Transcript HIV and Infant Feeding Regioanl Workshop on prevention of

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
developed
• 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
Transmission
Early Postpartum
(0-6 months)
Early Antenatal
(<36 wks)
Pregnancy
Labor and Delivery
Late Postpartum
(6-24 months)
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
100
80
Uninfected: 63
60
40
Breastfeeding: 15
20
0
Delivery: 15
Pregnancy: 7
Global Strategy for Infant
and Young Child Feeding
• Adopted by the WHA and
UNICEF Executive board in
2002
• Recognises that 2/3
deaths of annual
10.9 million U-5
deaths, occur
during 1st yr. and
are related to
inappropriate feeding
practices
Proportion of all < 5 yrs deaths that could be
prevented with infant feeding interventions
15
10
13
*
6
5
2
0
Breastfeeding
*Estimate would be 15%
without effects of HIV
Complementary
Feeding
NVP+RF
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
17-25x)
• Bacterial infection requiring hospitalization: 10x
risk
• 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
months
• 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
cancer
• Increased risk of new pregnancy
HIV/Infant feeding is about
Assessing the risks
Breastfeeding
HIV
Formula
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
babies
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
breastfeeding
• Emphasis on Code and BFHI implementation
Risk of transmission and some issues
Risk Factors For Postnatal
Transmission
Mother
Infant
• Immune/health status
• Breastfeeding duration
• Plasma viral load
• Non-exclusive BF
• Breast milk virus
• Age (first months)
• Breast inflammation
(mastitis, abscess,
nipple lesions)
• Lesions in mouth,
intestine
• New HIV infection
• Viral Characteristics
• Prematurity
• Infant immune response
Risk Factor:
Early Mixed breastfeeding
Cumulative HIV transmission Durban, SA
40
36
35
30
25
% 20
15
10
5
26
24
16
7
25
EBF to 3 mo
19
Partial BF
7
0
Birth
3 mo
6 mo
15 mo
Coutsoudis et al, 1999; 2001
Postnatal HIV Transmission
by Early Feeding Practices
% HIV+ at 18 months
ZVITAMBO, Zimbabwe
(n=2055)
15
14.7
10
5
7
12.8
8.7
0
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
50
40
40
%
30
26
Ever BF
20
Never BF
20
10
3
0
Illness
Hospitalization
Coutsoudis et al, 2003
Higher Rates of Hospitalization for NonBreastfed Infants of HIV+ Mothers in a
PMTCT Program in Pune, India
BF
Non-BF
62
86
hospitalizations
0
27*
deaths
0
4
sample
*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
programme
evidence –
mostly “grey
literature”
Mixed Feeding Before 6
Months
• Although results differed across programs, most HIVpositive 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
feeding
Attn: Counseling for IF options
• HIV positive women get adequate info on
all options on breastfeeding or replacement
feeding.
• 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
breastfeeding
National action
• A colloquium on infant feeding and HIV
• Strong partnerships established with
Government of India NACO, UNICEF and
others.
• 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
feeding
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
begin
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
services
– 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
approaches
• CODE implementation:
– Takes out baby food manufacturers out of programme
implementation
– 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
action
– 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+
women
• 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
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!
Challenges
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
Challenges
• 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 !