1. Infant Feeding in the context of maternal HIV infection MODULE 6

2. Objectives This presentation discusses : Consequences of malnutrition Infant feeding recommendations New data on infant feeding, postnatal transmission, and infant mortality Recommendations for an optimal approach to infant feeding that minimizes postnatal transmission and maximizes child survival

3. Why infant feeding matters

4. Global strategy on IYCF recommendation: WHO 2002 “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond”.

5. Global IYCF recommendation Timely – meaning that they are introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding that is at 6 months. Adequate – meaning that they provide sufficient energy, protein and micronutrient to meet a growing child’s nutritional needs; Safe – meaning that they are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats; Properly fed – meaning that they are given consistent with a child’s signals of appetite

6. National recommendation on IYCF Follows the global strategy on infant and young child feeding recommendations  EBF for the first 6 months  Initiation of complementary feeding at 6 months with continuation of breastfeeding until two years and beyond

7. Breast milk is best for babies Breastfeeding provides optimal nutrition for first 6 months of life and is associated with decreased infant illness and death over the 1st year of life. Lancet 2002 Children who are ‘replacement fed’ (get formula or animal milk) are at increased risk of mortality  Risk is highest in the youngest infant Breastfeeding is protective even in highly developed countries such as US, UK and Europe.  Infants in the UK who were breastfed had fewer hospitalizations for diarrhea and respiratory tract infections compared to non- breastfed children. Quigley et al, Pediatrics 2007

8. The Problem: Breastfeeding Poses a Substantial Risk for MTCT While breast milk contains all of the elements needed for perfect infant nutrition, it also can transmit HIV infection  When an HIV positive mother breastfeeds, her baby is exposed to HIV  HIV transmission risk continues the entire time an HIV positive mother breastfeeds her child BF transmission may account for >35% of MTCT of HIV Women with advanced disease are at highest risk for transmitting HIV to their babies during BF

9. Early Antenatal (<36 wks) Late Antenatal (36 wks to labor) Labor & Delivery Late Postpartum Early Postpartum Substantial Proportion of infections occur during BF 1-6 mos6-24 mos Breastfeeding 35-40% Breastfeeding can account for 35- 40% of all HIV transmission depending on duration 0-1 Pregnancy

10. 100 Infants born to HIV positive Mothers 32 of these babies will become infected with HIV if mothers do not receive any PMTCT intervention  20 of the 100 babies will become infected during pregnancy or delivery (in utero and peripartum transmission)  12 of the 100 babies will become infected through breastfeeding (postnatal transmission)  68 babies will remain uninfected

11. Infant feeding in Ethiopia Majority of women in Ethiopia breastfeed their infants  However, exclusive breastfeeding is not very common because of a variety of factors Can you list some of the reasons why women may not exclusively breastfeed? Majority of women in Ethiopia breastfeed until the child is 18-24 months old

12. Infant feeding and HIV: WHO 2001 “When replacement feeding is acceptable, feasible, affordable, sustainable and safe, (AFASS) 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).”

13. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding X Complete avoidance of breastfeeding X Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or child Improve breastfeeding practices Preventing acquisition of maternal HIV infection

14. What are the risk factors for postnatal transmission of HIV? Longer exposure to breast milk  Transmission of HIV can occur at any point during lactation.  Transmission rates increase with duration of breast-feeding. Advanced maternal HIV disease  High viral loads in blood or breast milk  Low CD4 lymphocyte counts Mother with recently acquired infection Maternal Breast problems  Mastitis  Cracked nipples Mixed feeding

15. Can avoidance of breastfeeding decrease the risk of MTCT? Complete avoidance of breast-feeding is the only way to completely avoid MTCT through breast milk. Exclusive replacement feeding e liminates transmission from breast-feeding - Commercial infant formula - Home-prepared formula with added nutrients BUT……

16. However replacement feeding is associated with a high risk of serious diarrheal infections and malnutrition  Formula is often unsafe having been diluted, improperly mixed, given inconsistently or prepared with unclean water  Babies miss out on the general health benefits of breast milk

17. Formula Feeding is associated with less HIV transmission but higher rates of early death in Mashi Study (Botswana) HIV transmission was higher in the breast fed (BF) group Early mortality was higher in the formula fed (FF) group Overall, no difference in 18 month HIV-free survival: HIV or death at 18 months: 14.2% in FF vs. 15.6% in BF Thior et al, JAMA 2006

18. Diarrhea Outbreak in Francistown, Botswana, 11/05-4/06 Tracy Creek, CROI 2007 Diarrhea Outbreak Kwashiorkor & Marasmus outbreak in March Heavy rains began in Nov 05 until Mar 06

19. CDC case study of diarrhea outbreak in Botswana, Feb-Mar 2006 N153 Age97% < 2 years Breast Feeding7% HIV exposed65% HIV infected18% Death22% (33/153) Not breastfeeding was associated with 8.5-fold increased risk of mortality Tracy Creek, CROI 2007

20. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding Complete avoidance of breastfeeding X Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or child Improve breast feeding practices Preventing acquisition of maternal HIV infection

21. Can shortening the duration of breastfeeding lower risk? Early weaning has been considered a potential means of reducing MTCT while providing some of the benefits of breastfeeding Is early weaning safe and does it improve HIV free survival?

22. Early Weaning: No Advantage in HIV-free Survival GROUP A EBF until 4 months Abrupt cessation of BF Introduce complementary foods and formula at 4mos The Zambian Exclusive Breastfeeding Study (ZEBS) Randomized Clinical Trial Sinkala et al, CROI 2007 The study intended to measure whether weaning early would improve HIV- free survival: lower rate of death and lower rate of new HIV infections Group B EBF for ≥4 months “Weaning as usual” [prolonged BF (~16mos]

23. Overall HIV-free Survival among Children without HIV & still Breastfeeding at 4 Months of Age by Group Assignment Group A Group B There is No Overall Benefit to Early Weaning Compared with Continued Breastfeeding P = 0.21 Sinkala et al, CROI 2007 Early weaning Continued BF As practiced Group B does better

24. Results of Early Weaning vs. Continued Breastfeeding  Early weaning was associated with a lower rate of new HIV infections but  Early weaning was also associated higher rate of death  So there appears to be NO advantage to early weaning

25. Weaning is a time of great vulnerability for all children Some mothers may not be able to provide proper weaning foods once breastfeeding has stopped Growth may decelerate Increased risk of diarrhea and malnutrition Increased risk of illness and death

26. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding Complete avoidance of breastfeeding Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or infant Improve breastfeeding practices Preventing acquisition of maternal HIV infection

27. What about Exclusive Breastfeeding? Several studies have now demonstrated that babies who exclusively breastfeed are at lower risk of acquiring HIV infection compared with infants who mix feed.

28. Exclusive Breastfeeding is associated with decreased Early Postnatal Transmission Exclusive BF Non-exclusive BF 4.0% 10.1% ZEBSZEBS Moses Sinkala et al, CROI February 2007

29. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding Complete avoidance of breastfeeding Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or child Prioritize HAART for pregnant women & lactating women with advanced disease ? ART to woman and/or infant for PMTCT during BF Improve breastfeeding practices Preventing acquisition of maternal HIV infection

30. What about keeping moms healthy to protect their babies? Multiple studies have demonstrated that women with advanced HIV disease are at highest risk for transmitting HIV to their babies

31. Women with Advanced HIV Disease are at Higher Risk of Infecting Their Infants through Breastfeeding Rate of Postnatal HIV Infection from Age 6 Weeks - 18 Months by Maternal Baseline CD4 Count: ZVITAMBO Study (N=2,055) Iliff PJ et al. AIDS 2005

32. Postnatal HIV Transmission is Strongly Related to Maternal CD4 count, ZEBS < 200: 45% of postnatal infections < 350: 83% of postnatal infections RR=12.8 RR=7.7 RR=3.3

33. Prioritizing Pregnant and Lactating Women for HIV Treatment Women with advanced disease are at highest risk for transmitting HIV to their infants during breastfeeding. Treating women with advanced disease with HAART should protect their babies from acquiring the virus. Need to ensure that women with advanced disease are retained in HIV care Keep lactating women not on HAART in postnatal care services and ensure regular monitoring of HIV disease stage

34. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding Complete avoidance of breastfeeding Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or child Improve breastfeeding practices Preventing acquisition of maternal HIV infection

35. Women with Mastitis and Nipple Lesions are at increased risk of transmitting HIV during lactation, Nairobi (N=410) Embree et al: AIDS 2000

36. Abrupt Weaning may be particularly problematic BM viral load increases when a woman weans abruptly If a woman tries to wean abruptly and then puts the baby to the breast a few days later (when the baby is crying for example) the breast milk may contain lots of virus and increase the risk of the baby getting HIV. Abrupt weaning confers a high risk of transmission if it is unsuccessful So, abrupt weaning is not recommended

37. Infant feeding in the context of HIV infection: Current recommendation Excusive breastfeeding for the first 6 months is recommended by HIV infected women if AFASS criteria cannot be met. Continue breastfeeding after 6 months is not AFASS with regular assessment of safety of replacement feeding,

38. National recommendation Infant Feeding during the 6 months of life Preferred Infant feeding option in Ethiopia: The preferred method for infant feeding in HIV- infected women is exclusive breastfeeding for the first 6 months of life. Early cessation of breastfeeding should be avoided since this is associated with increased risk of death form diarrheal illnesses, malnutrition and pneumonia.

39. National recmmendation  Alternative Infant feeding option : In the minority of women who choose to use replacement feeding, every effort should be made to ensure that it is done SAFELY. Home modified animal milk shall be used only as a temporary gap filling measure, for short duration, other wise infant formula is preferred for the first 6 months of life.

40. Feeding of infants and children from 6 – 24 months At 6 months of age all infants need complementary food in order to sustain normal growth. Appropriate complementary foods should be introduced at 6 months of age with continued breastfeeding. Breastfeeding should stop only when a nutritionally adequate diet without breast milk can be provided. This is usually around 12 to 18 months of age. Infants who are determined to be HIV-infected should continue to breastfeed according to recommendations for the general population.

41. Approaches that have been evaluated and/or considered to decrease the risk of MTCT associated with breastfeeding Complete avoidance of breastfeeding Shorten duration of breastfeeding Exclusive breastfeeding Antiretroviral therapy for the mother and/or child Improve breastfeeding practices Preventing acquisition of maternal HIV infection

42. How can we safely feed infants and at the same time reduce postnatal transmission of HIV infection? HIV INFECTIONS THROUGH BREASTFEEDING 300,000 per annum (UNAIDS) MORTALITY THROUGH AVOIDANCE OF BREASTFEEDING 1,500,000 per annum (UNICEF) 1,500,000 per annum (UNICEF) Same populations

43. How can we decrease postnatal transmission? Screen mothers for treatment eligibility TREAT sick mothers  Treat pregnant and lactating HIV infected women with low CD4 and advanced disease Actively support Exclusive Breast Feeding for as long as possible until 6 months  Avoid mixed feeding  Avoid early weaning  Avoid abrupt weaning Complementary feeding should be initiated after 6 months and breastfeeding should continue until 12-18 months.

44. Take Home Message Treat all women who qualify for HAART  particularly during pregnancy and lactation Formula feeding is unsafe Early weaning is unsafe Exclusive breastfeeding is best with the introduction of complementary foods no earlier than 6 months.