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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