Title: The substitution of infant formula for breast milk to limit HIV vertical transmission
1The substitution of infant formula for breast
milk to limit HIV vertical transmission
- Francine Noel, Marie-Marcelle Deschamps, Gyrlande
Bois,Jerry Bonhomme, Larrissa Jean-Baptiste, Jean
W. Pape - Les Centres GHESKIO,Port-au-Prince, Haiti and
Weill Medical College of Cornell University,New
York, USA - Sponsored by UNICEF, UNFPA, Elizabeth Glaser
Foundation
2Timing of HIV vertical transmission
Early Prenatal (lt36 wks)
Late Postpartum (6-24 months)
Early Postpartum (0-6 months)
Labor and Delivery
Late Prenatal (36 wks to labor)
5-10
10-20
10-20
Adapted from N Shaffer, CDC
3Feeding options recommended by WHO (2003)
- Breast-feeding
- Exclusive Breastfeeding
- Early weaning
- Heat Treatment
- Wet-nursing
- Lactarium
- Formula
- Commercial infant formula
- Home made infant formula
- Regular meal enriched with milk supplement after
6 months
4Issues
- In resource limited countries, if it were
possible to provide information regarding infant
feeding to an HIV-infected mother, the choice of
formula was impractical for economical reasons - Many questions still remain on the outcome of
children born to HIV-infected mothers who were
formula fed.
5Breast feeding-Advantages
- Bond between mother and infant (affective)
- Transmission of protective antibodies from mother
to infant - Prevention of respiratory diseases
- Prevention of diarrheal illnesses
- Economic
- Decreased frequency of pregnancies
6HIV transmission through B/F
- Duration of breast-feeding
- 0-6 months5
- 0-12 months9
- 0-24 months14
- Mixed diet (breast feeding exclusively, 25, vs
mixed diet, 36, at 15 months) - Clinical status of the mother (primary HIV
infection,clinical advanced disease)
Francine Noël, MD
7Background
- 60 of the cases of HIV reported in the Caribbean
are found in Haiti - HIV prevalence of 4-13 in women visiting
pre-natal clinics (2000) - Number of births to HIV() mothers per
year11,700 - Rate of vertical transmission estimated to be 30
8Background (continued)
- Infant mortality rate in non-infected
children80/1000 (Emmus 2000) - 60 of HIV-infected children die within a year of
age (GHESKIO)
9GHESKIO s experience-1999
- National protocol
- Number of hospitalizations and causes
- Mother
- -Prenatal care
- -AZT 300 mg bid from 36 weeks of gestation
- -AZT 300 mg every 3 hours during labor
- Newborn
- -AZT 2mg/kg / 6 hours for 1 week
- Medical follow-up
- Provision of formula for 9 months
10Formula-Implications
- 300 US salary per capita
- Average cost of 32 per child per month (288 for
9 months) - Cultural impact
- Stigmatization
- Logistic limitation potable water available for
41 of the population - Morbidity and mortality associated with an
increase of diarrheal disease
11Breast feeding situation in Haiti
- B/F in HIV() mothers varies
- B/F in HIV(-) mothers 98 initiate and 56 at
12-23 months - Mixed diet in HIV(-) mothers 70 by 3 months of
age
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15DATA
- Demographic data
- Weight at birth, 3, 6, 9, 10 months
- Number of episodes of diarrhea per child per
month and causes - Number of deaths and causes
- HIV status
16ResultsMarch, 1999-December, 2002
- 203 enrolled
- -4 breast-fed exclusively
- -25 had a mixed diet
- -172 formula-fed
- (Two children died before being fed)
- -Episodes of diarrhea/child/month in breast-fed
group.69(p0.051) - -Episodes of diarrhea/child/month in formula-fed
group.49(p0.051)
17Weight curve
18Results-continued
- -24 deaths-4/29(14) were breast-fed
- -20/172(12) were formula -fed
- Mean age of death221 days for the breast-fed
group vs 108 days in formula-fed group, p0.164
19Social impact of formula use
- Medical community
- Mothers and community
20Conclusions
- Results support evidence that provision of
formula is effective even in a limited resource
setting - Formula provision should be free of charge
- Counseling and continuous education of care
givers are mandatory - Formula provision is part of GHESKIO s protocol
with additional protein supplements after
interruption of provision
21Conclusions
- Other studies should look at
- further reduction of vertical transmission using
simpler and non-resistant protocol - - allowing breastfeeding when mothers are on HAART
22Acknowledgement
- HIV Infected mothers followed at GHESKIO
- MTCT team at GHESKIO
- SponsorsMOH, UNICEF, UNAIDS, Elizabeth Glaser
foundation - Vanderbilt University, Cornell University
23MESI ANPIL