1. HIV and Infant and Young Child Feeding
Judy Canahuati, MPhil, IBCLC
MCH, N & HIV Advisor
USAID/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)
Pregnancy
Labor and Delivery
Breastfeeding
HIV 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: 63
This 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: 15
Delivery: 15
Pregnancy: 7

4. WHO Recommendation When Replacement Feeding is: Acceptable Feasible
Affordable
Sustainable and
Safe,
Avoidance of All Breastfeeding by HIV-infected Mothers is Recommended….

5. WHO Recommendation
Otherwise, Exclusive Breastfeeding is Recommended During the First Months of Life.
And should be discontinued as soon as it is feasible.”* *

6. How Does An Infant Of An HIV+ Mother Go From This….

7. To This?

8. Illustrative Only: Schematic of approximate number of feeding episodes needed per day, by age and by food type
Young children need nearly as much protein and calcium as adults,
but their stomachs are small, so they must be fed many times per day
Common
Feeding
Frequency
Shortfalls
When 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<200
AZT 12 weeks to mothers, 4 weeks to infants
SD NVP for mothers and infants
Free infant formula for 12 months
High uptake since 2004, 80% receive AZT
HIV transmission to infants ~7% in recent data, an 80% reduction

12. Infant formula in Botswana
All HIV-positive women advised to formula feed
63% of all HIV-positive women used formula in 2005
Difficulty maintaining and distributing formula supply
Efforts 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 Botswana
Among infants of mothers who were HIV negative or unknown:
95% breastfed
Median age at weaning 12 months
20% weaned before 6 months
What 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 breastfeeding
Non-breastfed infants more vulnerable to diarrhea and death

15. Mashi study showed high mortality among formula fed infants
Harvard study in Botswana, results 2005
1200 infants of HIV-positive mothers
Half formula fed from birth
Half breastfed for 6 months
At 18 months, 15% in both groups had either acquired HIV or died
Formula fed group more likely to die
Breastfed group more likely to acquire HIV
No net advantage of formula
Harvard’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 outbreak
Nov 2005 – Feb 2006: Unusually heavy rains, flooding in Botswana
Jan 2006: Increase in pediatric diarrhea cases and deaths reported to MOH
Feb 2006: Large number of pediatric diarrhea admissions and deaths overwhelmed hospitals around the country
Facilities reported anecdotally that most affected infants were bottle fed – CDC assistance requested
Beginning 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
Year
Time period
Districts reporting
Cases
Deaths
2004 Q1 24
8478
2005
9166 21
2006 12
22500
470
This 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 findings
Water contamination was widespread in 4 northern districts
Public water supply contaminated in all villages
Water in Francistown not contaminated
Water in Botswana usually regarded as clean, multiple sources and treatment strategies
Diarrhea patients had multiple pathogens
Cryptosporidium (protozoal parasite)
Enteropathogenic e. coli (EPEC, classic “bottle diarrhea”)
Salmonella
Other pathogens
A 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 reasons
Interviewed parents about health, feeding, environment to determine what factors increased diarrhea risk
Characteristic
AOR* (95% CI)
Not breastfeeding
50.0 (4.5 – 100)
Storing drinking water
3.7 (1.5 – 9.1)
Overflowing latrines
3.0 (1.1 – 8.6)
Standing water near home
2.6 (1.1 – 6.3)
Caregivers not washing hands
2.5 (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 hospital
Demographics & illness
96% <2 years old (median 9 mos)
93% not breastfeeding
51% had poor growth before illness
35% had had diarrhea for >2 weeks
HIV
65% of mothers HIV positive (94% tested)
18% of infants HIV-infected
Among infants of positive mothers, 27% HIV infected (85% tested)

21. CDC findings: diarrhea inpatients Mortality
Risk factors for death
Not breastfed OR 8.5, p=0.04
Kwashiorkor OR 2.6, p=0.03
Not associated with death
Maternal HIV status
Infant HIV status
Socioeconomic status
Water source
Urban vs. rural residence
Which pathogen

22. CDC findings: diarrhea inpatients Course of illness (n=154)
Diarrhea prolonged: 43% discharged and readmitted at least once during study
Many developed severe acute malnutrition during or after diarrhea
42% developed marasmus
20% developed kwashiorkor
Most growing poorly before diarrhea, not adequately managed despite monthly weighing at clinics
High 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 formula
Reviewed records of 20 infant formula recipients who died
Most 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 started
In 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 unknown
Can be estimated from multiple sources
CDC household survey estimated 547 excess deaths in 3 districts during outbreak, 4x historical <5 mortality rate
Among formula-fed newborns CDC started following in January before outbreak, preliminary data indicates 10% dead when re-visited at age 3-4 months
One 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 years
Diarrhea not associated with HIV, many HIV-negative infants hospitalized and died
Seriously ill children nearly all non-breastfed
Poor nutritional status contributed to death of many children
Not breastfeeding was most significant risk factor for diarrhea and death

26. Lessons learned
Early weaning among HIV-negative women common, BF promotion needs strengthening
Formula program for HIV-positive women expensive, complex, data indicate it is not saving lives
Infant formula program needs review
Other feeding strategies likely to promote higher child survival
Infants who are formula-fed need clean water, more support and monitoring

27. Immediate way forward Botswana
CDC recommends formula policy review and external consultation
Women who are exclusively breastfeeding, have high CD4, are on ARV therapy have low risk of HIV transmission
Ensure every formula-fed infant has enough formula and safe water
Improve training for health staff in management of diarrhea and malnutrition
Study impact of point-of-use-water treatment, safe water vessels, soap and handwashing promotion
Reduces mortality in adults & older children with HIV
PEPFAR can fund for HIV-infected and -exposed children under new preventive care & OVC guidance
For 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 counseling
Health staff should be taught that formula fed infants are at risk, what to look for, and how to intervene
Outbreak 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 Months
Postpartum
Immediate skin-to-skin
BF 1st ½ hour if BF chosen
No BF if RF chosen
EBF/ERF
Counseling & Support
Post-partum care for mother
Decreased workload
Counseling for second
6 months & initiation of
RF where appropriate
Safer sex
Support to Pregnant
Women
Early ANC CT
Counseling & support to
disclose when appropriate
Improved Nutrition
Decreased Work Load
Safer sex
Appropriate
IYCF counseling
Nevirapine if indicated
Essential Obstetric
Interventions
Well-nourished
Infant and young
Child 0-2 yrs
HIV exposed and
not
6-24 months
Initiation of RF if Appropriate with
Animal milk or
CF with local food combinations +BM
No BF if RF chosen
Active feeding
Frequent feeding
Counseling & Support
Hygiene
Post-partum care for mother
Decreased workload
Safer sex
Community
Supportive

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 Infants
Updated 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 months
Frequent feeding of breastmilk and nothing else in first six months helps all children grow well
Add appropriate foods progressively starting around six months
Systemize 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 serves
HATIP: HIV&AIDS Treatment in Practice #74 and #75, “Safer Infant
Feeding”, Parts 1 & 2”
a list serve moderated by Dr. Ruth Hope
Updates on a range of relevant articles & events.
has both nutrition and HIVAIDS Working groups and
You don’t have to be a CORE member to collaborate with the working groups
Thanks to…
Ellen Piwoz, AED
Tim Quick, USAID
Mwate Chintu, Linkages PMTCT Advisor, Malawi
Tracy Creek, CDC