HIV and Infant and Young Child Feeding

1
HIV and Infant and Young Child Feeding

• Judy Canahuati, MPhil, IBCLC
• MCH, N HIV Advisor
• USAID/DCHA/FFP

2
Timing of Mother-to-Child Transmission No
intervention
Early Antenatal (lt36 wks)
Late Postpartum (6-24 months)
Early Postpartum (0-6 months)
Labor and Delivery
Breastfeeding
Pregnancy
Late Antenatal (36 wks to labor)
5-10
10-20
5-20
Adapted from CDC
3
MTCT in 100 HIV Mothers by Timing of
Transmission on average
Uninfected 63
Breastfeeding 15
Delivery 15
Pregnancy 7
4
WHO Recommendation

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

5
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_Pu
blications/NUTRITION/HIV_IF_Framework.pdf
6
How Does An Infant Of AnHIV Mother Go From
This.
7
To This?
8
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
9
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 200055451-5 Rutstein,S.
International Journal of Gyn/Obstet. 2005
89S7-S24..
Adjusted Relative Odds of Mortality
10
Botswana A Case Study on risks of not
breastfeeding
11
PMTCT in Botswana

• National PMTCT program started 1999
• Program provides
• ARV therapy for women with CD4lt200
• 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

12
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)

13
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

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Total non-breastfed infants in Botswana

• CDC estimate 35 (13,000) of Botswanas infants
  lt6 months old are not breastfeeding
• Non-breastfed infants more vulnerable to diarrhea
  and death

15
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

16
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

17
Botswana under-5 diarrhea
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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

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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

adjusted for SES, age, and mothers HIV status
(feeding not adjusted for HIV)
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CDC findings diarrhea inpatients

• 154 inpatients with diarrhea followed in hospital
• Demographics illness
• 96 lt2 years old (median 9 mos)
• 93 not breastfeeding
• 51 had poor growth before illness
• 35 had had diarrhea for gt2 weeks
• HIV
• 65 of mothers HIV positive (94 tested)
• 18 of infants HIV-infected
• Among infants of positive mothers, 27 HIV
  infected (85 tested)

21
CDC findings diarrhea inpatientsMortality

• Risk factors for death
• Not breastfed OR 8.5, p0.04
• Kwashiorkor OR 2.6, p0.03
• Not associated with death
• Maternal HIV status
• Infant HIV status
• Socioeconomic status
• Water source
• Urban vs. rural residence
• Which pathogen

22
CDC findings diarrhea inpatientsCourse of
illness (n154)

• 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

23
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

24
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 lt5
  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

25
Summary of outbreak

• Unusually heavy rains caused water contamination
• Outbreak of diarrhea malnutrition with high
  mortality among children lt 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

26
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

27
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

28
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

29
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
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HIV and Infant Feeding Technical Discussions at
WHOwhat 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

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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
32
Thanks to
Useful documents, websites and list
serves HATIP HIVAIDS Treatment in Practice 74
and 75, Safer Infant Feeding, Parts 1 2
http//www.aidsmap.com/cms1037664.asp PMTCTforum_at_
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
dont have to be a CORE member to collaborate
with the working groups

• Ellen Piwoz, AED
• Tim Quick, USAID
• Mwate Chintu, Linkages PMTCT Advisor, Malawi
• Tracy Creek, CDC