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					  HIV and Infant Feeding

       CARK Region Conference on
 Prevention of HIV Infection in Infants,
        Almaty March 1-3 2005

Dr. Arun Gupta MD FIAP
Regional Coordinator IBFAN Asia Pacific
    Outline of the Presentation

• Overview
• UN Goals and Guidelines
• Risk of transmission and some issues
• Experience from India, training materials
• Way forward
• Some challenges
  In 5 participating nations
Country                 EBF 0-6       I.M.R
• Turkmenistan          13            71
• Kazakhstan            36            61
• Tajikistan            14            53
• Uzbekistan            16            52
• Kyrgyzstan            24            52

                 Source : SOWC 2004
          Timing of Mother-to-Child
Early Antenatal                  Early Postpartum    Late Postpartum
(<36 wks)                        (0-6 months)        (6-24 months)

    Pregnancy       Labor and Delivery      Breastfeeding

    Late Antenatal
    (36 wks to labor)

      5-10%             10-20%                 10-20%

                                           Adapted from N Shaffer, CDC
MTCT in 100 HIV+ Mothers by
   Timing of Transmission

           Uninfected: 63

          Breastfeeding: 15
            Delivery: 15
             Pregnancy: 7
  Global Strategy for Infant
   and Young Child Feeding
• Adopted by the WHA and
  UNICEF Executive board in

• Recognises that 2/3
  deaths of annual
  10.9 million U-5
  deaths, occur
  during 1st yr. and
  are related to
  inappropriate feeding
Proportion of all < 5 yrs deaths that could be
prevented with infant feeding interventions


          Breastfeeding       Complementary            NVP+RF
     *Estimate would be 15%
     without effects of HIV
                                        Jones et al, 2003, Lancet
             Risks of artificial feeding
(in developing countries risks are elevated above these levels)

Increased levels of accute illness:
• Respiratory infections
• Middle ear infection: 3-4x risk
• Gastroenteritis: 3-4x risk (developing countries
• Bacterial infection requiring hospitalization: 10x
• Meningitis: 4x risk
• Higher mortality from sudden infant death
  syndrom (SIDS)
  Risks of Artificial feeding
Dose-related difference in mental development:
• Lower scores of mental development tests at 18
• Difference in mental development and school
  performance at 3-5 years
• Lower scores of prematures on intelligence tests
  at 7-8 years
• Deficits in neurological development (lack of
  essential fatty acids)
• Difference in visual acuity
               Risks …….
Effects on the health of mothers:
• Higher risk of impaired bonding, abuse,
  neglect and abandonment
• Increased risk of anemia due to early
  return of menstruation
• Increased risk of breast and ovarian
• Increased risk of new pregnancy
HIV/Infant feeding is about
   Assessing the risks
 Breastfeeding     Formula

     HIV         Mortality
    Unique global consensus
• 9 UN agencies ratified
  in 2003
• 5 priority actions,
  first being
  development of policy
  and plans for IYCF
  including HIV,
  promotion of exclusive
  breastfeeding for ALL
        UN Guidelines 2004

According to the UN
Guidelines, replacement
feeding choice be
supported by HIV positive
women when it is
acceptable, feasible,
affordable , sustainable
and safe for them.
Otherwise exclusive
breastfeeding during first
months is recommended.
Key elements on Infant Feeding
   in the European strategy
• Positioned firmly within the context of
  human rights
• Reiterating the UN recommendations
• Emphasis on counselling and support for
  the chosen option
• Interventions within the context of overall
  protection, promotion and support of
• Emphasis on Code and BFHI implementation
Risk of transmission and some issues
      Risk Factors For Postnatal
Mother                    Infant
• Immune/health status    • Breastfeeding duration
• Plasma viral load       • Non-exclusive BF
• Breast milk virus       • Age (first months)
• Breast inflammation     • Lesions in mouth,
  (mastitis, abscess,       intestine
  nipple lesions)
                          • Prematurity
• New HIV infection
                          • Infant immune response
• Viral Characteristics
                Risk Factor:
         Early Mixed breastfeeding
       Cumulative HIV transmission Durban, SA
 40                                        36
 30                              26
                            19                     EBF to 3 mo
% 20              16
                                                   Partial BF
 10       7   7

         Birth    3 mo      6 mo      15 mo

                                       Coutsoudis et al, 1999; 2001
                      Postnatal HIV Transmission
                       by Early Feeding Practices
  ZVITAMBO, Zimbabwe                                 (n=2055)

% HIV+ at 18 months


                       5    7

                           EBF   PBF    MBF           Total

                                               Piwoz et al., MoPpB2008
Feeding mode and Morbidity of children
       born to Women with HIV
Percent of children ill or hospitalized in the first two months


     30       26
                                                        Ever BF
 %                                        20
     20                                                 Never BF

     10                             3

               Illness           Hospitalization

                                               Coutsoudis et al, 2003
 Higher Rates of Hospitalization for Non-
 Breastfed Infants of HIV+ Mothers in a
      PMTCT Program in Pune, India

                                 BF              Non-BF

sample                           62                  86

hospitalizations                  0                 27*

deaths                            0                   4
*p<0.0001, no significant differences between BF and non-BF
for any other infant or maternal characteristics

                                           Phadke et al, 2003
         Global experience

A compilation
and review of
current global
evidence –
mostly “grey
     Mixed Feeding Before 6
• Although results differed across programs, most HIV-
  positive mothers ended up mixed feeding, often very soon
  after delivery, regardless of whether they chose to
  replacement feed or exclusively breastfeed initially
• Across cultures, there is great pressure to introduce other
  liquids or foods (often ritual) by two months or even earlier
• This issue needs wider Behaviour change focus
 Exclusive breastfeeding vs RF

• Both are a big challenge
• Aim at avoiding “mixed feeding”
• “World missing opportunity to reduce
  mother-to child HIV transmission
  through exclusive breastfeeding
  “….UNICEF Press Release
 Exclusive breastfeeding Vs RF
• As effective as RF in reducing MTCT
• New hope for countries where RF is not
  AFASS as increasing exclusive
  breastfeeding rates would in fact reduce
  infant HIV in general populations
• Exclusive breastfeeding is achievable may
  be up to 70% if not 100% (Macedonia,
  Armenia, and many countries have shown)
 Elements of PMTCT/PPTCT
• Voluntary and confidential HIV testing and
  counselling in routine antenatal care;
• Ensuring that ANC includes detection and
  treatment of sexually transmitted infections
  (STIs) and counselling on safer sex;
• Provision of prophylactic antiretroviral drugs to
  HIV-positive pregnant women and, in some
  regimens, to their babies;
• Safer obstetric practices;
• Counselling and support for informed decisions on
Attn: Counseling for IF options
• HIV positive women get adequate info on
  all options on breastfeeding or replacement
• Info: unbiased, accurate and individualized,
  it should be compatible with local cultures
  and her beliefs.
• Info alone is not enough , more efforts are
  needed to modify her behaviour, here
  comes role of counseling by health staff.
India experience
       Qualitative study
• Feasibility study reported that 70%
  women who chose RF return to „mixed
  feeding‟ in 2 weeks period.
• Counseling bias existed towards RF
• Where good IF counselling was made
  available, more women chose exclusive
          National action
• A colloquium on infant feeding and HIV
• Strong partnerships established with
  Government of India NACO, UNICEF and
• Led to several consultations and further to
  assessment of current status of counseling
  develop training for infant feeding options
       Assessment of
   VCCTC / PPTCT counselors

• None Knew about AAFSS
• None Knew 10 Steps of Successful BF
• None knew about national
  recommendation on optimal infant
      How did we address this
•   Combined the training modules of WHO/UNICEF on
    Breastfeeding(1998) and IF-HIV(2000) counseling, based on UN
    guidelines, updated including AFASS and exclusive breastfeeding.
    (Infant feeding and HIV Counselling course: 5-6 days)
•   Tested and prepared trainers ( existing set of trainers of
    breastfeeding counseling were chosen)
•   Trained all 54 counsellors of Delhi state having 11 centers of PPTCT
    ( 15 million population)
•   Added complementary feeding (3rd WHO/UNICEF course 2002)
•   3 in 1 course has been now ready and trainers are available , 7 days
    instead of 11 days.
    (6 days are needed additionally to prepare trainers)
Way forward
Key action for decision makers

• A national level colloquium to address
  this problem and build consensus
  among various partners, and share
  new information to plan ahead.
• And Assessment process can then
                   Key action….
Situation Assessment and analysis
   – Policy development addressing IF&HIV
   – Implementing the CODE
   – Prevention of HIV aims at women and children
   – Current programmes on breastfeeding for ALL babies
   – Does clarity exists on integration of counseling of HIV & IF in
   – Has the costs been calculated
   – Training materials, job aid available for health workers
   – Are woman provided counseling
   – Is there sufficient capacity to undertake this task
 Actions to strengthen existing
• CODE implementation:
   – Takes out baby food manufacturers out of programme
   – takes care of accurate unbiased information
   – it is for ALL babies and mothers,
   – Ensures independent research free from commercial interest
• BFHI : cans set standards of care and opportunity for
   – VCCT
   – Training facility for counsellors
   – Counselling on all feeding options
  Strengthen approaches for making
 breastfeeding safer for ALL women
• Provide adequate lactation counseling and support,
  involving families/communities
   – increase adherence to exclusive breastfeeding

   – promote good breastfeeding techniques
   – prevent cracked nipples, maintain breast health

• Immediate treatment for mastitis, other systemic
  infections that could affect viral load in BM
   – could prevent a sizeable fraction of BF transmission
   – may be most important in early month(s)

• Safe sex/condom use for prevention
 Make breastfeeding safer for HIV+
• Assist families with decisions about early
  breastfeeding cessation
   – assess health status of mother and infant
   – prepare for the process so that the transition is safe
     (cup-feeding, safe preparation/hygiene, stigma)
   – heat treat breast milk if weaning is gradual

   – could prevent ½ to ¾ of BF transmission

• Provide adequate infant nutrition after
  breastfeeding ends
   – appropriate breast milk substitutes and/or multi-nutrient
     supplements should be provided to prevent malnutrition
 Make replacement feeding safer for
            HIV+ women
• Provide safe water & environmental conditions
   – rural and urban areas may vary

• Family support, community understanding
• Postnatal follow-up and enhanced care
   – essential child health interventions

• Screen mothers, target use to those most at risk
• Take measures to prevent unnecessary use of RF
   – need to strengthen efforts to support optimal infant
     feeding for all
Some challenges
• HIV testing capacity -counseling on RF not
  possible without mother’s testing and knowing
  her status.
• Balancing risk of not breastfeeding vs risk of
  HIV from BF ->the role of BF in child survival
  in adverse conditions
• Prevention of ‘spillover’
• Increasing exclusive breastfeeding rates
• Replacing BM in infants’ diet. BF contributes
  100% nutrient needs of up to 6mos, 50% to
  1yr; and 35% up to 2yrs!
Identifying RF that is available and can meet the
  nutritional needs of baby, meets all AFASS
  conditions and avoids spillover effects to the
  majority of children.
Formative research and direct observations of
  homes in both rural and urban settings helps
  answer this, incl. discussions with mothers
Quality counselling is very important especially for
 infant feeding as poor counselling may lead to
 mixed feeding resulting in greater risk of HIV
 transmission via BF
• Capacity for follow up of HIV positive mothers,
  whether exclusively breastfeeding or exclusively
  artificially feeding/nutrition support/breast
  care/primary prevention!
• Monitoring and evaluation: Many programmes suffer
  from lack of M/E providing no or little evidence of
  health effects and benefits/impact of the different
  options, and extent of spillover.
• Ensuring Human Rights are not cast aside but rather
  embedded in legal frameworks
Thank you !