breast conditions like mastitis, sore-nipple and
  abscess should be recognized and promptly managed.
Making breastfeeding safer:

Mother should follow safe sex practices
 and avoid other high risk behaviour to
 prevent re-infection throughout the period
 of breastfeeding
  Avoid oronasal suction at the time of birth
  Oral ulcers or candidiasis of infant should be
   looked for and promptly treated
Making breastfeeding safer:

Mothers should be advised for their own
 health and nutrition and seek medical help
 if need arises
  Mothers should be evaluated for eligibility for
   HAART in the post-partum period
    - In view of emerging evidence, extended
      ARV prophylaxis to infant and/or mother
      should be considered for preventing
      postnatal transmission of HIV
Making breast-feeding safer (Infant ART)

  JAIDS 2008; 48:315-323 (Mitra study)
  398 infants of HIV + ve mothers
    Mothers recd ZDV + Lam from 36 wks gestation
    Infants: ZDV+ lami for 1 wk
           Lami upto 2 wks after stopping breast feeding at 6 mo
    HIV infection rate:
       • 3.8 % by 6 wks
       • 4.9 % by 6 mo
    HIV inf rate 50 % compared to concomitant PETRA
    Significantly lower inf in mothers with CD 4 counts
     >200/ mm3
Making breast-feeding safer (Infant ART)

  Lancet 2008; 372: 300-313 (SWEN study)
    Multicenter, including India
    Mothers recd NVP-SD during labour
    Babies recd NVP-SD(1047) or for 6 weeks (977)
    6 weeks inf rate 2.5 % in extended group and 5.15 %
     in SD gp (RR 0.54; 0.34-0.85)
    6 mo infection rate 6.3 % in extended gp and 8.3 %
     in SD gp (RR 0.8; 0.58-1.1)
  Conclusion: Benefit of extended dose only for
   short duration
Vitamin A supplementation:
  VAD has been linked to increased MTCT
  Mother and/ infant vit A administration may
   decrease MTCT
  Chochrane database review 2005:
    4 trials involving 3033 HIV +ve women
    No e/o vit A administration on MTCT (OR 1.14; 0.93-
    In one trial, risk was increased (OR1.53; 1.14-2.04)
Vitamin A supplementation:
 Am JCN 2005;81:454-60.
   14110 mother-infant pair to study infant mortality
   Randomized to receive vit A supple- mother &/or infant
   HR –m-supple-1.17 (0.87- 1.58)
   HR- n-supple-1.08 (0.8-1.46)
   Conclusion: vit supple may not reduce infant mortality
 J Inf Dis 2006;193;860-71
   4495 mother-infant pair
   Randomized to receive vit A supple- mother &/or infant
   Conclusion: vit A suppl. Did not reduce MTCT or deaths
    at 24 mo
      Thank you
for being an attentive audience