1. HIV and INFANT FEEDING: SUPPORTING MOTHERS TO MAKE INFORMED CHOICES Lída Lhotská IBFAN-GIFA Aidsfocus.ch, Bern, 26 April 2007 GIFA

2. HIV transmission through breastfeeding HIV may be transmitted of through breastfeeding well documented 2005 UNAIDS estimated over 300000 children were infected with HIV through breastfeeding. Infant feeding dilema caused by HIV

3. Breastfeeding HIV Mortality Formula feeding HIV/Infant feeding is about assessing the risks

4. Infant mortality by feeding mode and health environment Habicht et al., 1988

6. Optimal Infant Feeding Exclusive breastfeeding for 6 months Complementary feeding with continued breastfeeding from 6 to 24 months and beyond –Timely –Adequate –Safe –Appropriately fed (Global Strategy on Infant and Young Child Feeding, 2002)

7. Early UN recommendation on HIV and infant feeding 1.Based on epidemiological indicators in “settings” 2.As of 1998, based on Human rights principles –Enable HIV-positive women to make informed decision on infant feeding and provide them with support they need to carry it out –Range of infant feeding options agreed

8. Periods of Mother-to-Child Transmission Early Antenatal (<36 wks) Early Postpartum (0-6 months) Late Postpartum (6-24 months) Late Antenatal (36 wks to labor) 5-10%10-20% Pregnancy Labor and Delivery Breastfeeding Adapted from De Cock, 2000, CDC

9. Risk Factor: Early Mixed breastfeeding Coutsoudis et al, 1999; 2001 Cumulative HIV transmission Durban, SA

10. 2000 UN recommendation –When replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), avoidance of all breastfeeding by HIV + women is recommended. –For HIV+ women who choose to breastfeed: Exclusive breastfeeding during first months; to minimize risk, breastfeeding should be discontinued as soon as feasible.

11. UN Recommendations 2007 HIV- women or HIV status unknown Exclusive breastfeeding for 6 months and continued breastfeeding for 2 years or beyond HIV+ women Exclusive breastfeeding for 6 months unless replacement feeding Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS) Most appropriate infant feeding option for HIV-exposed infant depends on individual circumstances, including consideration of health services, counselling and support.

12. Basis for the new recommendation 1.Mushi study (Botswana, 2006): Any gains from reducing HIV transmission by giving free formula were lost through increase mortality from diarrhoea and other conditions such as pneumonia in the context/conditions in which the study was conducted.

13. 2.CDC: Botswana case study Tracy Creek, 2006 Following heavy rains, outbreak of diarrhoea associated with increase of under 5 mortality in the general child population Not breastfeeding and poor growth before illness the biggest risk factors for death Serious difficulties with IF provision to HIV- positive mothers: 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

14. CDC: Botswana case study “Safe” (from AFASS) should probably be empirically demonstrated, not assumed: programs contemplating formula use should verify that formula saves lives in their context before widespread implementation

15. 3.South Africa research HIV transmission: Mixed feeding vs Exclusive breastfeeding Hazard ratio Coovadia et al., Lancet, Vol. 369, 2007

16. Periods of Mother-to-Child Transmission Early Antenatal (<36 wks) Early Postpartum (0-6 months) Late Postpartum (6-24 months) Late Antenatal (36 wks to labor) 5-10%10-20% Pregnancy Labor and Delivery Breastfeeding Adapted from De Cock, 2000. CDC, with Coovadia, 2007 4.04% 6 wks-6mos

17. What do the 2007 recommendations imply  Unbiased counselling, sensitive to the individual’s situation, and support to a mother before delivery and in the first months to choose and implement an infant feeding option  2 main options: 6 months exclusive breastfeeding and replacement feeding, with other local options discussed only if mother interested  NOT 1 time decision !  need continued re- assessment

18. Policy imperatives Adopted by the World Health Assembly in 2004 and 2006 by resolutions on HIV/AIDS and HIV/AIDS and nutrition

19. Framework for priority action on HIV/IF Develop or revise a comprehensive national infant and young child feeding policy which includes HIV/IF Implement and enforce the International Code of Marketing of Breastmilk Substitutes and WHA resolutions Intensify efforts to protect, promote and support appropriate IYCF practices in general, while recognizing HIV as one of the exceptionally difficult circumstances Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their IF decisions Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.

20. Revision of the recommendations When more evidence on ARVs and breastfeeding become available (2008-9 Kesho Bora study) Also expecting first results regarding vaccine development