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

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 10-20 percent during labor and delivery; and another 10-20 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

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

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

WHO Recommendation Otherwise, 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

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

To This?

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

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

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.

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

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)

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.

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

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…

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 2000. 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.

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 & 2005. It became evident early in Q1 of this year that cases had increased somewhat, and mortality had increased dramatically.

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.

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)

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)

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

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

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

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

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

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

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

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

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

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…

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

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” http://www.aidsmap.com/cms1037664.asp PMTCTforum@yahoogroups.com: 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 Thanks to… Ellen Piwoz, AED Tim Quick, USAID Mwate Chintu, Linkages PMTCT Advisor, Malawi Tracy Creek, CDC