Presentation on theme: "Update on HIV and infant feeding"— Presentation transcript:
1 Update on HIV and infant feeding Peggy Henderson and Constanza VallenasDepartment of Child and Adolescent Health and Development, WHORome, 25 February 2007
2 UN Recommendations HIV- women or HIV status unknown Exclusive breastfeeding for 6 months and continued breastfeeding for 2 years or beyondHIV+ womenMost appropriate infant feeding option for HIV-exposed infant depends on individual circumstances, including consideration of health services, counselling and supportIf a woman is HIV-negative or does not know her HIV status, then the general public health recommendation on infant and young child feeding shown at the top of this slide applies. However, given the need to avoid transmission from HIV-positive women to their infants while at the same time avoiding putting them at increased risk of other morbidity and mortality, UN guidelines state that “when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life, and breastfeeding should be discontinued as soon as conditions are in place, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding."To help HIV-positive mothers make the best choice, they should receive counselling that includes information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option for their situations.
3 Selecting an option: AFASS To be a better option for the individual than exclusive breastfeeding, replacement feeding has to be AFASS:AcceptableFeasibleAffordableSustainable ANDSafeFor the mother and baby
4 Balancing risks for HIV-positive women HIV transmissionIF BREASTFEEDINGMortality Infectious diseases MalnutritionIF NOT BREASTFEEDING
5 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) ~ 4%Breastfeeding as usual (varying duration) 5 to 20%
6 Balancing risks – 2 Relative risk of infectious disease mortality among non-breastfed infants 5.8Relative risk126.96.36.199.4Age (months)WHO Collaborative Study Team, Lancet, 2000
7 Balancing risks – 3 Mixed feeding carries higher risk of HIV transmission than exclusive breastfeedingHazard ratioCoovadia et al., Lancet, in press
8 Balancing Risks - 4 No Difference in 18-Month mortality/HIV infection between Formula and Breastfed InfantsFF: 33 infected, 62 deathsBF: 53 infected, 48 deathsp=0.60p=0.86p=0.08% HIV-Infected or DeadFF arm:91% never breastfedBF+ZDV arm:Median duration of BF = 5.8 monthsDuring the first 5 months:50% any formula18% exclusive breastfeedingThior et al., JAMA, 2006
9 Counselling based on broad definition of AFASS for her and her baby Supporting a mother to choose and implement an option: Before delivery and in the first monthsCounselling based on broad definition of AFASS for her and her baby2 main options (replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interestedSupport for choice
10 Median duration of EBF = 159 days High EXCLUSIVE breastfeeding rates achievable with good quality counselling and supportMedian duration of EBF = 159 daysCoovadia et al., Lancet, in press
11 UNCERTAINTIES EXPRESSED BY COUNTRIES If AFASS criteria not met at 6 months, should the mother continue breastfeeding?What lessons have been learnt on bottlenecks in implementing AFASS?What to say to an HIV-positive BF mother whose infant tests negative at 6 wks?What to feed after early cessation in resource-poor settings?
12 SUGGESTIONS FOR CLARIFICATIONS Guidance generally clear, but would like more specificity, e.g.:Say 6 months Ex BF for HIV-positive mothers who choose that option, to be consistent with general population – but, recognize that some mothers will be able to stop soonerInstead of broad transition period from Ex BF to RF say something like "until the baby is able to take all its milk by cup"Provide flow chart for counsellorsProvide scenarios on counselling mothers according to disease progression/serostatus of infant
13 Emerging evidenceEarly BF cessation associated with increased morbidity and mortality in HIV-exposed infantsProviding free infant formula from birth does not necessarily lead to better HIV-free survival compared to EBF
14 Infant infections by feeding mode HRp95% CIEBF1.0BM + fluid1.560.308BM + solids10.870.018BM+FF1.820.057MBF pre-3/121.540.011MBF post-3/121.530.021Vertical Transmission Study, in Press
15 Emerging evidence HIV-positive infants benefit from continued BF Availability of health system support important in assessing AFASSSeverity of disease in mother important, but AFASS criteria still more critical
16 Emerging evidenceImproved adherence, longer duration of exclusive breastfeeding achieved in HIV-infected and HIV-uninfected mothers given consistent messages and frequent, high quality counsellingNot enough evidence re ARVs and breastfeeding to draw firm conclusions, but HIV-infected mothers who need ARVs should have them
17 Supporting a mother at key decision points in first months If mother breastfeeding:Early testing (PCR):Baby HIV-negative: replacement feeding if AFASSBaby HIV-positive: continue breastfeedingImprovement in financial/social/support situation: re-assess AFASS to consider replacement feedingMother on ARVs: Risk of transmission low, but replacement feeding if AFASSContinued support for choice for all mothers
18 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 foodsno such foods available – risk of mixed feeding for a few months probably less than risk of severe malnutritionIf breastfeeding already stopped:Continue with milk of some kind and complementary foodsContinued support for choice
19 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 breastfeedWhere breast-milk substitutes provided, safe and appropriate use and prevention of spilloverLink infant feeding with effective reproductive and child health services
20 Updating guidanceConsensus Statement from 2006 Technical Consultation (new evidence and experience, updated recommendationsFull 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)
23 2000 and 2006 RecommendationsThe most appropriate infant feeding option for an HIV-infected mother should continue to depend on her individual circumstances, including her health status and the local situation, but should take greater consideration of the health services available and the counselling and support she is likely to receive.Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time.When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommendedWhen replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended.Otherwise, exclusive breastfeeding is recommended during the first months of life.To minimize HIV transmission risk, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV and malnutrition).
24 2000 and 2006 RecommendationsWhen HIV-infected mothers choose not to breastfeed from birth or stop breastfeeding later, they should be provided with specific guidance and support for at least the first 2 years of the child’s life to ensure adequate replacement feeding. Programmes should strive to improve conditions that will make replacement feeding safer for HIV-infected mothers and families.Governments and other stakeholders should re-vitalize breastfeeding protection, promotion and support in the general population. They should also actively support HIV-infected mothers who choose to exclusively breastfeed, and take measures to make replacement feeding safer for HIV-infected women who choose that option.
25 Diarrhoeal Disease Outbreak in Botswana: CDC Study of risk factors CharacteristicAOR* (95% CI)Not breastfeeding50.0 (4.5 – 100)Storing drinking water3.7 (1.5 – 9.1)Overflowing latrines3.0 (1.1 – 8.6)Standing water near home2.6 (1.1 – 6.3)Caregivers not washing hands2.5 (1.1 – 5.0)
26 CDC findings: diarrhea inpatients Mortality Risk factors for deathKwashiorkor RR 2.0, 95% CINo breastfeeding children died (ns)Not associated with deathMaternal HIV statusInfant HIV statusSocioeconomic statusWater sourceUrban vs. rural residenceSpecific pathogen
27 CDC findings: formula supply Reviewed records of 20 infant formula recipients who diedMost given appropriate amount of formula at birth (6 tins)After birth, infants received only 51% of the formula they should have received before their illnessIn many cases, mothers returned to clinics multiple times per month but still not given adequate formula