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Programs to improve infant and young child nutrition in the context of HIV

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Presented at RENEWAL’s Satellite Session "Nutrition Security, Social Protection and HIV: Operationalizing Evidence for Programs in Africa" at the XVIII International AIDS Conference. By Rene Ekpini

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Programs to improve infant and young child nutrition in the context of HIV

  1. 1. Infant and young child nutrition in the context of HIV Rene Ekpini E Senior Adviser UN I CEF, N ew York Vienna , 18 July 2010
  2. 2. Mother-to-Child transmission in 100infants born to HIV-positive mother by timing of transmission 63 uninfected 15 15 7
  3. 3. Significant breakthroughs ininterventions to reduce postnatal HIV transmission • Appropriate infant feeding counselling and support for safer infant feeding practices • Lifelong antiretroviral therapy for women in need of treatment for their own health • Triple ARV prophylaxis continued through breastfeeding in HIV-positive mothers • Extended ARV prophylaxis to infants through breastfeeding
  4. 4. Exclusive breastfeeding associated with lower postnatal transmission; ZambiaThea D et al. 14th CROI , 2007, Los Angeles, CA Abs. LB 10.1% Non-exclusive BF 4.0% Exclusive BF P=0.002
  5. 5. Adverse effects of abstinence frombreastfeeding are greater in programmes than in clinical trials 0-6 months 0-12 months Botswana Clinical Trial Rakai, Uganda programme 6X 2X Thior I, Lockman S, Smeaton LM et Kagaayi J, Gray RH, Brahmbhatt H. et al. JAM A 2006; 296: 794-805 al. PLoS ONE 2008; Dec 3: e3877
  6. 6. Rates of exclusive breastfeeding in HIV- infected women in resource-limited settings
  7. 7. No overall benefit in HIV-free survivalto early cessation vs. continued breastfeedingThea D et al. 14 th CROI , 2007, Los Angeles, CA Abs. LB Stopped breastfeeding Continued breastfeeding Overall HIV-free survival among children without HIV and still breastfeeding at age 4 Months of age by group assignment (abrupt vs standard cessation) p = 0.21
  8. 8. Increased diarrhea-related hospitalizations and deaths among the weaned Fawzy A, Arpadi S, Aldrovandi G et al. IAS Conference Cape Town July 2009
  9. 9. Early cessation of breastfeeding particularlyharmful for children who became HIV-infectedThea D et al. 14th CROI , 2007, Los Angeles, CA Abs. LB Survival of HIV-infected Children with Positive Results before Age 4 Months by Group Assignment (Abrupt vs Standard Weaning) Continued Breastfeeding Stopped Breastfeeding p = 0.01
  10. 10. Maternal HAART studies to prevent HIV postnatal transmission and cumulative MTCT Between age 4-6 weeks and 6-7 months HIV transmission rates 4 non-randomized-controlled studies show reduced HIV breastfeeding transmission% TR at 6 months 6 mo EBF 6 mo EBF 6 mo EBF 6 mo EBF Courtesy: Lynne Mofenson
  11. 11. Breastfeeding, Antiretroviral and Nutrition (BAN) study3 Arms: 1) Control 2) Mothers receive LPv/r for 28 wks throughout BF 3) Breastfeeding infants received daily NVP for 6 mths 10.0 Control Maternal LPV/r Inf NVP 9.0Infant HIV transmission and mortality rates % 8.0 7.6% 7.0 6.4% 6.0 p=0.001 4.7% 5.0 p=0.003 4.0 2.9% 3% 3.0 1.8% 2.0 1.0 0.0 Transmission at 6 mo Death at 6 mo
  12. 12. PEPI-Malawi Infant Prophylaxis Trial: Postnatal HIV Infection Rates at Age 14 Weeks inInfants Uninfected at Birth by Maternal CD4 Category M ofenson L et al. I AS,Capetow n, South Africa, July 2009 Abs. TuP EC053 CD4 <200 CD4 200-350 CD4 >350 % Postnatal Relative Risk Relative Risk % Relative infection (95% CI) % Postnatal (95% CI) Postnatal Risk (95% CI) [% Efficacy] infection [% Efficacy] Infection (95% CI) (95% CI) (95% CI) [% Efficacy]Control 17.6% 1.0 9.0% 1.0 5.5% 1.0 (12.2-25.2) (5.9-13.8) (3.8-7.9)Ex tended 5.8% 0.33 3.4% 0.37 1.4% 0.25NVP (3.0-10.8) (0.16-0.68) (1.7-6.7) (0.17-0.84) (0.7-3.0) (0.12-0.59) [67%] [63%] [75%]Ex tended 6.1% 0.36 3.2% 0.32 2.3% 0.42NVP+AZT (3.3-12.4) (0.17-0.78) (1.3-6.3) (0.13-0.78) (1.3-4.1) (0.22-0.83) [64%] [68%] [58%] Extended Infant Prophylaxis is Effective in Reducing Postnatal Infection in all Maternal CD4 Cell Count Strata
  13. 13. Summary of existing evidence on the use of ARVs for PMTCT• Starting ART if maternal CD4 < 350 is critical for the health of mothers and their infants• For mothers with CD4 >350: – Efficacy of maternal HAART vs short AZT/sdNVP appears similar for preventing in utero MTCT (Kesho Bora) – Longer AP duration (AZT or HAART) is more effective – Both maternal HAART and infant prophylaxis prevent postnatal infection (BAN, Kesho Bora) – Different maternal HAART regimens appear equivalent for prevention (Mma Bana)
  14. 14. 2009 WHO guidelines refer to two key approaches1. Lifelong antiretroviral therapy for all pregnant women in need of treatment for their own health2. Maternal or infant ARV prophylaxis beginning as early as 4 weeks of gestation or as soon as possible thereafter until cessation of all breastfeeding
  15. 15. 2009 WHO recommendationsRecommendation 1:Ensuring mothers receive the care they needM others k now n to be HI V-infected should be providedwith lifelong antiretroviral therapy or antiretroviralprophylaxis interventions to reduce HIV transmissionthrough breastfeeding according to WHOrecommendations
  16. 16. 2009 WHO recommendationsRecommendation 2:M others k now n to be HI V-infected (and w hose infantsare HI V uninfected or of unk now n HI V status) shouldexclusively breastfeed their infants for the first 6months of life, introducing appropriate complementaryfoods thereafter, and continue breastfeeding for thefirst 12 months of life.Breastfeeding should then only stop once anutritionally adequate and safe diet without breastmilk can be provided.When HIV-infected mothers decide to stopbreastfeeding (at any time) they should do sogradually within one month
  17. 17. Are we there yet?
  18. 18. Translating the policy discourse into effective programme - 1 Quality data for action • Evidence-informed policy development Nationalpolicy level • Management and planning capacity atManagement and national and sub-national levelCoordination • Capacity of health care workers, counselorsService and community cadres to deliver servicesdelivery level System approach including civil society and communities
  19. 19. Translating the policy discourse into effective programme - 2 • To define what integration means on the ground – Integration is a mantra without definition – not clearly understood what interventions should/can be integrated and how • Policy advocacy for a shift toward “HIV-free survival” and, improved maternal health and survival as the preferred metric for effectiveness of PMTCT programmes • Strengthening the evidence (M&E – Operational research ) to inform policy formulation and programming around infant feeding, and maternal and child nutrition
  20. 20. Translating the policy discourse into effective programme - 3• Define the minimum IF package’ closely linked with delivery of ARVs and translate concepts (e.g. AFASS) into meaningful routine counselling practices aroung infant feeding and nutrition• Implementing IF and nutrition counselling and support as an integral component of continuum of care of pregnant women, mothers and their children (including routine immunization, cotrimoxazole prophylaxis, early infant diagnosis)• Involving individuals, families and communities as partners and clients• Promoting and supporting innovations (e.g. Rapid SMS)
  21. 21. Balancing cost and outcomesCost of scenarios - 10,000 HIV mothers (US$) Assume eligibility criteria for ART <350
  22. 22. Beyond the multitude of mountains there isa shinning sun of hope

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