Chatterjee (UNICEF) on HIV and Infant Feeding


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  • Chatterjee (UNICEF) on HIV and Infant Feeding

    1. 1. Infant feeding in the context of HIV: Challenges in resource limited settings Anirban Chatterjee, MD; DSc. UNICEF New York
    2. 2. Overview of presentation <ul><li>Epidemiology of child mortality and HIV </li></ul><ul><li>Evidence on risks with different feeding options </li></ul><ul><li>Support for HIV-positive mothers </li></ul><ul><li>infant feeding decisions </li></ul>
    3. 3. 9.2 million died before they reached their fifth birthday Loaiza E, et al. Lancet 2008
    4. 4. Total: 33 million (30 – 36 million) Western & Central Europe 730 000 [580 000 – 1.0 million] Middle East & North Africa 380 000 [280 000 – 510 000] Sub-Saharan Africa 22.0 million [20.5 – 23.6 million] Eastern Europe & Central Asia 1.5 million [1.1 – 1.9 million] South & South-East Asia 4.2 million [3.5 – 5.3 million] Oceania 74 000 [66 000 – 93 000] North America 1.2 million [760 000 – 2.0 million] Latin America 1.7 million [1.5 – 2.1 million] East Asia 740 000 [480 000 – 1.1 million] Caribbean 230 000 [210 000 – 270 000] Adults and children estimated to be living with HIV, 2007
    5. 5. Estimated number of children (<15 years) newly infected with HIV, 2007 Total: 370 000 (330 000 – 410 000) Western & Central Europe <200 [<100] Middle East & North Africa 5700 [3800 – 8000] Sub-Saharan Africa 330 000 [300 000 – 360 000] Eastern Europe & Central Asia 3200 [2400 – 4300] South & South-East Asia 21 000 [14 000 – 29 000] Oceania <1000 North America < 500 [<200] Latin America 4600 [4200 – 8300] East Asia 2000 [1200 – 3100] Caribbean 1800 [1500 – 2100]
    6. 6. Preventive interventions for improving child survival Jones et al, Lancet, 2003
    7. 7. Not breastfeeding increases risk of infectious disease mortality Relative risk Age (months) WHO Collaborative Study Team, Lancet, 2000 Nearly 6 times increased risk of death in early infancy if not breastfeeding
    8. 8. Poor hygiene increases risk of infant mortality Habicht et al, Mother's milk and sewage, Paediatrics, 1988 Nearly 5 times increased risk of death if not breastfeeding AND do not have access to safe water and toilets
    9. 9. Timing and risk of mother-to-child transmission (MTCT) of HIV
    10. 10. Timing and risk of mother-to-child transmission (MTCT) of HIV De Cock KM, JAMA 2000;283(9):1175-82 Breast-feeding Non-breastfeeding Timing 25-45 % 15-30 % Total 40 % 10-15 % - - Postnatal 40 % 10-20 % 67 % 10-20 % Intra-partum 20 % 5-10 % 33 % 5-10 % In-utero Proportion MTCT Proportion MTCT
    11. 11. Average MTCT in 100 HIV+ Mothers by Timing of Transmission Uninfected: 65 Breastfeeding: 15 Delivery: 13 Pregnancy: 7
    12. 12. Risk factors for HIV transmission through breastfeeding <ul><li>Maternal </li></ul><ul><li>Immune status (CD4) </li></ul><ul><li>Viral load (in blood, BM) </li></ul><ul><li>Breast health problems (mastitis) </li></ul><ul><li>Sero-conversion while Breastfeeding </li></ul><ul><li>Infant </li></ul><ul><li>Breastfeeding duration </li></ul><ul><li>Breastfeeding pattern </li></ul><ul><ul><li>Exclusive vs. mixed </li></ul></ul><ul><li>Oral lesions </li></ul>
    13. 13. Does replacement feeding always lead to better outcomes?
    14. 14. Risks of formula feeding among HIV-exposed children <ul><li>Botswana MASHI Study: feeding intervention </li></ul><ul><li>1200 women randomized to: </li></ul>Formula feed with 1 month ZDV prophylaxis (government standard) Exclusively breastfeed with extended infant ZDV prophylaxis through 6 months vs. <ul><li>Thior et al, JAMA, 2006 </li></ul>Research Question : Will formula feeding lead to better outcomes among HIV-exposed children
    15. 15. Early Mortality is Higher in Formula-Fed Infants Thior I et al. JAMA 2006;296:794-805 p=0.21 p=0.003 p=0.005 Predominant causes of infant death: Diarrheal disease and pneumonia
    16. 16. Early mortality higher in formula fed children in South Africa Coovadia et al., Lancet , 2007 15 % Replacement Feeding 6 % Exclusive BF Mortality at 3 mth of age Infant Feeding practice
    17. 17. Increased hospitalization among replacement fed children in India Phadke MA, et al. Journal of Nutrition 2003 27 86 Replacement-fed 0 62 Breast-fed Number of hospitalizations Number of children Infant Feeding Practice
    18. 18. Can HIV transmission through breastfeeding be reduced?
    19. 19. Exclusive breastfeeding carries lower risk of HIV transmission than mixed feeding (South Africa) Hazard ratio Coovadia et al., Lancet , 2007
    20. 20. Exclusive breastfeeding reduced HIV transmission: Zimbabwe Iliff et al, AIDS, 2005
    21. 21. What is the evidence on use of HAART for PMTCT?
    22. 22. Antiretrovirals during breastfeeding <ul><li>Increasing evidence that ART to breastfeeding mothers who need them for their own health brings low rates of breastfeeding transmission. </li></ul><ul><li>Two major approaches being studies </li></ul><ul><li>HAART for mothers during pregnancy and breastfeeding </li></ul><ul><li>Prophylaxis to children </li></ul>
    23. 23. Antiretrovirals during breastfeeding: Treatment to mothers <ul><li>Kisumu Breastfeeding Study, Kenya (maternal ART) </li></ul><ul><ul><li>Transmission 3.9% at 6 weeks, 6.7% at 18 months </li></ul></ul><ul><li>MASHI, Botswana (maternal ART and infant prophylaxis) </li></ul><ul><ul><li>Transmission 1.2% at one month for breastfeeders, 1.1% for formula feeders </li></ul></ul><ul><li>Kesho-Bora (5 sites in Africa) (maternal ART) </li></ul><ul><ul><li>Transmission at 12 months 7.6% with CD4<200; 5.8% >500 (7.5% in BF, 0% in never-BF) </li></ul></ul>
    24. 24. Antiretrovirals during breastfeeding: Extended prophylaxis to infants <ul><li>PEPI-Malawi </li></ul><ul><ul><li>14 weeks NVP or NVP+ZDV to infant, BF cessation at 4 – 6 months </li></ul></ul><ul><ul><li>9 months transmission 5.2% /6.4% (10.6%) </li></ul></ul><ul><ul><li>18 months transmission 10.1%/10.2%, not much better than sdNVP + 1 week AZT (13.9%) </li></ul></ul><ul><li>SWEN (Ethiopia, India, Uganda) </li></ul><ul><ul><li>NVP for 6 weeks </li></ul></ul><ul><ul><li>Transmission at 6 weeks 2.5% vs 5.3% for sdNVP </li></ul></ul><ul><ul><li>Transmission at 6 months not significantly different </li></ul></ul><ul><ul><li>Very high resistance </li></ul></ul>
    25. 25. Public Health Implications <ul><li>Issues of drug resistance and future treatment options for mother and/or child. </li></ul><ul><li>Safety issues for the child as yet unknown. </li></ul><ul><li>How long should ART be given to mothers- since duration of breastfeeding varies so much? </li></ul><ul><li>Need consultation once final results from ongoing studies become available </li></ul>
    26. 26. Recommendations for HIV-positive women <ul><li>Depends on individual circumstances , including consideration of health services, counselling and support available </li></ul><ul><li>Exclusive breastfeeding for first six months of life recommended if replacement feeding not AFASS: </li></ul><ul><ul><li>A cceptable </li></ul></ul><ul><ul><li>F easible </li></ul></ul><ul><ul><li>A ffordable </li></ul></ul><ul><ul><li>S ustainable AND </li></ul></ul><ul><ul><li>S afe </li></ul></ul><ul><li>If AFASS, then exclusive replacement feed from birth </li></ul><ul><li>Repeated assessments , including at time of early infant diagnosis and at six months </li></ul>
    27. 27. Balancing risks for HIV-positive women <ul><li>Increased risk of </li></ul><ul><li>HIV transmission </li></ul><ul><li>(However not all infected) </li></ul><ul><li>IF BREASTFEEDING </li></ul>Increased risk of Mortality Infectious diseases Malnutrition IF NOT BREASTFEEDING
    28. 28. Acceptable <ul><li>The mother perceives no barrier, cultural or social, to replacement feeding and has no fear of stigma. She will be able to cope with pressure from family and friends to breastfeed. </li></ul><ul><li>While some formula feeding is “acceptable” in many countries, is total avoidance of breastfeeding “acceptable”? </li></ul>
    29. 29. Is formula feeding really acceptable? When they see me coming with the tins they laugh at me . There’s a lot of thinking within the community that the babies that are fed on formula are those who are HIV-positive She fetches the milk with a bag and she waits till the clinic is empty so they do not see what type of milk is there Doherty TD et al. Bull of WHO 2006 In settings with general access to clean water, structured antenatal counseling and sustained provision of free infant formula approximately half of HIV positive women chose replacement feeding Leroy V, JAIDS 2007 South Africa Ivory Coast
    30. 30. Feasible <ul><li>The mother has adequate time, knowledge, skills and other resources to prepare the replacement food and feed the infant up to 12 times in 24 hours. </li></ul><ul><li>Do mothers have extra time to prepare formula when it’s only food infant will have for first 6 months? </li></ul><ul><li>Need for reasonable home infrastructure and family support, especially for night feeds. </li></ul><ul><li>Availability of electricity, electric kettle, bottle cleaning brush, flask to store boiled water were found to be important </li></ul>Doherty T, et al. J Nut 2006
    31. 31. Affordable <ul><li>The mother and family can purchase formula, including all ingredients, fuel, clean water, soap and equipment, without compromising the health and nutrition of the family, and also possible increased medical costs. </li></ul><ul><li>If provided for free, can government/NGOs afford to give formula to all HIV-positive women for as long as infant needs it? </li></ul><ul><li>If not free, what if circumstances change in the first six months? </li></ul>
    32. 32. Cost of infant formula for 12 months in different countries (2003) <ul><li>China- $200 </li></ul><ul><li>India - $117 </li></ul><ul><li>Nigeria- $311 </li></ul><ul><li>Thailand-$251 </li></ul><ul><li>Zimbabwe-$125 </li></ul><ul><li>This is just the cost of formula and does not include fuel, water or health care costs . </li></ul><ul><li>It represents between 22-107% of GNI/capita in different countries </li></ul>
    33. 33. Sustainable <ul><li>Availability of a continuous and uninterrupted supply and dependable system of distribution of formula for as long as the infant needs it. </li></ul><ul><li>If provided for free, will supply system be able to cope? </li></ul><ul><li>Will mother always be able to find it when needed?   </li></ul>
    34. 34. Maintaining sustainable supply of infant formula <ul><li>Evidence from Botswana highlights the difficulty in maintaining availability at facility level-storage, distribution, projection of needs. </li></ul><ul><li>Most received appropriate amounts at birth </li></ul><ul><li>After birth mothers received only 51% of the supply they needed </li></ul><ul><li>Mothers had to return multiple times but still could get enough supplies </li></ul>
    35. 35. Safe <ul><li>Replacement foods are correctly and hygienically prepared and stored, and fed in nutritionally adequate quantities, with clean hands and with clean utensils, preferably by cup. </li></ul><ul><li>Is there a safe water supply? Can water be hot each time? </li></ul>
    36. 36. Progress towards the MDG target on safe drinking water, by region (1990 and 2004)
    37. 37. Modeling the impacts of different feeding options <ul><li>Among HIV-uninfected children born to HIV-positive mothers in Africa </li></ul><ul><li>9.6% would be saved yearly with exclusive breastfeeding </li></ul><ul><li>vs. </li></ul><ul><li>4% with replacement feeding </li></ul>David S et al. J Hum Lact 2008
    38. 38. Usefulness of AFASS criteria for reducing risk of HIV transmission or death South Africa Doherty T et al, AIDS 2007 Criteria Piped water Fuel Status divulged
    39. 39. Pre-conditions for supplying formula <ul><li>Code implemented to prevent “spillover” </li></ul><ul><li>Formula only to HIV-positive women where other AFASS conditions met </li></ul><ul><li>Guidelines for distribution available </li></ul><ul><li>Counsellors trained </li></ul><ul><li>Health and nutritional status of infants monitored </li></ul><ul><li>Supplied for as long as infant needs it </li></ul>
    40. 40. Do no harm <ul><li>Programs offering free infant formula must </li></ul><ul><li>Avoid creating a situation which promotes inequity and where only women with access to safe water, electricity and better education are benefiting. </li></ul><ul><li>Avoid creating a situation where infant formula is seen as a better option than breast feeding even by HIV-uninfected women. </li></ul><ul><li>Ensure closer follow-up of children on infant formula for infectious disease morbidity. </li></ul>
    41. 41. Supporting a mother at key decision points in first months <ul><li>Early infant diagnosis (PCR) at 6 weeks : </li></ul><ul><ul><li>Baby HIV-negative: mother may feel obliged to stop breastfeeding, so need for supportive counselling to decide on best option </li></ul></ul><ul><ul><li>Baby HIV-positive: continue breastfeeding </li></ul></ul><ul><li>Continued counselling and support for all mothers </li></ul>
    42. 42. Supporting a mother when practices change <ul><li>At 6 months of age : </li></ul><ul><li>Breast milk by itself no longer sufficient– decision needs to be taken on whether to continue some breastfeeding </li></ul><ul><li>If other milks, animal source-foods available – cease all breastfeeding and give other foods </li></ul><ul><li>No such foods available – continue breastfeeding </li></ul><ul><li>Continued counselling and support for all mothers </li></ul>
    43. 43. Conclusions <ul><li>Appropriate Infant feeding by HIV+ mothers is critical for HIV-free child survival and involves balancing of risks . </li></ul><ul><li>Exclusive breastfeeding for 6 months can substantially reduce HIV transmission. </li></ul><ul><li>Formula feeding will be a better choice only if it is AFASS and mother can do exclusive formula feeding . </li></ul>
    44. 44. Conclusions <ul><li>Current experience from PMTCT programmes providing free infant formula does not suggest it is achieving the desired impact- i.e. increasing HIV-free child survival </li></ul><ul><li>Mothers and children need close and continued support for infant feeding - irrespective of choice </li></ul>
    45. 45. Acknowledgements <ul><li>Ellen Piwoz </li></ul><ul><li>Peggy Henderson </li></ul><ul><li>Tracy Creek </li></ul>