POSITIVELY BREASTFEEDING:of HIVA descriptive study of the MTCTfollowing the implementation of WHO2010 breastfeeding guidelines in Haiti Jordan Dozier, MD Keisha Bonhomme, MD
Objectives To describe the possible risk of HIV transmission in pediatric patients breastfed by HIV-infected mothers from 2008-2012 To discuss how the implementation of the WHO 2010 breastfeeding guidelines have been received in other resource limited countries.
BACKGROUND Breastfeeding involves considerable risk of HIV transmission Risk of MTCT without breastfeeding is 15-25% in mothers not on ARV prophylaxis Risk increases 5-20% to a total of 20-45% Cumulative effect However, not breastfeeding in resource-limited settings present considerable risk to infant survival According to the MASHI study conducted by Lockman et al. breastfeeding in comparison to breast-milk substitutes reduces infant morbidity and mortality associated with infectious diseases, i.e. diarrhea
BACKGROUND WHO breastfeeding guidelines over the years: 2001- when replacement feeding is AFASS HIV-infected mothers should avoid breastfeeding; otherwise exclusive breastfeeding for the first few months of life is recommended. 2006- guidelines updated to more strongly communicate need for implementation of exclusive breastfeeding 2009- guidelines updated to incorporate recent evidence of ARV role in decreasing MTCT 2010- guidelines updated to include recommendations whose objective is to balance HIV prevention with protection from other causes of child mortality
BACKGROUND Theory into Action! A study conducted between 2003 – 2007 by Homsy et al in rural Uganda looked at the effect HAART had on MTCT in the context of EBF. Out of 118 infants born, 114 of which had at least one PCR test conducted and 93% of which were exclusively breastfeeding, there were ZERO cases of MTCT transmission. There was however a 19% mortality rate in this cohort. (>65% due to gastroenteritis) Important to note however was that there was a SIX FOLD increase risk of death associated with early weaning (< 6 months)
METHODS Criteria: Four sites were chosen from a national database solely consisting of pediatric patients. Only sites with greater than 150 patients were included. Patients who received two or more PCR tests with documented results were further assessed. Amongst those patients the following data were observed: Conversion vs Non-conversion Delay in days between each test (Mean, Range)
METHODS Database of 794 GHESKIO HIV-exposed pediatric patients and 911 tests from 2008-2012 Database of HIV-exposed pediatric patients from 2010-2012 St. Damien (244 pts / 294 tests) Cayes (218 pts / 237 tests) Cap Haitien (159 pts / 177 tests) Patient demographics did not include information on infant age, breastfeeding compliance or maternal ART compliance
RESULTSSite # pts with ≥ 2 tests Mean delay between tests (range)GHESKIO 113 130.8 (1 to 549 days...)St Damien 49 115.5 (11 to 362 days)Cayes 18 147 (21 to 250 days)Cap Haitien - Justinien 18 173 (21 to 407 days)
RESULTS In total, there were two patients who had a change in HIV status from Negative to Positive: One from GHESKIO (delay: 529 days) One from St. Damien (delay: 144 days) There were no conversions noted from Positive Negative, reflecting the sensitivity of PCR testing There were 11 patients who had tests repeated but results were not available at the time of this analysis
CONCLUSIONSAll conclusions are made under the presumption that HIV+ mothers have been compliant with both their ART treatment as well as have exclusively breastfed their children.Given the observed occurrence of two conversions out of 1415 patients, the risk of transmission may be minimal in ARV compliant mothers who breastfeed.However, further assessment of the benefits involved with breastfeeding is needed to conclusively determine if the national recommendation has had a positive effect on the morbidity and mortality of infants in Haiti.
DISCUSSION Possible Confounders GHESKIO culture vs. General practice throughout Haiti Maternal ART compliance Breastfeeding compliance within the context of cultural change How to improve compliance? Decrease availability of free formula (nationally) in hopes of reducing the common practice of mixed feeding Prospective, controlled study needed to draw definitive conclusion
DISCUSSION cont’d Home Visits? Study in Uganda showed that home-based peer counseling improved levels of exclusive breastfeeding Mothers appreciated non-dogmatic, non-didactic approach of peer-counselors (71%) vs health-care worker (16%) Women felt empowered by lessons learned and justified in decision to refuse old formula feeding practices
DISCUSSION cont’d Standardized counseling sessions? Weakness in success of PMTCT programs is the continuous change of policy framework In a study conducted by Doherty et al in South Africa, poor quality of counseling, unclear counselor messages and availability of free formula provided incentive to choose formula Partner involvement; in a study conducted by Moland et al modifications to infant feeding were shown to be highly dependent upon male support in some settings
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