1. The big debate: Infant feeding and HIV
Dr. S. Katyayan
M.B.B.S. (HONS),M.D. (Paed.), P.G.D.M.L.S.(Pune)

2. Transmission of HIV from Mother to the Baby
100,000 HIV + Indian women become pregnant every year
30,000 children become HIV + every year

3. SO WHAT ARE THE INFANT AND YOUNG CHILD NUTRITION(IYCN) WHO Norms

4. Timing of MTCT The risk of HIV transmission through breast milk & transmission during pregnancy

5. How does transmission occur during breastfeeding
Exact mechanism is unknown
HIV virus in blood passes into milk
Cell free, cell associated virus observed in milk
Virus sheds intermittetently (Undetectable %)
Levels vary between breasts of samples taken at the same time
Infant consumes HIV
Enters and infects thru permeable mucous membranes, lymphoid tissues and lesions in the mouth and gut
Although the baby may consume 500,000 virons, and >25, 000 infected cells per day majority don’t become infected
Immune factors in BM may play a role
Lewis X component (LECTIN) in human milk binds DC-SIGN and inhibits HIV-1 transfer to CD4+ T-lymphocytes (present in the tonsils of the baby)

6. Risk Factors for Postnatal Transmission
Mother
Immune status
Plasma Viral load
Breast milk Virus
Breast Infection (mastitis, abscess, sore and bleeding nipples)
New HIV infection
Viral characteristics
Infant
Breastfeeding duration
Non exclusive breast feeding
Age (first months)
Lesions in the mouth, intestine
Prematurity
Infant immune response

7. Risk factors for postnatal transmisson: Maternal Immune Status
HIV transmission from 6 wks to 24 months in West Africa by maternal baseline CD4
The higher the CD4 count( >500) the less the transmission
Therefore the maternal immune status is important 14
Cumulative HIV Transmission (%)
1.4

8. Risks factors for postnatal Transmission: Breast milk Viral Load
BM viral load was consistently higher in women with low CD4 counts (p<0.01). BM RNA was associated with increased MTCT, ofter adjusting for maternal DC 4 (or = 2.82) 4 3 2 1
Mean Log 10 HIV RNA
CD4< CD4 >= 500
Pillay ct al , 2000

9. Risks factors for postnatal Transmission: Maternal Viral Load
Viral RNA can be a important predictor of intra partum MTCT
Plasma viral load may also be a risk factor in Breastfeeding
Higher risk in of transmission in women infected postnatally (Early Viraemia)

10. Preavalance of Breast Patholgies in HIV +ve women
Mastitis(Clinical and subclinical)
Subclinical mastitis is associated with higher viral load
Mastitis associated with higher risk of transmission
Nipple lesions
Nipple lesions and breast abscesses are also associated with an increased risk of transmission
Breast abscess

11. Risks factors for postnatal Transmission Breast health II
18-20% of overall MTCT may be attributed to mastitis
If BF accounts for 40% of all transmission then mastitis (Breast health problems) may account for 50% of all transmission

12. Risks factors for postnatal Transmission: Duration of breastfeeding
Risk of breastfeeding persists as long as BF is practiced
Risk of HIV transmission is higher in first 6 months
Several possible explanations
Higher prevalance of mastitis
Infant gut more immature
More breast milk consumed

13. Note: results represent worst case scenario as these populations were mixed breastfed with no lactation mx to prevent breast problems

14. Cumulative probability of HIV among 549 children born to HIV+ women by type of feeds Coutsoudis et al. AIDS 2001, 15:379-87
Exclusively breastfed group ( ) is statistically significantly different from mixed fed ( ), but is not statistically significantly different from never breastfed ( )group until 15 months, controlling for 15 variables.

15. TYPE OF FEEDS Risk of HIV infection over time in 157 children never breastfed; 118 EBF; and 276 mixed breastfeeders

16. Infant mortality among children born to HIV+ mothers by early feeding Pattern (0-3months) in Harare, Zimbawe (n-892 in 2002)
deaths/1000
Adjusted HR for BM + NHM VS EBF = 5.97 (P, 0.001) : Predominant BF vs EBF=2.52 (P=0.04) ; Partial BF vs EBF=2.84 (p=0.02)

17. Postnatal Risk of Transmission of HIV: Infant Oral Lesions
Disruption of skin and muccousmembrane of mouth and gut associated with incrase risk of Transmission
Epithelial integrity
Infant oral thrush associated with increased risk of transmission

18. So what should HIV+ mothers in resource poor settings do?

19. Infants who do not breast feed have an increased risk of dying in the first year
Pooled Odds Ratios
0 - 1
2 - 3
4 - 5
6 - 8
9 - 11
Age in months

20. Where IMR>40, this model indicates that
Model for Per 1000 HIV-Positive Mothers
(IMR 96)
Ross and Labbok, AJPH, 2004
Where IMR>40, this model indicates that
EBF might be the best choice feeding option for HIV+ Moms
Ross J et al. 2004, AJPH

21. So what are the risks of not breastfeeding?

22. Not breastfeeding increases mortality RR of infectious disease mortality among non-breastfed infants
WHO, Lancet 2000
5.8
4.1
2.6
1.8
1.4
<2
2-3
4-5
6-8
9-11
Age (months)

23. % of infants who had an illness episode in the first 2 months
Not breastfeeding in the first 2 months significantly increases morbidity in infants born to HIV infected women Durban VITA/breastfeeding study
% of infants who had an illness episode in the first 2 months
Coutsoudis et al. in press, Acta Paediatr, Aug 2003.

24. % of infants who had 3 or more morbidity episodes
HIV infected children who were not breastfed had significantly more morbidity Durban breastfeeding study
% of infants who had 3 or more morbidity episodes
Coutsoudis et al. in press, Acta Paediatr, Aug 2003

25. Facts: HIV infected children who were not breastfed
had significantly more recurrent diarrhoea
Frederick et al, Los Angeles Study 1997
(138 HIV infected children, 43% breastfed)

26. Facts:
HIV infected children who were not breastfed progressed to AIDS more quickly
Frederick et al, Los Angeles Study 1997
(138 HIV infected children, 43% breastfed)

27. Where HIV+ women receive counseling and free infant formula, its use is not optimal

28. If you answer no to any of these questions,
formula feeding may not be the best option
Do you have easy access to clean safe water
Do you have easy facilities to boil water
Do you have facilities to sterilise bottles etc.
Do you have a fridge with regular electricity
Do you have a guaranteed income of R150/month to spend on formula, bottles, teats, sterilising fluid etc.
Does your family know your status & will they
support you to formula feed
Will it be acceptable to give f/feeds at night or when baby is crying in public
Do you have easy access to clinic/hospital if child gets diarrhea

29. Feeding options currently recommended by the WHO
Breastfeeding
exclusive breastfeeding
Heat-treated breast milk
wet-nursing
milks banks
early cessation of breastfeeding (as soon as)
Treatment & prophylaxis of mother and baby
Replacement feeding
commercial infant formula
home prepared infant formula (modified, with additional nutrients)
enriched family diet with BMS/MN supplements after 6 months

30. Can we make breastfeeding safer for HIV+ women
Assist families with early breasfeeding cessation
Access health status of mother and infant
prepare for the process so that the transition is safe (cup-feeding , safe preparation /hygiene, stigma)
heat treat breast milk if weaning is gradual
could prevent sizeable fraction of BF transmission
Provide adequate nutrition after breastfeeding ends
appropriate breast milk substitutes and /or multi-nutrient supplements should be provided to prevent malnutrition

31. Key Messages Help mother to stay healthy Help baby to stay healthy
Constant updating of knowledge about IYCN and HIV
Good Counseling Skills
Respect wishes of mother after Counseling s
Exclusive Breastfeeding for six months is the best option in our setting
Consider each point of AFASS in depth before advising replacement feeds
Rapid weaning with home cooked food as replacement at six months or before.
Treatment of the mother with NRV’s

32. Replacement Feeds must be
acceptable, A
feasible, F
affordable, A
safe and S
Sustainable S

33. Thank you
Dr. S. Katyayan
MBBS, MD, PGDMLS.