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HIV and Infant and Young Child Feeding Judy Canahuati, MPhil, IBCLC MCH, N & HIV Advisor USAID/DCHA/FFP.

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Presentation on theme: "HIV and Infant and Young Child Feeding Judy Canahuati, MPhil, IBCLC MCH, N & HIV Advisor USAID/DCHA/FFP."— Presentation transcript:

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) Late Antenatal (36 wks to labor) Late Postpartum (6-24 months) Early Postpartum (0-6 months) Adapted from CDC 5-10% 10-20%5-20% Labor and DeliveryBreastfeeding Pregnancy

3 MTCT in 100 HIV+ Mothers by Timing of Transmission – on average Uninfected: 63 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 Otherwise, Exclusive Breastfeeding is Recommended During the First Months of Life. And should be discontinued as soon as it is feasible.”* * health/New_Publications/NUTRITION/HIV_IF_F ramework.pdf WHO Recommendation

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 When growth problems occur Common Feeding Frequency Shortfalls

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;55:451-5 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

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

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

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

17 Botswana under-5 diarrhea YearTime period Districts reportin g CasesDeaths 2004Q124847824 2005Q124916621 2006Q11222500470

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

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 CharacteristicAOR* (95% CI) Not breastfeeding50.0 (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) *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

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 Well-nourished Infant and young Child 0-2 yrs HIV exposed and not Framework for Community Support of IYCF in context of HIV: Mother- Baby Friendly Communities 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 0-6 Months Postpartum Immediate skin-to-skin BF 1 st 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 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 Supportive Community

30 HIV and Infant Feeding Technical Discussions at WHO…what to look for? HIV and Infant Feeding Technical Consultation Interagency Task Force in Geneva 25-27 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… ? Could AFASS become… ? A ll mothers need support to breastfeed exclusively during first six months F requent feeding of breastmilk and nothing else in first six months helps all children grow well A dd appropriate foods progressively starting around six months S ystemize administration of AFASS as additional foods added if mom is HIV+ S afer 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 Mwate Chintu, Linkages PMTCT Advisor, Malawi Tracy Creek, CDC 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. http://www.coregroup.org has both nutrition and HIVAIDS Working groups and You don’t have to be a CORE member to collaborate with the working groups

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