Exclusive Breastfeeding and Prevention of Mother-to-Child Transmission Counseling in the Context of HIV/AIDS

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Exclusive Breastfeeding and Prevention of
Mother-to-Child Transmission Counseling in the
Context of HIV/AIDS

• Evidence-based Guidance from these UN Agencies
  UNAIDS, UNICEF, WHO, UNFPA (United Nations
  Population Fund)

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Talking Points

• Exclusive Breastfeeding in normal circumstances.
• Risk of Mother-to-Child Transmission (MTCT) of
  HIV infection overall and from breastfeeding.
• Risk of not breastfeeding in resource-poor
  settings.
• What is the Optimal Feeding Plan for infants of
  women living with HIV/AIDS? Recommendations from
  the UN
• Guiding a mother to the Optimal Feeding Plan
  according to her unique situation.
• Implementing, counseling, and supporting the
  mother and her feeding choice.

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UN and Global Objectives

• To increase child survival, while reducing HIV
  infection in infants and young children.
• Prevention of HIV transmission through
  breastfeeding should take into consideration the
  broad context of the need to promote
  breastfeeding of infants and young children in
  the general population.i

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Exclusive Breastfeeding in Normal Circumstances

• Exclusive breastfeeding for the first 6 months.
• 6-24 months Breastfeeding with appropriate
  complementary feeding.
• This is the recommended feeding plan in terms of
• Health and nutrition of the infant
• Health of the mother
• Benefits to the community and society as a whole

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Overall HIV Infection Rates of Infants Born to
HIV Positive Women

• Timing Transmission rate
• During pregnancy 510
• During labour and delivery 1015
• During breastfeeding 520
• Overall without breastfeeding 1525
• Overall with breastfeeding to 6 months 2035
• Overall with breastfeeding to 18 to 24
  months 3045

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Maternal risk factors for increased transmission
rate

• Low CD4 count
• High viral load in breastmilk and plasma
• Maternal seroconversion during breastfeeding
• Longer breastfeeding duration
• Breast conditions (i.e. mastitis)
• Nutrition status may influence risk of
  transmission overall and BF transmission

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Risk of not breastfeeding in resource poor
settings

• Higher exposure to infectious disease and
  malnutrition
• Varies with environment
• Availability of suitable replacement feeds and
  clean water
• Varies with individual circumstances
• Mothers education and economic status
• Meta-analyses show that not breastfeeding
  increases the risk of mortality
• -six-fold in the first two months
• -2.5 fold in the first six months
• -Increased risk continues to decline
  thereafter

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Relative risk for diarrhea mortality (0-1 month)
by type of feeding
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Behavior Change Communication to promote broad
public awareness

• Key Messages
• Exclusive breastfeeding as the social norm.
• Importance of continued breastfeeding and
  complementary feeding
• HIV/AIDS awareness and prevention, including
  testing
• Urging men to protect women from HIV-infection

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Current UN Recommendations for infant feeding in
the Context of HIV/AIDS

• HIV-infected women should exclusively breastfeed
  their infants, since research shows it is more
  beneficial than predominant or partial
  breastfeeding in terms of the overall health of
  the infant as well as risk of transmission.
• The most appropriate infant feeding option for
  an HIV-infected mother should continue to depend
  on her individual circumstances, including her
  health status and the local situation, but should
  take greater consideration of the health services
  available and the counseling and support she is
  likely to receive.
• When replacement feeding is acceptable,
  feasible, affordable, sustainable, and safe
  (AFASS), avoidance of all breastfeeding by
  HIV-infected mother is recommended. Otherwise,
  exclusive breastfeeding is recommended for the
  first months of life.

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• National programmes should provide all
  HIV-exposed infants and their mothers with a full
  package of child survival and reproductive health
  interventions with effective linkages to HIV
  prevention, treatment and care services. In
  addition, health services should make special
  efforts to support primary prevention for women
  who test negative in antenatal and delivery
  settings, with particular attention to the
  breastfeeding period.
• Governments should ensure that the package of
  interventions referenced above, as well as the
  conditions described in current guidance, are
  available before any distribution of free
  commercial infant formula is considered.

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Replacement Feeding Options

• Commercial infant formula
• Wet nursing by an HIV-negative woman.
• Breastmilk banks
• Expressing and heat-treating breastmilk
• Home modified animal milk

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Updated Findings and Recommendations

• Home modified animal milk no longer recommended
  as a feeding replacement for all six months due
  to a lack of sufficient micronutrients.
• Evidence shows that mixed feeding of breastfeed
  and replacement feeding carries a higher risk of
  transmission than exclusive BF.
• Early cessation of breastfeeding is no longer
  recommended unless there is an AFASS replacement
  feeding option. This included breastfeeding
  after 6 months age.
• Data from Zambia confirmed previous
  recommendations that infants who are HIV-infected
  should continue to be breastfed.

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Guiding HIV-infected mothers to their optimal
feeding choice
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Guiding HIV-positive mothers

• Infant feeding counseling and support should be
  incorporated into antenatal care and MCH services
  as soon as possible.
• Is AFASS replacement feeding available?
• No Advise exclusive breastfeeding
• Yes Review replacement feeding options
• AFASS, rather than the mothers immune status,
  should be the main factor in balancing the risks.

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Implementing, counseling, and supporting the
mother and her feeding choice
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Implementing, counseling, and supporting

• Inform mother of benefits and risks of each
  feeding option and whether or not AFASS options
  are available
• Coercion or counselor bias should be avoided
• Support mothers feeding choice
• Monitor infants growth
• Early infant diagnosis at 6 weeks
• Continue counseling and MCH services for 24
  months

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References

• Inter-agency Task Team WHO, UNICEF, UNAIDS,
  UNFPA. HIV Transmission through Breastfeeding A
  review of available evidence. World Health
  Organization, 2004
• Inter-agency Task Team WHO, UNICEF, UNAIDS,
  UNFPA. HIV Transmission through Breastfeeding A
  Guide for Decision-Makers. World Health
  Organization, 2003
• Inter-agency Task Team WHO, UNICEF, UNAIDS,
  UNFPA. HIV and Infant Feeding An Update. World
  Health Organization, 2007

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Thank You

• Questions?