Meeting the Challenge of Infant Feeding in the Context of HIV

Dr. JP Dadhich MD

•Coordinator, BPNI Taskforce on Research and Interventions•Co-coordinator, IBFAN Asia Pacific WG on HIV & Infant Feeding

New Delhi, India

10th IWHM, September 2005, New Delhi

Outline

• Magnitude of HIV/AIDS

• Global response

• Risk factors for transmission from parents

to child

• Challenges in HIV and IF

• Partnership

Magnitude of HIV/AIDS Pandemic

• By the end of 2003, an estimated 38 million people were infected with HIV

• Over 95 % were in developing countries

• Approximately 17 million people with HIV are women

• 2.1 million are children under 15

Known Routes of HIV transmission India

7.24

2.61 2.992.87

84.29

Sexual IDUs Blood & blood proucts Perinatal Unidentified

NACO, 2002

Situation of PTCT in India

27 million pregnancies per year

108,000 infected pregnancies

Annual Cohort of 32,000 infected newborns

0.4% prevalence

30% transmission

Overview of HIV Transmission to Children

Timing of Parent-to-child Transmission

Early Antenatal(<36 wks)

Late Antenatal(36 wks to labor)

Late Postpartum(6-24 months)

Early Postpartum(0-6 months)

Adapted from N Shaffer, CDC

5-10% 10-20% 10-20%

Labor and Delivery BreastfeedingPregnancy

PTCT in 100 HIV+ Mothers by Timing of Transmission

0

10

20

30

40

50

60

70

80

90

100

Uninfected: 63

Breastfeeding: 15

Delivery: 15

Pregnancy: 7

Risk Factors For PTCT

• Feeding method

• Immune/health status of mother

• Plasma viral load

• Breast inflammation (mastitis, abscess,

bleeding nipples)

Early Mixed Breastfeeding

7

16

19

25

7

2426

36

0

5

10

15

20

25

30

35

40

Birth 3 mo 6 mo 15 mo

% EBF to 3 moPartial BF

Coutsoudis et al, 1999; 2001

Cumulative HIV transmission Durban, SA

Exclusive Breastfeeding Falls Rapidly From First Month Onwards

0

20

40

60

80

100

< 1 1 2 3 4 5 6

Months

Perc

en

tag

es

Exclusive Breastfeeding Mixed Feeding

(NFHS-II-1999)

Maternal Virus Load and Perinatal Transmission

Viral Load Transmission Rate (%)

< 1000 copies/ml 0

1000 –10000 16.6

10,001-50,000- 21.3

50,001-100,000 30.9

> 100,000 40.6

Garcia BM. NEJM, 1999

Maternal Immune Status

HI V transmission from 6 w - 24 mo in

West Africa by maternal baseline CD4

21.8

2

0

5

10

15

20

25

CD4 < 500 CD4 >= 500

Transmission

(%)

Leroy et al 2003

Breast Pathology

Prevalence of breast pathologies on clinical exam.InHIV+ women in Africa

• Mastitis: 7-11% • Nipple lesions: 11-13% • Breast abscesses:12%

Estimated f raction of MTCT

due to breast infection

1820

0

5

10

15

20

25

Malawi Kenya

%

(Embree et al; John et al; Semba et al)

Technical and Programmatic Guidance

Global strategy on infant and young child feeding (2002)

HIV & infant feeding: framework for priority action

(who/UNICEF/UNFPA/UNAIDS/world bank/UNHCR/WFP/FAO/IAEA)

HIV & infant feeding: guidelines for decision-makers

(WHO/UNICEF/UNFPA/UNAIDS)

HIV & infant feeding: A guide for health care managers and

supervisors (WHO/UNICEF/UNFPA/UNAIDS)

WABA/UNICEF colloquium at Arusha 2002

IBFAN/BPNI/UNICEF colloquium at new Delhi 2003

Unique Global Consensus

• 9 UN agencies ratified in 2003

• 5 priority actions, first being development of policy and plans for IYCF including HIV, promotion of exclusive breastfeeding for ALL babies

WHO/UNAIDS/UNICEF Guidelines on HIV&IF (1997-2005)

HIV- or status unknown• Exclusive breastfeeding

(EBF) for 6 months and continued breastfeeding for 2 years

HIV+• When replacement feeding

is acceptable, feasible, affordable, safe and sustainable, avoidance of all breastfeeding is recommended.Otherwise EBF is recommended for the first months of life

Feeding Options for First 6 Months

• Replacement feeding:– Commercial infant formula– Home-modified animal milk

• Breastfeeding:– Exclusive with early cessation

• Breast-milk feeding options:– Expressed and heat-treated BM– Wet-nursing– BM banks

Summary of Background

• Major public health problem with socio-economic dimensions

• Global guidelines are available

• Fair knowledge about the mode and various risk factors for PTCT

Challenges in HIV and IF

Challenges….

Implementation of UN tools and inclusion of PTCT in national programs is not a

priority

HIV IF – Status at National Level5 Country Assessment IBFAN-AP, WABA; 2005

Issue CountryA’stan B’desh Indonesia Malaysia Nepal

National program on HIV/AIDS

No Yes Yes Yes No

Nodal agency on HIV

No Yes Yes Yes No

Policy on PPTCT No Yes Draft ready

Yes No

National policy on HIV IF

No No Yes

AF

Yes

AF

No

Capacity building in IF Counseling

absent absent Lack of training program

Needs strengthening

Absent

Challenges….

• Information to parents and community is negligible, inadequate and improper

• Training of health workers and counselors is lacking or inadequate

Where HIV+ Women Receive Counseling and Free Infant Formula,

Its Use Is Not Optimal

100% 98%89%

33%

46%

0%

20%

40%

60%

80%

100%

120%

Brazil

Thailand

Botswana

Uganda

Cote d"I voire

Bacterial Contamination and Improper Preparation of Commercial Infant Formula in a PMTCT Program (Durban, South Africa)

Contamination of milk samples 64% E Coli 26% Enterococci

Over dilution of milk samples 22% for infants <= 12 months78% for children > 12 months

Bergström, 2003

Assessment of PPTCT CounselorsBPNI, NACO -2004

• Inadequate, Biased Knowledge

• Inappropriate Practices

• Insufficient Skill Transfer

Challenges….

Keeping mothers healthy is not a priority action

Focus on Maternal Health & Nutrition

• Keeping HIV+ mothers well may be among the

most important things we can do to prevent P/N

transmission and maternal survival

• BF transmission was ~2% between 6 w-24

months in women with CD4 >500 (Leroy et al,

2003)

• No programmatic intervention to ensure maternal

health

Expanding Use of ARVs

• Legitimate demand for a single standard of care regardless of socioeconomic conditions currently HAART for mother, peri-natal ARV therapy

• Lower prices, wider variety of available regimens, easier logistics, expanding postnatal use and availability of ARVs

Challenges….

• Infant feeding is linked with child survival, but ignored in context to HIV

• Paucity of research directed towards HIV free survival

• Available research is not being disseminated

Proportion of All < 5 Yrs Deaths That Could Be Prevented With Infant Feeding Interventions

13

6

2

0

5

10

15

Breastfeeding ComplementaryFeeding

NVP+RF

Jones et al, 2003, Lancet

*

*Estimate would be 15% without effects of HIV

Risks of artificial feeding(in developing countries risks are elevated above these levels)

Increased levels of accute illness:• Respiratory infections• Middle ear infection: 3-4x risk• Gastroenteritis: 3-4x risk (developing countries 17-

25x)• Bacterial infection requiring hospitalization: 10x risk• Meningitis: 4x risk

• Higher mortality from sudden infant death syndrom (SIDS)

HIV/Infant feeding is about Assessing the risks

Breastfeeding Formula

HIV Mortality

Ross J et al. 2004, AJPH

Cumulative HIV-free Survival

600.0

650.0

700.0

750.0

800.0

850.0

900.0

0 6 12 18 24

Age (months)

HIV

-free

sur

vivo

rs/1

000

live

birt

hs

No postnatalintervention/Status Quo BFpatterns (B24)

No BF by HIV-infected mothers(B0)

Short duration (6 months) BFby HIV-infected mothers (B6)

Short duration "safer" BF (6months) by HIV-infectedmothers (SB6)

"Safer" BF (24 months) by HIV-infected mothers (SB24)

Model for Per 1000 HIV-Positive Mothers

(IMR 96) Ross and Labbok, AJPH, 2004

Feeding Mode and Survival

• Multi-centric trial from Ghana, India, Peru

• Published in bulletin of WHO

• Non-breastfed infants had a higher risk of dying V/V breastfed infants

Bahl et al. 2005

Challenges….

Making feeding safer is not seen as an option to prevent PTCT

Strengthen Approaches for Making Breastfeeding Safer for ALL Women

• Provide adequate lactation counseling and support, involving families/communities– Increase adherence to exclusive breastfeeding– Prevent cracked nipples, maintain breast health

• Immediate treatment for mastitis, other systemic infections that could affect viral load in BM– Could prevent a sizeable fraction of BF transmission

• Safe sex/condom use for prevention of fresh inf

Make Breastfeeding Safer for HIV+ Women

• Avoid mixed feeding,ensure exclusive breastfeeding

• Prevent breast problems• Minimize maternal viral load• Improve maternal immunity• Provide ARVs to mother and child

Make Replacement Feeding Safer for HIV+ Women

• Provide safe water & environmental conditions

• Adequate sustained supply

• Ensure hygiene

• Family support, community understanding – take care of stigma

Challenges….

Policy makers, planners, health care providers and counselors are not

sensitized on gender issues

 Gender Issues in HIV and Infant

Feeding

• The terminology used “mother to child transmission” (MTCT) puts the blame on the mother, the woman – who is already often a victim of the HIV epidemic

• Stigma and discrimination against the women is much stronger

• Often seen as a vector, blamed for spread• Risks violence, abandonment, neglect,

destitution

Gender Issues in HIV and Infant Feeding

• Information from health system almost always directed at mothers/women

• Women/mothers are tested, women are made responsible for feeding, caring etc

• Men are not targeted as equally responsible

Issues for Partnership

• Gender sensitization of policy makers,

planners, health care providers, media and

counselors

• Universalizing preventive services like VCT,

skilled counseling on feeding options

• Empowering parents to choose interventions

which ensures improved HIV free survival

• Publicizing available research and knowledge

Thanks !!!!

Thanks !!!