Transcript Title
Update on HIV and infant
feeding
Peggy Henderson and Constanza Vallenas
Department of Child and Adolescent Health and
Development, WHO
Rome, 25 February 2007
UN Recommendations
HIV- women or HIV status unknown
Exclusive breastfeeding for 6 months and continued
breastfeeding for 2 years or beyond
HIV+ women
Most appropriate infant feeding option for HIV-exposed
infant depends on individual circumstances, including
consideration of health services, counselling and support
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Selecting an option:
AFASS
To be a better option for the individual than exclusive breastfeeding,
replacement feeding has to be AFASS:
Acceptable
Feasible
Affordable
Sustainable AND
Safe
For the mother and baby
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Balancing risks
for HIV-positive women
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HIV transmission
Mortality
Infectious diseases
Malnutrition
IF BREASTFEEDING
IF NOT
BREASTFEEDING
Balancing risks - 1
HIV transmission
Risk of HIV transmission with full package of MTCT
prevention Interventions
(HAART, replacement feeding, caesarean section)
< 2%
Risk of HIV transmission through breastfeeding:
Exclusive breastfeeding (6 weeks – 6 months)
Breastfeeding as usual (varying duration)
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~ 4%
5 to 20%
Balancing risks – 2
Relative risk of infectious disease mortality
among non-breastfed infants
7
Relative risk
6
5.8
5
4.1
4
3
2.6
1.8
2
1.4
1
<2 m
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2 - 3 m
4 - 5 m
6 - 8 m
Age (months)
WHO Collaborative Study Team, Lancet, 2000
9 - 11 m
Balancing risks – 3
Mixed feeding carries higher risk of HIV transmission
than exclusive breastfeeding
13
Hazard ratio
11
9
7
5
3
1
BF+formula
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Coovadia et al., Lancet, in press
BF+solids
EBF
Balancing Risks - 4
No Difference in 18-Month mortality/HIV infection
between Formula and Breastfed Infants
30%
% HIV-Infected or Dead
Formula
p=0.60
20%
p=0.86
p=0.08
10%
FF: 33 infected, 62 deaths
BF: 53 infected, 48 deaths
Breast + AZT
12.5% 12.9%
13.9%
8.9%
6.1%
0%
1 Month
7 Months
18 Months
Infant age
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15.1%
Thior et al., JAMA, 2006
Supporting a mother to choose and implement
an option:
Before delivery and in the first months
Counselling based on broad definition of AFASS for her
and her baby
2 main options (replacement feeding and exclusive
breastfeeding for 6 months), with other local options
discussed only if mother interested
Support for choice
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High EXCLUSIVE breastfeeding rates
achievable with good quality counselling and support
Median duration of
EBF = 159 days
% exclusively breastfed
100
80
81.90%
60
66.50%
40
40.10%
20
0
6 weeks
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Coovadia et al., Lancet, in press
≥ 3 months
Age
6 months
Emerging evidence
Early BF cessation associated with increased morbidity
and mortality in HIV-exposed infants
Providing free infant formula from birth does not
necessarily lead to better HIV-free survival compared to
EBF
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Infant infections by feeding mode
HR
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p
95% CI
EBF
1.0
BM + fluid
1.56
0.308
0.66-3.69
BM + solids
10.87
0.018
1.51-78.00
BM+FF (@12wks)
1.82
0.057
0.98-3.36
EBF
1.0
MBF pre-3/12
1.54
0.011
1.10-2.15
MBF post-3/12
1.53
0.021
1.07-2.20
Vertical Transmission Study, in Press
Emerging evidence
HIV-positive infants benefit from continued BF
Availability of health system support important in
assessing AFASS
Severity of disease in mother important, but AFASS
criteria still more critical
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Emerging evidence
● Improved adherence, longer duration of exclusive breastfeeding
achieved in HIV-infected and HIV-uninfected mothers given
consistent messages and frequent, high quality counselling
● Not enough evidence re ARVs and breastfeeding to draw firm
conclusions, but HIV-infected mothers who need ARVs should
have them
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Supporting a mother
at key decision points in first months
If mother breastfeeding:
Early testing (PCR):
Baby HIV-negative: replacement feeding if AFASS
Baby HIV-positive: continue breastfeeding
Improvement in financial/social/support situation: re-assess AFASS
to consider replacement feeding
Mother on ARVs: Risk of transmission low, but replacement feeding
if AFASS
Continued support for choice for all mothers
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Supporting a mother when practices
change at 6 months
If still breastfeeding:
if other milks, animal source-foods available – cease all breastfeeding
and give other foods
no such foods available – risk of mixed feeding for a few months
probably less than risk of severe malnutrition
If breastfeeding already stopped:
Continue with milk of some kind and complementary foods
Continued support for choice
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Implications for scaling-up in countries
Good quality infant feeding counselling and support for mothers
(training, motivation, supervision)
Protection, promotion and support for infant feeding for all women
to help HIV-positive women who breastfeed
Where breast-milk substitutes provided, safe and appropriate use
and prevention of spillover
Link infant feeding with effective reproductive and child health
services
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Updating guidance
Consensus Statement from 2006 Technical Consultation (new
evidence and experience, updated recommendations
Full consultation report (1st quarter 2007)
Update of Review of transmission (1st quarter 2007)
Technical update (2nd quarter 2007)
Minimal revision of existing tools (as reprinted)
Complete revisions when more evidence on ARVs and
breastfeeding available (~2008-9)
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THANK YOU
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