Presentation on theme: "HIV and Infant and Young Child Feeding"— Presentation transcript:
1 HIV and Infant and Young Child Feeding Judy Canahuati, MPhil, IBCLCMCH, N & HIV AdvisorUSAID/DCHA/FFP
2 Timing of Mother-to-Child Transmission: No intervention Early Antenatal(<36 wks)Early Postpartum(0-6 months)Late Postpartum(6-24 months)PregnancyLabor and DeliveryBreastfeedingHIV transmission from mothers to infants occurs during pregnancy, at the time of labor and delivery, and postnatally through breastfeeding.This slide summarizes the timing of HIV transmission during these periods. In the absence of any interventions to prevent or reduce transmission, about 5-10 percent of HIV infected mothers pass the virus to their infants during pregnancy; between percent during labor and delivery; and another percent postnatally through breastfeeding to 24 months.Labor and delivery is the single time point of greatest risk with as much infection occurring within 24 hours as occurs postnatally within 24 months of breastfeeding. Most short course ARV prophylaxis regimens aim to reduce HIV transmission during this time.Late Antenatal(36 wks to labor)5-10%10-20%5-20%Adapted from CDC
3 MTCT in 100 HIV+ Mothers by Timing of Transmission – on average Uninfected: 63This slide illustrates this data on HIV transmission in a slightly different way. Imagine 100 HIV+ women. Using the midpoints of the ranges described in the previous slide, you would expect 7 of their infants to be infected with HIV during pregnancy, another 15 during labor and delivery; and another 15 over the course of about 2 years of breastfeeding. 63 infants would not become infected with HIV, even if breastfed and without any intervention in place to prevent transmission.Breastfeeding: 15Delivery: 15Pregnancy: 7
4 WHO Recommendation When Replacement Feeding is: Acceptable Feasible AffordableSustainable andSafe,Avoidance of All Breastfeeding by HIV-infected Mothers is Recommended….
5 WHO RecommendationOtherwise, Exclusive Breastfeeding is Recommended During the First Months of Life.And should be discontinued as soon as it is feasible.”**http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_Framework.pdf
6 How Does An Infant Of An HIV+ Mother Go From This….
8 Illustrative Only: Schematic of approximate number of feeding episodes needed per day, by age and by food typeYoung children need nearly as much protein and calcium as adults,but their stomachs are small, so they must be fed many times per dayCommonFeedingFrequencyShortfallsWhen growth problems occur
9 Relative Risk of Death from ARI and Diarrhea Among Non-Breastfed Children in Two Studies, Compared to Breastfed Infants (set at ARO of 1) WHO Collaborative Team on the Role of Breastfeeding in the Prevention of Infant Mortality, Lancet 2000;55: Rutstein,S. International Journal of Gyn/Obstet. 2005; 89:S7-S24..Adjusted Relative Odds of Mortality
10 Botswana: A Case Study on risks of not breastfeeding The CDC investigation was focused in Francistown, Botswana’s second largest city, and its surrounding districts. CDC has an office in the second largest referral hospital in the country, and our investigation began there.
11 PMTCT in Botswana National PMTCT program started 1999 Program provides ARV therapy for women with CD4<200AZT 12 weeks to mothers, 4 weeks to infantsSD NVP for mothers and infantsFree infant formula for 12 monthsHigh uptake since 2004, 80% receive AZTHIV transmission to infants ~7% in recent data, an 80% reduction
12 Infant formula in Botswana All HIV-positive women advised to formula feed63% of all HIV-positive women used formula in 2005Difficulty maintaining and distributing formula supplyEfforts to strengthen logistics, counseling, and application of WHO criteria for replacement feeding (acceptable, affordable, feasible, safe, sustainable)
13 Infant feeding among HIV-negative women 2006 CDC household survey of 539 children in northern BotswanaAmong infants of mothers who were HIV negative or unknown:95% breastfedMedian age at weaning 12 months20% weaned before 6 monthsWhat about women who are not HIV-positive? Women who are negative or have not been tested are advised to breastfeed for two years or more. CDC conducted a household survey this year, and found that 95% of these infants were breastfed, with a median age at weaning of 12 months. Twenty percent of infants, however, were weaned before they were 6 months old.
14 Total non-breastfed infants in Botswana CDC estimate 35% (~13,000) of Botswana’s infants <6 months old are not breastfeedingNon-breastfed infants more vulnerable to diarrhea and death
15 Mashi study showed high mortality among formula fed infants Harvard study in Botswana, results 20051200 infants of HIV-positive mothersHalf formula fed from birthHalf breastfed for 6 monthsAt 18 months, 15% in both groups had either acquired HIV or diedFormula fed group more likely to dieBreastfed group more likely to acquire HIVNo net advantage of formulaHarvard’s MASHI study, findings of which were released in 2005, were the first indication that there could be problems with infant formula in Botswana. The study compared infants of HIV-postiive mothers who were formula fed to those who were breastfed. Mortality among formula fed infants was significantly higher. At 18 months, HIV-free survival was equal…
16 2006 diarrhea outbreakNov 2005 – Feb 2006: Unusually heavy rains, flooding in BotswanaJan 2006: Increase in pediatric diarrhea cases and deaths reported to MOHFeb 2006: Large number of pediatric diarrhea admissions and deaths overwhelmed hospitals around the countryFacilities reported anecdotally that most affected infants were bottle fed – CDC assistance requestedBeginning in November last year, Botswana experienced unusually heavy rains with extensive flooding. Botswana is usually a dry country.The last time there was significant rains and flooding was in In January, an increase in pediatric diarrhea cases and deaths was reported to the ministry of health. By February, a very large number of pediatric diarrhea admissions and deaths overwhelmed hospitals around the country. Health workers reported anecdotally that most of the affected patients were bottle fed. CDC assistance was requested in late February.
17 Botswana under-5 diarrhea YearTime periodDistricts reportingCasesDeaths2004Q1248478200591662120061222500470This table shows reported under-5 diarrhea cases in the first quarter for the past three years. Botswana is a desert country and usually has a minimal burden of diarrheal disease and mortality, with only about 20 deaths reported in the first quarters of 2004 & It became evident early in Q1 of this year that cases had increased somewhat, and mortality had increased dramatically.
18 CDC findingsWater contamination was widespread in 4 northern districtsPublic water supply contaminated in all villagesWater in Francistown not contaminatedWater in Botswana usually regarded as clean, multiple sources and treatment strategiesDiarrhea patients had multiple pathogensCryptosporidium (protozoal parasite)Enteropathogenic e. coli (EPEC, classic “bottle diarrhea”)SalmonellaOther pathogensA multidisciplinary CDC team conducted several investigations and assisted the ministry of health with outbreak control. The next several slides summarize the most important findings from these investigations.
19 CDC findings: risk factors for diarrhea We compared children visiting emergency room with diarrhea to those visiting for other reasonsInterviewed parents about health, feeding, environment to determine what factors increased diarrhea riskCharacteristicAOR* (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)Part of the CDC investigation was determining risk factors for developing diarrhea. We compared children visiting the emergency room for diarrhea with children visiting for other illnesses. We interviewed parents about the child’s health, feeding history, and environment in order to learn what factors led to diarrhea. The most significant risk factor was not breastfeeding. Children who had diarrhea were about 50 times as likely to be non-breastfed than other children. Other risk factors included storing drinking water, having an overflowing latrine, having standing water near the home, and caregivers not washing their hands after using the toilet.*adjusted for SES, age, and mother’s HIV status (feeding not adjusted for HIV)
20 CDC findings: diarrhea inpatients 154 inpatients with diarrhea followed in hospitalDemographics & illness96% <2 years old (median 9 mos)93% not breastfeeding51% had poor growth before illness35% had had diarrhea for >2 weeksHIV65% of mothers HIV positive (94% tested)18% of infants HIV-infectedAmong infants of positive mothers, 27% HIV infected (85% tested)
21 CDC findings: diarrhea inpatients Mortality Risk factors for deathNot breastfed OR 8.5, p=0.04Kwashiorkor OR 2.6, p=0.03Not associated with deathMaternal HIV statusInfant HIV statusSocioeconomic statusWater sourceUrban vs. rural residenceWhich pathogen
22 CDC findings: diarrhea inpatients Course of illness (n=154) Diarrhea prolonged: 43% discharged and readmitted at least once during studyMany developed severe acute malnutrition during or after diarrhea42% developed marasmus20% developed kwashiorkorMost growing poorly before diarrhea, not adequately managed despite monthly weighing at clinicsHigh mortality: 21% (32/154) died
23 CDC findings: formula supply Some mothers told us their children stopped growing because clinics would not give them enough formulaReviewed records of 20 infant formula recipients who diedMost given appropriate amount of formula at birth (6 tins)After birth, these infants received only 51% of the formula they should have received before their illness startedIn many cases, mothers returned to clinics multiple times per month and were still not given adequate formula
24 Total outbreak mortality Many infants died outside of health facilities, actual mortality higher than reported to MOH but total unknownCan be estimated from multiple sourcesCDC household survey estimated 547 excess deaths in 3 districts during outbreak, 4x historical <5 mortality rateAmong formula-fed newborns CDC started following in January before outbreak, preliminary data indicates 10% dead when re-visited at age 3-4 monthsOne village we visited lost 30% of their formula-fed babies (and no other babies) during outbreak
25 Summary of outbreak Unusually heavy rains caused water contamination Outbreak of diarrhea & malnutrition with high mortality among children < 2 yearsDiarrhea not associated with HIV, many HIV-negative infants hospitalized and diedSeriously ill children nearly all non-breastfedPoor nutritional status contributed to death of many childrenNot breastfeeding was most significant risk factor for diarrhea and death
26 Lessons learnedEarly weaning among HIV-negative women common, BF promotion needs strengtheningFormula program for HIV-positive women expensive, complex, data indicate it is not saving livesInfant formula program needs reviewOther feeding strategies likely to promote higher child survivalInfants who are formula-fed need clean water, more support and monitoring
27 Immediate way forward Botswana CDC recommends formula policy review and external consultationWomen who are exclusively breastfeeding, have high CD4, are on ARV therapy have low risk of HIV transmissionEnsure every formula-fed infant has enough formula and safe waterImprove training for health staff in management of diarrhea and malnutritionStudy impact of point-of-use-water treatment, safe water vessels, soap and handwashing promotionReduces mortality in adults & older children with HIVPEPFAR can fund for HIV-infected and -exposed children under new preventive care & OVC guidanceFor Botswana, CDC recommends a review of the national program’s formula policy and an external consultation to benefit from the accumulated experience of researchers working in this area. We also need to ensure
28 Implications for other programs Programs offering formula should ensure clean water, uninterrupted supply of formula, growth monitoring, nutrition counselingHealth staff should be taught that formula fed infants are at risk, what to look for, and how to interveneOutbreak reinforces use of WHO criteria for replacement feeding (acceptable, affordable, feasible, sustainable, and safe)“Safe” cannot be assumed: new programs should verify that formula saves lives in their context before widespread implementation
29 Framework for Community Support of IYCF in context of HIV: Mother-Baby Friendly Communities 0-6 MonthsPostpartumImmediate skin-to-skinBF 1st ½ hour if BF chosenNo BF if RF chosenEBF/ERFCounseling & SupportPost-partum care for motherDecreased workloadCounseling for second6 months & initiation ofRF where appropriateSafer sexSupport to PregnantWomenEarly ANC CTCounseling & support todisclose when appropriateImproved NutritionDecreased Work LoadSafer sexAppropriateIYCF counselingNevirapine if indicatedEssential ObstetricInterventionsWell-nourishedInfant and youngChild 0-2 yrsHIV exposed andnot6-24 monthsInitiation of RF if Appropriate withAnimal milk orCF with local food combinations +BMNo BF if RF chosenActive feedingFrequent feedingCounseling & SupportHygienePost-partum care for motherDecreased workloadSafer sexCommunitySupportive
30 HIV and Infant Feeding Technical Discussions at WHO…what to look for? HIV and Infant Feeding Technical Consultation Interagency Task Force in Geneva October reviewing research on Prevention of HIV infections in Pregnant Women, Mothers and their InfantsUpdated guidance, clarifying Global Strategy on IYCF in relation to HIV to be posted soon.Stay tuned…
31 Could AFASS become… ?All mothers need support to breastfeed exclusively during first six monthsFrequent feeding of breastmilk and nothing else in first six months helps all children grow wellAdd appropriate foods progressively starting around six monthsSystemize administration of AFASS as additional foods added if mom is HIV+Safer infant feeding includes prevention of HIV during pregnancy and after birth, breast health, good latch on, less workload for mother & health care
32 Thanks to… Ellen Piwoz, AED Tim Quick, USAID Useful documents, websites and list servesHATIP: HIV&AIDS Treatment in Practice #74 and #75, “Safer InfantFeeding”, Parts 1 & 2”a list serve moderated by Dr. Ruth HopeUpdates on a range of relevant articles & events.has both nutrition and HIVAIDS Working groups andYou don’t have to be a CORE member to collaborate with the working groupsThanks to…Ellen Piwoz, AEDTim Quick, USAIDMwate Chintu, Linkages PMTCT Advisor, MalawiTracy Creek, CDC