Transcript HIV and Infant Feeding:

Risk of mortality is greater among women
without access to hygiene, sanitation,water
RR of Infant Mortality by Feeding Mode and Health Environment
6
5.2
Relative Risk
5
4
3
2.5
2
1
1
0
Exclusive BF
no BF (with toilet
no BF (no toilet or
& piped water)
piped water)
Habicht et al., 1988
1
Percent of Total Population with
Access to Safe Water
100
80
60
Rural
40
Urban
20
Honduras
India
Tanzania
Nigeria
Malawi
Botswana
0
UNICEF, 2002
2
Percent of Total Population with
Access to Adequate Sanitation
100
80
60
Rural
40
Urban
20
0
Botswana
Malawi
Nigeria
Tanzania
India
Honduras
UNICEF, 2002
3
Feeding Options Currently
Recommended by WHO (1998)
• Breastfeeding
– exclusive breastfeeding
– heat-treated breast
milk
– wet-nursing
– milks banks
– early cessation of
breastfeeding (as soon
as feasible)
• Replacement feeding
– commercial infant
formula
– home prepared infant
formula (modified, with
additional nutrients)
– enriched family diet
with BMS/MN
supplements after 6
months
4
What do we know about the feasibility
of exclusive breastfeeding?
(BFHI/MCH/IMCI) -1
100%
% infants breastfed exclusively in previous 24 hours
@ 3 months
< 6 months
80%
@ 5 months
< 4 months
60%
40%
20%
Ba
ng
la
de
sh
ex
ico
M
Be
la
ru
s
Be
nin
r
ad
ag
as
ca
M
Gh
an
a
0%
Program
Control
5
EBF rates at 6 weeks - over time and after the
introduction of an education and counseling
program on safer breastfeeding practices in
Harare, Zimbabwe (n=9,931)
%
Education and counseling
intervention began
60
50
40
30
20
10
0
11/97 to
7/98 to
2/99 to
9/99 to
11/99 to
6/98
1/99
8/99
10/99
01/00
Study Period
ZVITAMBO data
6
Exclusive breastfeeding rates in
PMTCT programs with infant feeding
counseling - Barcelona AIDS abstracts
100%
87%
80%
59%
60%
42%
40%
31%
20%
0%
Zambia
South Africa
India
Botswana
Methodologies and ages at measurement varied
7
Methods used for measuring
exclusive breastfeeding produce
different rate estimates
n=970 mothers exposed to infant feeding counseling
Exclusive Breastfeeding at 3 months
50
40
30
20
10
0
31.7
14.1
Conditional
38.8
20.9
Ever
7 day recall
24 hr recall
Ever
ZVITAMBO data
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What do we know about the
feasibility of early/rapid
breastfeeding cessation? -1
Potential risks for
infant
• Dehydration
• Anorexia
• Later behavior
problems
• Malnutrition
• Illness or death
Potential risks for
mother
• Engorgement
• Mastitis
• Increased risks of
pregnancy
• Depression
• Stigma
• Possible reversion to
breastfeeding
Piwoz et al, 2002
9
What do we know about the feasibility of
early breastfeeding cessation? -2
Barcelona AIDS Conference
• Early, rapid cessation is possible (Uganda, Zambia,
Botswana)
• Problems encountered
– breast engorgement; mastitis; babies crying, trouble
sleeping, appetite loss, diarrhea; financial constraints with
replacement feeding; family objections
– more problems when cessation < 6 months (Botswana)
• Trained counselors were able to help mothers
overcome problems
• Provision of replacement feeds, family support
facilitated process
• Impact on HIV transmission, survival not yet known
10
% contribution of BM
Breast milk contributes > 50% of the
nutrient intake of children > 6
months in developing countries and
won’t be easy to replace
100
90
80
70
60
50
40
30
20
10
0
Energy
Protein
Calcium
Vitamin A Vitamin C
6-8 months
Folate
Zinc
9-11 months
Adapted from WHO, 1998; Dewey and Brown, 2002 using data from Bangladesh,
Ghana, Guatemala, Peru
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What do we know about the
feasibility of other breastfeeding
options?
• Heat-treated breast milk
– heating milk to 56-62.5 degrees C for 12-15 min
inactivates HIV in human milk (Jeffreys et al 2001)
– no data on feasibility of daily use from birth
– may be practical during transition period with early
cessation
• Use of wet nurse - no data
– monitoring HIV status of wet nurse a challenge
– practice may be less common because of HIV
• Milk banks - no data
– may be feasible in some settings (Brazil, LA Region)
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What do we know about the
feasibility of commercial formula?
• High acceptance/adherence in some countries with
access to clean water, health care, subsidized cost
– Thailand, Brazil, South Africa, Botswana
• Adherence with exclusive use may be higher than
for exclusive BF (Botswana)
• Stigma associated with its use widely reported in
Africa
• Access to safe water, health care needed
• Proper instruction on safe preparation, feeding
• Cost - > 6 months supply
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Formula use in selected programs
where provided free
100%
100%
98%
89%
80%
60%
46%
40%
33%
20%
0%
Brazil
Thailand
Botswana
Uganda
Cote
d'Ivoire
Barcelona AIDS Conference
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Uptake of Infant Formula in
PMTCT program sites in SA
100%
80%
60%
40%
20%
0%
W. Cape
Mpumalanga
Kwa Zulu
Eastern Cape
Natal
Peri/Urban
Rural
McCoy et al, 2002
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Evidence of Spillover?
Infant feeding patterns in PMTCT vs.
non-PMTCT sites in Botswana
(< 6 months, 24 hr recall)
EBF is lower, mixed feeding is higher in PMTCT sites
80%
70%
60%
50%
40%
30%
20%
10%
0%
P< 0.001
PMTCT: HIV-neg
mothers
Comparison: Status
unknown
Exclusive
BF
Use Infant Give other
Formula
fluids
MOH/UNICEF, 2002
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What do we know about the
feasibility of home prepared formula?
• Nutritional adequacy and cost studied in KwaZulu
Natal, SA
• Fresh and powdered full-cream milk
• Findings:
– intakes of vitamins E, C, folic acid, pantothenic acid <
33% of adequate intake (AI)
– intakes of zinc, copper, selenium, vitamin A < 80% AI
– intakes of EFA were < 20-60% AI
– cost was $9.80/month or 20% of average monthly income
– preparation time was 20-30 minutes for 120 ml
Papathakis et al, 2002
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Challenges for the Future
• Policy issues:
– Can we reframe the debate on breastfeeding versus
replacement feeding?
– What is the role of commercial infant formula?
• Implementation:
– How do we implement October 2000 guidance/scale up?
• Research:
– Risk analysis and counseling hampered by uncertainty
– Can breastfeeding or replacement feeding be made safer
for HIV+ women?
• Learning from ALL our experience
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Can we reframe our thinking and
discussion on this issue? -1
• Let’s talk about improving HIV-free
survival instead of reducing HIV
transmission
– reflects higher objective
– resolves conflicting strategies
• Let’s talk about reducing postnatal
transmission instead of HIV transmission
through breastfeeding
– more accurate
– less emotional
– less burdened with the weight of history
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Can we reframe our thinking and
discussion on this issue? -2
• Focus on maternal health & nutrition
– Keeping HIV+ mothers well may be among the most
important things we can do to prevent P/N transmission
– BF transmission was ~2% between 6 w-24 months in WA
study among women with CD4 >500 (Leroy et al, 2002)
– Nutrition depletion, weight loss during BF may increase
risk of maternal mortality (Nduati et al, 2001)
– Keeping mothers alive will improve child’s chances for
survival (Nduati et al, 2001)
– ARV use during BF now being studied
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Can we make breastfeeding safer for
HIV+ women? -1
• Enhance health/nutrition care for 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)
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Can we make breastfeeding safer for
HIV+ women? -2
• Assist families with 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 sizeable fraction of BF transmission
• Provide adequate nutrition after breastfeeding
ends
– appropriate breast milk substitutes and/or multi-nutrient
supplements should be provided to prevent malnutrition
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HIV-free Survivors
HIV and Infant Feeding Risk Analysis in
Setting where IMR=89/1000: Improving
maternal health & safer BF practices
1000
950
900
SBF+HM
850
RF
800
750
0
6
12
18
24
Age (months)
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during
delivery, healthy mother, EBF, lactation management (SBF+HM) reduces
postnatal transmission by 67%; IMR=89/1000
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HIV-free Survivors
HIV and Infant Feeding Risk Analysis in
Setting where IMR=100/1000: Improving
maternal health & safer BF practices
1000
950
900
SBF+HM
850
RF
800
750
0
6
12
18
24
Age (months)
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during
delivery, healthy mother, EBF, lactation management (SBF+HM) reduces
postnatal transmission by 67%;
24
HIV-free Survivors
HIV and Infant Feeding Risk Analysis in
Setting where IMR=135/1000: Improving
maternal health & safer BF practices
1000
950
900
SBF+HM
850
RF
800
750
0
6
12
18
24
Age (months)
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during
delivery, healthy mother, EBF, lactation management (SBF+HM) reduces
postnatal transmission by 67%;
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What is the role of commercial
formula for replacement feeding?
• It is the best option for RF if conditions can be met
– formulated specially for humans, nutritionally fortified
– safe water, access to health care, training in safe preparation,
feeding required to make it safe
– postnatal follow-up also required (monitor growth, ensure
adequate access/availability)
– cost will make it NOT affordable for poor families to purchase
– cost may make it NOT sustainable for governments
– Code of Marketing of BMS protects against misuse if
enacted/enforced
– But “spillover” may be unavoidable if BF support for HIVnegative and status unknown mothers is not adequate
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Can we make replacement feeding
safer for HIV+ women?
• Provide safe water & environmental conditions
• 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
• We must strengthen, not abandon, our efforts to
support optimal infant feeding for all because of
HIV. The need is even greater when PMTCT
programs provide infant formula to HIV+ women.
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Thank you
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