Update on HIV and infant feeding Peggy Henderson and Constanza Vallenas Department of Child and Adolescent Health and Development, WHO Rome, 25 February 2007

UN Recommendations HIV- women or HIV status unknown Exclusive breastfeeding for 6 months and continued breastfeeding for 2 years or beyond HIV+ women Most appropriate infant feeding option for HIV-exposed infant depends on individual circumstances, including consideration of health services, counselling and support If 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.

Selecting an option: AFASS To be a better option for the individual than exclusive breastfeeding, replacement feeding has to be AFASS: Acceptable Feasible Affordable Sustainable AND Safe For the mother and baby

Balancing risks for HIV-positive women HIV transmission IF BREASTFEEDING Mortality Infectious diseases Malnutrition IF NOT BREASTFEEDING

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%

Balancing risks – 2 Relative risk of infectious disease mortality among non-breastfed infants 5.8 Relative risk 4.1 2.6 1.8 1.4 Age (months) WHO Collaborative Study Team, Lancet, 2000

Balancing risks – 3 Mixed feeding carries higher risk of HIV transmission than exclusive breastfeeding Hazard ratio Coovadia et al., Lancet, in press

Balancing Risks - 4 No Difference in 18-Month mortality/HIV infection between Formula and Breastfed Infants FF: 33 infected, 62 deaths BF: 53 infected, 48 deaths p=0.60 p=0.86 p=0.08 % HIV-Infected or Dead FF arm: 91% never breastfed BF+ZDV arm: Median duration of BF = 5.8 months During the first 5 months: 50% any formula 18% exclusive breastfeeding Thior et al., JAMA, 2006

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 months Counselling based on broad definition of AFASS for her and her baby 2 main options (replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interested Support for choice

Median duration of EBF = 159 days High EXCLUSIVE breastfeeding rates achievable with good quality counselling and support Median duration of EBF = 159 days Coovadia et al., Lancet, in press

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?

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 sooner Instead 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 counsellors Provide scenarios on counselling mothers according to disease progression/serostatus of infant

Emerging evidence Early BF cessation associated with increased morbidity and mortality in HIV-exposed infants Providing free infant formula from birth does not necessarily lead to better HIV-free survival compared to EBF

Infant infections by feeding mode HR p 95% CI EBF 1.0 BM + fluid 1.56 0.308 0.66-3.69 BM + solids 10.87 0.018 1.51-78.00 BM+FF (@12wks) 1.82 0.057 0.98-3.36 MBF pre-3/12 1.54 0.011 1.10-2.15 MBF post-3/12 1.53 0.021 1.07-2.20 Vertical Transmission Study, in Press

Emerging evidence HIV-positive infants benefit from continued BF Availability of health system support important in assessing AFASS Severity of disease in mother important, but AFASS criteria still more critical

Emerging evidence Improved adherence, longer duration of exclusive breastfeeding achieved in HIV-infected and HIV-uninfected mothers given consistent messages and frequent, high quality counselling Not enough evidence re ARVs and breastfeeding to draw firm conclusions, but HIV-infected mothers who need ARVs should have them

Supporting a mother at key decision points in first months If mother breastfeeding: Early testing (PCR): Baby HIV-negative: replacement feeding if AFASS Baby HIV-positive: continue breastfeeding Improvement in financial/social/support situation: re-assess AFASS to consider replacement feeding Mother on ARVs: Risk of transmission low, but replacement feeding if AFASS Continued support for choice for all mothers

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 foods no such foods available – risk of mixed feeding for a few months probably less than risk of severe malnutrition If breastfeeding already stopped: Continue with milk of some kind and complementary foods Continued support for choice

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 breastfeed Where breast-milk substitutes provided, safe and appropriate use and prevention of spillover Link infant feeding with effective reproductive and child health services

Updating guidance Consensus Statement from 2006 Technical Consultation (new evidence and experience, updated recommendations Full 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)

THANK YOU

ADDITIONAL SLIDES

2000 and 2006 Recommendations The 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 recommended 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. 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).

2000 and 2006 Recommendations When 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.

Diarrhoeal Disease Outbreak in Botswana: CDC Study of risk factors 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)

CDC findings: diarrhea inpatients Mortality Risk factors for death Kwashiorkor RR 2.0, 95% CI 1.1-3.8 No breastfeeding children died (ns) Not associated with death Maternal HIV status Infant HIV status Socioeconomic status Water source Urban vs. rural residence Specific pathogen

CDC findings: formula supply Reviewed records of 20 infant formula recipients who died Most given appropriate amount of formula at birth (6 tins) After birth, infants received only 51% of the formula they should have received before their illness In many cases, mothers returned to clinics multiple times per month but still not given adequate formula