This document summarizes an update published in 2007 on HIV transmission through breastfeeding. It reviews scientific evidence from 2001 to 2007 on the risk of HIV transmission through breastfeeding, the impact of different infant feeding options on child health outcomes, and strategies to reduce transmission through breastfeeding in developing countries. The update aims to inform public health recommendations around infant feeding by HIV-infected mothers.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
This lecture describes the approach to screening, diagnosis and management of HIV and TB infection among pregnant patients. Prevention of Mother to Child Transmission of HIV infection mainly based on the Philippine Obstetrical and Gynecological Society Clinical Practice Recommendations.
Family planning counselling involves helping clients make informed choices about family size and birth spacing. It is done through individual, couple, or group counselling. The counsellor provides information about available methods, their pros and cons, and ensures clients understand how to properly use the chosen method. Effective counselling follows principles like maintaining privacy and receiving informed consent. Counsellors should be respectful of clients' cultural beliefs and use a step-by-step approach like BRAIDED or GATHER to determine needs, provide options, help choose a suitable method, demonstrate its use, and arrange follow-up care.
Vertical transmission is major contributor- HIV among children
No intervention – as high as 45%
With interventions – as low as less than 5%
Minimal manipulation
NVD vs. C-section
Anti retroviral prophylaxis vs. anti retroviral therapy
Exclusive breastfeeding vs. exclusive replacement feeding
Follow-up and care.
This document discusses HIV/AIDS, including transmission, signs and symptoms, stages of infection, treatment and prevention of mother-to-child transmission. It notes that HIV can be transmitted sexually, through infected body fluids or from mother to child. The stages of infection are acute infection, clinical latency and AIDS. Signs may include flu-like symptoms during acute infection and infections over time as immunity declines. Prevention of mother-to-child transmission is important, as without intervention up to 45% of babies may be infected, but can be reduced to less than 5% with antiretroviral treatment and safe delivery practices.
- Teenage pregnancy rates in Sarawak, Malaysia are high, with over 40% of adolescents being unmarried and birth rates of 62 per 1000. Teenage pregnancies often result in negative health outcomes for both mother and child such as preterm birth, low birth weight, increased risk of infection, and interrupted education.
- Issues with teenage pregnancy include biological immaturity of the mother, higher risks of pregnancy complications, and social issues like poor nutrition, substance abuse, and interrupted education. Teenage mothers also face higher risks of domestic abuse and their children have an increased likelihood of developmental and social problems.
- Management of teenage pregnancies focuses on nutrition counseling, antenatal care, treating infections,
Prevention of Mother to Child Transmission of HIV 2018Helen Madamba
Babies of pregnant women living with HIV can be born free of HIV infection. HIV counselling and testing is the gateway to diagnosis, treatment, care and support. Healthcare services need to provide enabling environments to support and empower women living with HIV and their children, to increase HIV knowledge and reduce stigma and discrimination.
Mother to child transmission of HIV can occur during pregnancy, childbirth, and breastfeeding. The risk is higher if the mother's HIV infection is in an advanced stage, if she is malnourished, has other STDs, or her membranes rupture early. Antiretroviral therapy and cesarean delivery before labor can reduce transmission risk. Exclusive breastfeeding for 6 months poses a lower risk than mixed feeding. India's PMTCT program provides counseling, testing, antiretroviral prophylaxis to pregnant women and newborns to prevent transmission and aims to reduce transmission by 50% by 2010.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
This lecture describes the approach to screening, diagnosis and management of HIV and TB infection among pregnant patients. Prevention of Mother to Child Transmission of HIV infection mainly based on the Philippine Obstetrical and Gynecological Society Clinical Practice Recommendations.
Family planning counselling involves helping clients make informed choices about family size and birth spacing. It is done through individual, couple, or group counselling. The counsellor provides information about available methods, their pros and cons, and ensures clients understand how to properly use the chosen method. Effective counselling follows principles like maintaining privacy and receiving informed consent. Counsellors should be respectful of clients' cultural beliefs and use a step-by-step approach like BRAIDED or GATHER to determine needs, provide options, help choose a suitable method, demonstrate its use, and arrange follow-up care.
Vertical transmission is major contributor- HIV among children
No intervention – as high as 45%
With interventions – as low as less than 5%
Minimal manipulation
NVD vs. C-section
Anti retroviral prophylaxis vs. anti retroviral therapy
Exclusive breastfeeding vs. exclusive replacement feeding
Follow-up and care.
This document discusses HIV/AIDS, including transmission, signs and symptoms, stages of infection, treatment and prevention of mother-to-child transmission. It notes that HIV can be transmitted sexually, through infected body fluids or from mother to child. The stages of infection are acute infection, clinical latency and AIDS. Signs may include flu-like symptoms during acute infection and infections over time as immunity declines. Prevention of mother-to-child transmission is important, as without intervention up to 45% of babies may be infected, but can be reduced to less than 5% with antiretroviral treatment and safe delivery practices.
- Teenage pregnancy rates in Sarawak, Malaysia are high, with over 40% of adolescents being unmarried and birth rates of 62 per 1000. Teenage pregnancies often result in negative health outcomes for both mother and child such as preterm birth, low birth weight, increased risk of infection, and interrupted education.
- Issues with teenage pregnancy include biological immaturity of the mother, higher risks of pregnancy complications, and social issues like poor nutrition, substance abuse, and interrupted education. Teenage mothers also face higher risks of domestic abuse and their children have an increased likelihood of developmental and social problems.
- Management of teenage pregnancies focuses on nutrition counseling, antenatal care, treating infections,
Prevention of Mother to Child Transmission of HIV 2018Helen Madamba
Babies of pregnant women living with HIV can be born free of HIV infection. HIV counselling and testing is the gateway to diagnosis, treatment, care and support. Healthcare services need to provide enabling environments to support and empower women living with HIV and their children, to increase HIV knowledge and reduce stigma and discrimination.
Mother to child transmission of HIV can occur during pregnancy, childbirth, and breastfeeding. The risk is higher if the mother's HIV infection is in an advanced stage, if she is malnourished, has other STDs, or her membranes rupture early. Antiretroviral therapy and cesarean delivery before labor can reduce transmission risk. Exclusive breastfeeding for 6 months poses a lower risk than mixed feeding. India's PMTCT program provides counseling, testing, antiretroviral prophylaxis to pregnant women and newborns to prevent transmission and aims to reduce transmission by 50% by 2010.
The document discusses the Safe Motherhood Initiative, which aims to reduce deaths and illnesses among women and infants in developing countries by improving access to family planning services, maternal healthcare, and education. It was launched in 1987 with the goal of cutting maternal deaths in half by 2000. The initiative promotes primary healthcare, antenatal care, clean and safe delivery services, essential newborn care, and postnatal services. It also aims to monitor health services and conduct research to generate best practices. The document outlines support for Safe Motherhood initiatives through events in India to raise awareness of maternal health issues.
The document provides guidance on counselling women during pregnancy on various topics:
1. Nutritional counselling focuses on maintaining a healthy diet, weight gain, and consuming nutrients like iron and calcium.
2. Counselling on breastfeeding emphasizes initiating breastfeeding within an hour of birth and exclusively breastfeeding for six months.
3. Counselling addresses having safe sex during pregnancy, domestic violence prevention, and post-natal family planning to space pregnancies.
The document discusses the Baby Friendly Hospital Initiative (BFHI), which aims to promote breastfeeding through 10 steps implemented in maternity facilities. It also describes the International Code of Marketing of Breastfeeding Substitutes, which sets standards to protect breastfeeding and ensures product marketing does not undermine it. Proper breastfeeding technique involves positioning the baby, holding the breast, and allowing the baby to latch effectively.
This document discusses HIV infection in pregnancy and factors affecting mother-to-child transmission. It notes that over 600,000 children are infected with HIV annually through mother-to-child transmission. The transmission rate can be affected by viral load, stage of infection, use of antiretroviral therapy, and duration of rupture of membranes during delivery. Proper prenatal care, treatment of opportunistic infections, nutrition support, and antiretroviral therapy for the mother can help reduce transmission risk from mother to child.
Gestational diabetes (GDM) is glucose intolerance that begins or is first recognized during pregnancy. It can be caused by either pre-existing type 2 diabetes or a new onset of diabetes during pregnancy. The document discusses screening, diagnosis and management of both pre-existing diabetes and GDM during pregnancy. It aims to provide optimal glucose control to support fetal growth while avoiding risks of hyper- and hypoglycemia. Treatment involves medical nutrition therapy, glucose monitoring and may require insulin therapy in some cases. Close monitoring is needed throughout pregnancy and postpartum to support maternal and fetal health.
This document discusses pediatric growth charts. It begins by introducing growth charts and their uses, such as monitoring a child's growth over time and identifying high-risk children. It then focuses on the WHO growth charts, describing their development based on a multinational study and how they establish breastfeeding as the biological norm. The basics of growth chart construction and interpretations are explained. Advantages include being a gold standard and better suiting aboriginal populations, while limitations include not reflecting all feeding practices and potentially discouraging breastfeeding.
Gestational diabetes mellitus (GDM) is glucose intolerance that develops during pregnancy and accounts for 90% of cases of diabetes in pregnancy. Risk factors include age over 25, BMI over 25, family history of diabetes, and certain ethnic backgrounds. GDM is caused by insulin resistance during pregnancy and can lead to complications for both mother and baby if not well-controlled such as preeclampsia, macrosomia, and neonatal hypoglycemia. Diagnosis involves screening all pregnant women between 24-28 weeks gestation with a glucose challenge test followed by a 3-hour 100g oral glucose tolerance test for those who fail. Management focuses on tight glycemic control through diet, exercise, glucose monitoring, and possibly insulin
The document provides dietary guidelines for pregnant women, recommending a balanced diet that meets increased caloric and nutrient needs. It emphasizes consuming complex carbohydrates, sprouted grains, and home-cooked foods. A daily diet should include cereals, pulses, vegetables, fruits, milk, and moderate fats/oils. Key nutrients like folic acid, iron, iodine, vitamins, calcium are vital for fetal development and lactation. Traditional Indian concepts of Sattvic foods like vegetables are best.
Prenatal care is important for both the health of the mother and baby. It allows doctors to monitor the health of the mother by checking her weight, blood pressure, and stomach size at each appointment. Prenatal care can also detect any medical conditions the baby may have. While prenatal care is important, many women do not receive it due to cost. However, assistance is available for low-income women through healthcare centers across the country. The article encourages all pregnant women to seek the recommended amount of prenatal care for a healthy pregnancy and baby.
This document discusses factors that define high risk newborns and their management and follow up. It identifies demographic, medical history, pregnancy, delivery, and neonatal factors that increase morbidity and mortality risks. It outlines assessments and interventions needed for different at-risk groups, including extra care to prevent hypothermia, hypoglycemia, and infection. High risk newborns require intensive care and multidisciplinary follow up after discharge to screen for developmental delays and other issues. The goal is early identification and intervention to optimize outcomes.
The document discusses neonatal and child health care. It provides statistics on infant mortality rates globally and in different regions. Almost two-thirds of infant deaths occur in the first month of life, and among those two-thirds die in the first week. The leading causes of neonatal death are preterm birth, severe infections like sepsis and pneumonia, and birth asphyxia. Reducing neonatal mortality is important to achieving Millennium Development Goals around reducing child mortality. The document outlines efforts to prioritize and improve newborn health.
The document discusses newborn feeding, including types of feeding like breastfeeding and formula feeding. It covers the physiology of breastmilk secretion and milk let-down. The advantages of breastfeeding are enumerated, along with contraindications and considerations for breastfeeding in the context of HIV. Proper positioning for breastfeeding is also described.
The document outlines guidelines for postpartum care in India, including:
- Scheduling at least 3 postpartum visits for the mother and baby on the 3rd day, 7th day, and 6th week after delivery.
- Conducting examinations and monitoring vital signs during the visits, counseling on diet, rest, hygiene, breastfeeding, family planning, and identifying any danger signs that require emergency referral.
- Providing immediate postpartum care for the first hour after delivery and ensuring the mother and baby are not left unattended for the first 48 hours to monitor for complications.
1) Prevention of Mother to Child Transmission (PMTCT) programs provide antiretroviral drugs, counseling, and support to pregnant women living with HIV to reduce the risk of transmitting the virus to their babies during pregnancy, childbirth, and breastfeeding.
2) Key interventions include antiretroviral prophylaxis for pregnant and breastfeeding women and their infants, safer delivery and infant feeding practices, and treatment, care and support for women and families.
3) In Tanzania, the national PMTCT program incorporates antiretroviral prophylaxis including various combination drug regimens during antenatal, intrapartum, postpartum, and infant periods, depending on when
Management of lbw low birthweight babiesVarsha Shah
This document discusses the management of low birth weight babies. It defines low birth weight as under 2500g and notes that 30% of neonates in India have low birth weight. It describes the higher mortality and morbidity risks for these babies and identifies two types: preterm/small for gestational age and intrauterine growth retardation. The document outlines identification methods, common problems, feeding and care guidelines, supplementation needs, and indicators for referral.
A high risk pregnancy is one complicated by factors that adversely impact maternal or fetal outcomes. Initial screening considers maternal age and reproductive history, including prior miscarriages, preterm births, or babies with health issues. Medical disorders like infections, cardiac issues, and pre-eclampsia can also increase risk. Examinations evaluate uterine size and pelvic structure, while special tests may be needed. High risk pregnancies face greater risks of complications during labor, delivery, postpartum, and for the newborn. Care involves counseling, specialized antenatal and delivery management.
This document discusses improving child health through community-based approaches. It notes that while medical treatment has reduced childhood deaths, many children still die without receiving care. A community-based approach involves local people, adapts to community needs, and builds on existing resources by enhancing community structures and expertise. The key is introducing crucial child care practices widely, like exclusive breastfeeding for six months, appropriate complementary feeding, ensuring good nutrition, treating childhood illnesses at home when possible and seeking care when needed.
Improving child health imci the integrated approachPaul Mark Pilar
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document discusses the Safe Motherhood Initiative, which aims to reduce deaths and illnesses among women and infants in developing countries by improving access to family planning services, maternal healthcare, and education. It was launched in 1987 with the goal of cutting maternal deaths in half by 2000. The initiative promotes primary healthcare, antenatal care, clean and safe delivery services, essential newborn care, and postnatal services. It also aims to monitor health services and conduct research to generate best practices. The document outlines support for Safe Motherhood initiatives through events in India to raise awareness of maternal health issues.
The document provides guidance on counselling women during pregnancy on various topics:
1. Nutritional counselling focuses on maintaining a healthy diet, weight gain, and consuming nutrients like iron and calcium.
2. Counselling on breastfeeding emphasizes initiating breastfeeding within an hour of birth and exclusively breastfeeding for six months.
3. Counselling addresses having safe sex during pregnancy, domestic violence prevention, and post-natal family planning to space pregnancies.
The document discusses the Baby Friendly Hospital Initiative (BFHI), which aims to promote breastfeeding through 10 steps implemented in maternity facilities. It also describes the International Code of Marketing of Breastfeeding Substitutes, which sets standards to protect breastfeeding and ensures product marketing does not undermine it. Proper breastfeeding technique involves positioning the baby, holding the breast, and allowing the baby to latch effectively.
This document discusses HIV infection in pregnancy and factors affecting mother-to-child transmission. It notes that over 600,000 children are infected with HIV annually through mother-to-child transmission. The transmission rate can be affected by viral load, stage of infection, use of antiretroviral therapy, and duration of rupture of membranes during delivery. Proper prenatal care, treatment of opportunistic infections, nutrition support, and antiretroviral therapy for the mother can help reduce transmission risk from mother to child.
Gestational diabetes (GDM) is glucose intolerance that begins or is first recognized during pregnancy. It can be caused by either pre-existing type 2 diabetes or a new onset of diabetes during pregnancy. The document discusses screening, diagnosis and management of both pre-existing diabetes and GDM during pregnancy. It aims to provide optimal glucose control to support fetal growth while avoiding risks of hyper- and hypoglycemia. Treatment involves medical nutrition therapy, glucose monitoring and may require insulin therapy in some cases. Close monitoring is needed throughout pregnancy and postpartum to support maternal and fetal health.
This document discusses pediatric growth charts. It begins by introducing growth charts and their uses, such as monitoring a child's growth over time and identifying high-risk children. It then focuses on the WHO growth charts, describing their development based on a multinational study and how they establish breastfeeding as the biological norm. The basics of growth chart construction and interpretations are explained. Advantages include being a gold standard and better suiting aboriginal populations, while limitations include not reflecting all feeding practices and potentially discouraging breastfeeding.
Gestational diabetes mellitus (GDM) is glucose intolerance that develops during pregnancy and accounts for 90% of cases of diabetes in pregnancy. Risk factors include age over 25, BMI over 25, family history of diabetes, and certain ethnic backgrounds. GDM is caused by insulin resistance during pregnancy and can lead to complications for both mother and baby if not well-controlled such as preeclampsia, macrosomia, and neonatal hypoglycemia. Diagnosis involves screening all pregnant women between 24-28 weeks gestation with a glucose challenge test followed by a 3-hour 100g oral glucose tolerance test for those who fail. Management focuses on tight glycemic control through diet, exercise, glucose monitoring, and possibly insulin
The document provides dietary guidelines for pregnant women, recommending a balanced diet that meets increased caloric and nutrient needs. It emphasizes consuming complex carbohydrates, sprouted grains, and home-cooked foods. A daily diet should include cereals, pulses, vegetables, fruits, milk, and moderate fats/oils. Key nutrients like folic acid, iron, iodine, vitamins, calcium are vital for fetal development and lactation. Traditional Indian concepts of Sattvic foods like vegetables are best.
Prenatal care is important for both the health of the mother and baby. It allows doctors to monitor the health of the mother by checking her weight, blood pressure, and stomach size at each appointment. Prenatal care can also detect any medical conditions the baby may have. While prenatal care is important, many women do not receive it due to cost. However, assistance is available for low-income women through healthcare centers across the country. The article encourages all pregnant women to seek the recommended amount of prenatal care for a healthy pregnancy and baby.
This document discusses factors that define high risk newborns and their management and follow up. It identifies demographic, medical history, pregnancy, delivery, and neonatal factors that increase morbidity and mortality risks. It outlines assessments and interventions needed for different at-risk groups, including extra care to prevent hypothermia, hypoglycemia, and infection. High risk newborns require intensive care and multidisciplinary follow up after discharge to screen for developmental delays and other issues. The goal is early identification and intervention to optimize outcomes.
The document discusses neonatal and child health care. It provides statistics on infant mortality rates globally and in different regions. Almost two-thirds of infant deaths occur in the first month of life, and among those two-thirds die in the first week. The leading causes of neonatal death are preterm birth, severe infections like sepsis and pneumonia, and birth asphyxia. Reducing neonatal mortality is important to achieving Millennium Development Goals around reducing child mortality. The document outlines efforts to prioritize and improve newborn health.
The document discusses newborn feeding, including types of feeding like breastfeeding and formula feeding. It covers the physiology of breastmilk secretion and milk let-down. The advantages of breastfeeding are enumerated, along with contraindications and considerations for breastfeeding in the context of HIV. Proper positioning for breastfeeding is also described.
The document outlines guidelines for postpartum care in India, including:
- Scheduling at least 3 postpartum visits for the mother and baby on the 3rd day, 7th day, and 6th week after delivery.
- Conducting examinations and monitoring vital signs during the visits, counseling on diet, rest, hygiene, breastfeeding, family planning, and identifying any danger signs that require emergency referral.
- Providing immediate postpartum care for the first hour after delivery and ensuring the mother and baby are not left unattended for the first 48 hours to monitor for complications.
1) Prevention of Mother to Child Transmission (PMTCT) programs provide antiretroviral drugs, counseling, and support to pregnant women living with HIV to reduce the risk of transmitting the virus to their babies during pregnancy, childbirth, and breastfeeding.
2) Key interventions include antiretroviral prophylaxis for pregnant and breastfeeding women and their infants, safer delivery and infant feeding practices, and treatment, care and support for women and families.
3) In Tanzania, the national PMTCT program incorporates antiretroviral prophylaxis including various combination drug regimens during antenatal, intrapartum, postpartum, and infant periods, depending on when
Management of lbw low birthweight babiesVarsha Shah
This document discusses the management of low birth weight babies. It defines low birth weight as under 2500g and notes that 30% of neonates in India have low birth weight. It describes the higher mortality and morbidity risks for these babies and identifies two types: preterm/small for gestational age and intrauterine growth retardation. The document outlines identification methods, common problems, feeding and care guidelines, supplementation needs, and indicators for referral.
A high risk pregnancy is one complicated by factors that adversely impact maternal or fetal outcomes. Initial screening considers maternal age and reproductive history, including prior miscarriages, preterm births, or babies with health issues. Medical disorders like infections, cardiac issues, and pre-eclampsia can also increase risk. Examinations evaluate uterine size and pelvic structure, while special tests may be needed. High risk pregnancies face greater risks of complications during labor, delivery, postpartum, and for the newborn. Care involves counseling, specialized antenatal and delivery management.
This document discusses improving child health through community-based approaches. It notes that while medical treatment has reduced childhood deaths, many children still die without receiving care. A community-based approach involves local people, adapts to community needs, and builds on existing resources by enhancing community structures and expertise. The key is introducing crucial child care practices widely, like exclusive breastfeeding for six months, appropriate complementary feeding, ensuring good nutrition, treating childhood illnesses at home when possible and seeking care when needed.
Improving child health imci the integrated approachPaul Mark Pilar
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Implementation manual who surgical safety checklist 2009Paul Mark Pilar
The document is an implementation manual for the WHO Surgical Safety Checklist from 2009. It provides guidance on how to use the checklist to improve safety in the operating room. The checklist divides surgery into three phases - before induction of anesthesia, before skin incision, and before the patient leaves the operating room. It describes the safety steps to be completed in each phase, including confirming the patient's identity and consent, checking for allergies, and making sure counts are correct before the patient leaves the OR. The goal is for teams to consistently follow critical safety steps to minimize risks for surgical patients.
Informal consultation on clinical use of oxygenPaul Mark Pilar
This document summarizes a meeting that discussed improving clinical oxygen therapy in small hospitals in developing countries. Key topics included:
- The epidemiology of hypoxemia in various patient populations and settings. It is a major problem in children, neonates, surgery, and obstetrics.
- Availability of oxygen is often limited in district hospitals in developing countries. Surveys found oxygen unavailable or not delivered effectively.
- Experience introducing oxygen concentrators in Malawi as part of a child lung health program, which helped make oxygen available in more hospitals.
- Available oxygen sources like concentrators, with a focus on appropriate models for developing country settings.
- Indications for oxygen therapy and methods of monitoring and delivery.
Indicators for assessing infacnt and young child feeding practicesPaul Mark Pilar
This document provides guidance on measuring indicators for assessing infant and young child feeding practices. It includes an example questionnaire with modules on household rosters, initiation of breastfeeding, and infant and young child feeding. It also provides instructions for interviewers on administering the questionnaire. Additionally, the document offers suggestions for adapting the questionnaire based on survey context. Finally, it details the calculations needed to determine indicator values from the collected data, including early initiation of breastfeeding, exclusive breastfeeding under 6 months, and minimum acceptable diet. The goal is to improve the standardized and accurate measurement of these important infant feeding indicators.
Introducing zinc in a diarrheal disease control programPaul Mark Pilar
This document provides guidance on conducting formative research to introduce zinc as a treatment for childhood diarrhea in developing countries. The research involves 8 steps: 1) understanding local concepts and practices related to diarrhea; 2) developing culturally appropriate messages about zinc; 3) testing message effectiveness; 4) gathering feedback on zinc tablets; 5) designing labels and logos; 6) developing counseling materials; 7) conducting a behavioral trial; and 8) planning for future zinc promotion. The goal is to introduce zinc in a way that enhances, rather than undermines, existing efforts to promote oral rehydration solutions for diarrhea treatment and prevention.
The World Health Organisation is a global tool to ensure safety in surgery. The principles and procedures are described for how to implement it in your organisation.
Infant and young child feeding a tool for assessing national practices polici...Paul Mark Pilar
This document provides a tool for assessing national practices, policies, and programs related to infant and young child feeding. It contains three parts:
1. An assessment of key infant feeding practices based on WHO indicators.
2. An evaluation of national policies and achievement of targets from the Innocenti Declaration and Global Strategy.
3. An analysis of components of a comprehensive national infant feeding program.
The tool is designed to help countries identify strengths and weaknesses in order to improve protection, promotion, and support of optimal infant feeding. It can assist in developing plans and tracking progress toward global goals.
My slides for a presentation to some surgeons in Scotland on the WHO Surgical Safety Checklist, built with Lego. Based on Atul Gawande's book/research.
There are four major barriers that prevent mothers from breastfeeding their babies:
1. Community and cultural pressures that discourage breastfeeding.
2. Lack of support from health workers due to shortages. Having a skilled birth attendant doubles the chances of initiating breastfeeding within the first hour.
3. Insufficient maternity legislation in most poor countries. Paid maternity leave of at least 14 weeks is needed to support breastfeeding.
4. Marketing activities of some breastmilk substitute companies that undermine breastfeeding. Strong legislation is needed to restrict inappropriate promotion. Addressing these barriers through community empowerment, health system strengthening, supportive policies and regulation of companies could significantly increase breastfeeding rates and save children's
◆ Pregnant adolescents face greater health risks than older mothers and often lack access to adequate healthcare and social support. Meeting their needs is critical to achieving key global development goals related to maternal and child health.
◆ While the clinical needs of pregnant adolescents are similar to other first-time mothers, their youth and inexperience require additional consideration. Comprehensive care, from antenatal visits to delivery and postpartum support, is needed to ensure healthy outcomes.
◆ Addressing the needs of pregnant adolescents also requires social reforms. Improving access to education, healthcare services that are responsive to adolescents, and programs that reintegrate young mothers can help break cycles of poverty and early pregnancy.
This document discusses breastfeeding recommendations for mothers with COVID-19. It reviews evidence that the risk of SARS-CoV-2 transmission through breastmilk is low compared to the benefits of breastfeeding for infant and maternal health. World Health Organization guidelines recommend supporting breastfeeding even for COVID-19 positive mothers by emphasizing infection prevention practices. While some studies found SARS-CoV-2 RNA in breastmilk, the virus likely lacks viability. Additionally, children generally experience mild or no symptoms of COVID-19. Therefore, the health advantages of breastfeeding outweigh the transmission risk. Healthcare providers should restore breastfeeding support services and counsel mothers on safe practices like hand hygiene.
1. Breastfeeding provides numerous health benefits for both infants and mothers. It reduces the risk of breast cancer in mothers and lowers the risk of HIV transmission from mother to child.
2. Exclusive breastfeeding for the first 3-6 months of life protects infants from common illnesses like diarrhea and pneumonia. It also supports optimal infant nutrition and development.
3. For HIV-positive mothers, exclusive breastfeeding or replacement feeding with formula can be appropriate depending on individual circumstances. Proper support is crucial to help mothers make informed choices about infant feeding.
The key points are:
1. Optimal nutrition during infancy and early childhood is essential for growth, health and development. Poor nutrition is responsible for one-third of under-5 deaths and increases risk of illness.
2. Inappropriate nutrition can also lead to childhood obesity, which is an increasing public health problem.
3. Early nutritional deficits are linked to long-term impairment in growth, health, and intellectual performance. They may reduce adult physical work capacity.
Sustained research successes during the first two decades of the AIDS epidemic, an unprecedented expansion of HIV prevention and treatment programs during the last decade, and recent global attention and leadership have set the stage for the virtual elimination of new HIV infections in infants in the next decade.
World Health Organization's Guide to Infant and Child NutritionChris Johnson
The document discusses the importance of optimal infant and young child feeding for growth, health and development. Inadequate nutrition is associated with one third of deaths in children under 5 years old globally and can also lead to long term health and developmental problems. The WHO and UNICEF adopted a Global Strategy for Infant and Young Child Feeding in 2002 to promote appropriate feeding practices from birth to 2 years of age, a critical period of growth and development. Health professionals have a key role in supporting mothers to follow the recommended feeding practices outlined in the strategy.
The document discusses the revised training package for the Baby Friendly Hospital Initiative (BFHI). Some key points:
- The BFHI was launched in 1991 to promote breastfeeding. Over 15,000 facilities in 134 countries have achieved Baby-Friendly status.
- However, progress in designating new hospitals has slowed since 1996. On average, less than seven hospitals per country are designated each year.
- WHO and UNICEF have developed a revised 20-hour training course package to revitalize the BFHI both quantitatively and qualitatively.
- The package includes updates to certain steps and new/optional criteria on areas like HIV/AIDS, labor/childbirth care, and compliance with
The global strategy aims to improve infant and young child feeding to enhance nutritional status, growth, development, health and survival. It defines poor feeding practices as a major threat, noting that over 60% of under-5 deaths are due to malnutrition. The strategy seeks to raise awareness of problems, identify solutions, and provide essential interventions through a comprehensive approach.
Improving Child Nutrition: The achievable imperative for global progressUNICEF Publications
This document is a report by UNICEF on improving child nutrition globally. It discusses the causes and consequences of undernutrition, the current state of child nutrition, and interventions that can address stunting and other forms of undernutrition. It highlights success stories from various countries that have scaled up nutrition programs and reduced undernutrition rates. The report emphasizes the importance of focusing on the first 1,000 days of a child's life from pregnancy to age 2 to prevent stunting and ensure proper growth and development.
Randomized, Controlled Trial Of A Prenatal And Postnatal Lactation ConsultantBiblioteca Virtual
This randomized controlled trial evaluated the effectiveness of a prenatal and postnatal lactation consultant intervention on the duration and intensity of breastfeeding up to 12 months. Over 300 low-income women receiving prenatal care at two community health centers were randomly assigned to an intervention or control group. The intervention group received individualized support from lactation consultants including prenatal meetings, a postpartum hospital visit, and home visits/phone calls. The trial found the intervention group was more likely to breastfeed through 20 weeks and had higher breastfeeding intensity scores at 13 and 52 weeks compared to the control group. US-born women in the control group had the lowest breastfeeding intensity. The study concluded the "best-practices" lactation
South Africa faces a high burden of disease due to four colliding epidemics: HIV/AIDS, tuberculosis, non-communicable diseases, and violence and injuries. While health expenditures are relatively high, health outcomes remain poor due to issues across the healthcare system including poor clinical care quality, administrative shortcomings, and avoidable community factors. To improve health outcomes, the document recommends addressing structural and health systems bottlenecks such as improving health worker morale, expanding mid-level workers, task-shifting, strengthening community health programs, and reorienting training to focus on public health.
The document discusses prevention of parent-to-child transmission (PPTCT) of HIV. It outlines NACO's four-pronged strategy for PPTCT, which includes primary prevention of HIV among women, preventing unintended pregnancies in HIV+ women, preventing transmission from mother to child, and treatment/care for women and children living with HIV. It then discusses factors influencing transmission risk and interventions to reduce risk during pregnancy, delivery, and infancy including antiretroviral prophylaxis and therapy.
This document discusses HIV in pregnancy and mother-to-child transmission. It covers epidemiology of HIV in women, transmission routes including vertical transmission, factors affecting mother-to-child transmission, and strategies to prevent mother-to-child transmission including antenatal care, antiretroviral protocols, HAART, and infant feeding options. The minimum package of care and current Zambian protocols are also summarized.
The document discusses common bacterial infections in children. The most common bacterial infections in babies are skin, ear, and throat infections, while the most common viral infections are respiratory infections such as RSV. Over 44% of child deaths under age 5 occur during the neonatal period, with approximately 2.6 million neonatal deaths worldwide in 2015. Bacterial infections and sepsis are major causes of neonatal mortality. Prevention strategies discussed include immunization of mothers and children, breastfeeding, hygiene practices like chlorhexidine cord care, and education of health professionals in neonatal resuscitation. Prudent antibiotic use and stewardship programs are important to prevent antibiotic resistance.
Emily Chambers Sharpe of the Office of the Global AIDS Coordinator discusses the importance of nutrition and the relationship between ARVs and breastfeeding in preventing mother to child transmission of HIV.
This document from the WHO provides an updated list of acceptable medical reasons for use of breast milk substitutes. The document summarizes conditions for infants where breast milk substitutes may be needed, such as classic galactosemia or maple syrup urine disease. It also outlines maternal conditions where breastfeeding may need to be avoided, such as HIV infection, or temporarily avoided like with severe illness. The document acknowledges that breastfeeding is best for infants in most situations.
Acceptable Medical Reasons For Use Of Breast Milk SubstitutesBiblioteca Virtual
This document from the WHO provides an updated list of acceptable medical reasons for use of breast milk substitutes. The document summarizes conditions for infants where breast milk substitutes may be needed, such as classic galactosemia or maple syrup urine disease. It also outlines maternal conditions where breastfeeding may need to be avoided, such as HIV infection, or temporarily avoided like with severe illness. The document acknowledges that breastfeeding is best for infants in most situations.
Acceptable medical reasons for use of breast milk substitutesPaul Mark Pilar
The document provides an updated list of acceptable medical reasons for using breast milk substitutes. It acknowledges that almost all mothers can breastfeed successfully but notes there are rare health conditions of the infant or mother that may necessitate not breastfeeding temporarily or permanently. The list includes specific infant conditions that require specialized formulas such as galactosemia and maple syrup urine disease. It also notes preterm or low birth weight infants may need supplemental feeding for a limited time. The document was developed based on reviews of current evidence and expert consultation.
Born too soon the global action report on preterm birthPaul Mark Pilar
The report Born Too Soon analyzes the global problem of preterm birth. It features the first estimates of preterm birth rates by country and is authored by over 45 international experts. The report finds that about 15 million babies are born prematurely each year, which is more than 1 in 10 babies worldwide. Prematurity is the leading cause of newborn death and the second leading cause of death in children under 5 years of age. Many preterm babies who survive face lifelong disabilities. The report highlights proven solutions to save lives of preterm babies and reduce rates of death and disability.
Similar to Hiv transmission thru breastfeeding (20)
Guidelines prevention and_management_wound_infectionPaul Mark Pilar
This document provides guidance from the WHO on preventing and managing wound infections. It outlines three key principles: do not close infected wounds, do not close contaminated wounds that are over six hours old, and use antibiotic prophylaxis and surgical debridement to prevent infections. It then describes three protocols: 1) wound toilet and surgical debridement to clean wounds, 2) management of tetanus-prone wounds with vaccination and immunoglobulin, and 3) antibiotic prophylaxis and treatment for wounds at high risk of infection.
Global priorities for patient safety researchPaul Mark Pilar
This document outlines global priorities for patient safety research as identified by a WHO expert group. The group found common priorities across developing, transitional, and developed countries including inadequate training and skills, lack of communication, and healthcare-associated infections. They developed a table of the top six priorities for each setting and identified over 50 priority research topics and questions. The document calls for more applied, evaluative research to develop effective and affordable solutions to improve patient safety worldwide.
1) Home visits for newborns in the first week of life can prevent 30-60% of newborn deaths in high mortality settings. WHO and UNICEF now recommend at least two home visits for all home births - one within 24 hours of birth and another on day 3.
2) During home visits, health workers should promote practices like exclusive breastfeeding, keeping the baby warm, and hygienic cord and skin care. They should also identify danger signs and counsel families on care seeking. Additional care is needed for low birthweight and sick newborns.
3) In many developing countries, community health workers can conduct home visits when skilled attendants are not available. Home visits help improve new
Foundation module the midwife in the communityPaul Mark Pilar
This document provides an introduction to a set of midwifery education modules developed by the World Health Organization (WHO) to help upgrade midwifery skills and strengthen maternal and newborn health services. The modules aim to help midwives and others develop skills to respond appropriately to major causes of maternal mortality such as hemorrhage, abortion complications, obstructed labor, puerperal sepsis, and eclampsia. The modules cover topics like managing complications in pregnancy and childbirth, the midwife's role in the community, and include skills for both prevention and management of complications as well as general midwifery skills. They are intended to be used for in-service training of midwives but can also
Family and community practices that promote child survival growth and develop...Paul Mark Pilar
The document reviews evidence on 12 key family and community practices that promote child survival, growth, and development. It finds that interventions to improve each of the practices have the potential to substantially reduce child mortality and morbidity and improve development. However, the potential impact varies between practices depending on current prevalence, the strength of evidence linking the practice to outcomes, and the feasibility and effectiveness of interventions to increase the practice. It identifies gaps in knowledge about some practices, such as how to best improve care-seeking. The review confirms the importance of the practices but finds that more evidence is still needed to guide the development and evaluation of large-scale programs in some areas.
Evidence for the ten steps to succesful breastfeedingPaul Mark Pilar
This document reviews evidence for the Ten Steps to Successful Breastfeeding, which are the foundation of the WHO/UNICEF Baby Friendly Hospital Initiative. The review finds that implementing each individual Step has some positive effect on breastfeeding outcomes, but implementing all Ten Steps together can have the greatest impact. Conversely, omitting one or more Steps may limit the overall effectiveness of those that are in place. The evidence shows improved breastfeeding rates across different settings and cultures from implementing the Ten Steps within maternity facilities. While many other factors also influence breastfeeding, improving healthcare practices through the Ten Steps is seen as fundamental to realizing gains from other breastfeeding promotion activities. The review methodology prioritizes experimental and quasi-experimental studies, with
Evidence on the long term effects of brestfeedingPaul Mark Pilar
This document presents a summary of 5 systematic reviews on the long-term effects of breastfeeding. The reviews examined the relationship between breastfeeding and blood pressure, cholesterol levels, risk of overweight/obesity, risk of type-2 diabetes, and school achievement/intelligence. The reviews found that breastfeeding was associated with lower blood pressure and cholesterol levels in adulthood, lower risk of overweight/obesity, and lower risk of type-2 diabetes. Breastfeeding was also associated with higher school achievement and intelligence levels, although there was more heterogeneity in those findings. Publication bias and residual confounding did not fully explain the observed effects, suggesting that breastfeeding provides meaningful long-term health benefits.
Evidence for the ten steps to succesful breastfeedingPaul Mark Pilar
This document provides evidence for the Ten Steps to Successful Breastfeeding as outlined by the World Health Organization. It summarizes research showing that implementing policies to support breastfeeding, training health care staff, preparing mothers during pregnancy, ensuring early skin-to-skin contact and breastfeeding, providing breastfeeding guidance, restricting formula and pacifier use, practicing rooming-in, and feeding on demand all have significant benefits for increasing breastfeeding rates and improving health outcomes for both mothers and babies. The document concludes that fully implementing these Ten Steps is an effective global strategy for promoting and supporting breastfeeding.
This document provides guidance on simple treatment methods for emergency drinking water at the point-of-use. It describes straining water through a clean cloth to remove debris, aeration to increase oxygen and remove contaminants, and storage to allow settling and die-off of bacteria over time. It also outlines basic filtration methods like sand filters and charcoal or ceramic filters, noting that filtered water still requires disinfection. Proper treatment can provide a safe short-term water supply until a long-term solution is established.
Developmental difficulties in early childhoodPaul Mark Pilar
This document summarizes research on developmental difficulties in early childhood, with a focus on low- and middle-income countries. It covers topics such as conceptualizing child development and risk factors, epidemiology of developmental difficulties, prevention, early detection, assessment, classification systems, and early intervention. The overall aim is to review evidence on supporting healthy development and addressing developmental difficulties in young children living in resource-poor settings.
Dengue guidelines for diagnosis treatment prevention and controlPaul Mark Pilar
This document provides guidelines for the diagnosis, treatment, prevention and control of dengue. It is a joint publication between the World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases. The document contains 6 chapters that cover the epidemiology and burden of dengue disease, clinical management and delivery of clinical services, vector management and delivery of vector control services, laboratory diagnosis and diagnostic tests, surveillance, emergency preparedness and response, and new avenues for dengue vaccines and antiviral drugs. It is intended to provide up-to-date guidance for professionals on managing dengue cases and preventing transmission.
Community based strategies for breastfeeding promotion and support in develop...Paul Mark Pilar
This document discusses community-based strategies for promoting and supporting breastfeeding in developing countries. It summarizes evidence that community interventions can effectively improve breastfeeding practices and associated health outcomes for infants and mothers. Key factors for successful community interventions include partnerships, formative research, monitoring and evaluation, training, management, and integrating breastfeeding promotion into primary health services. Case studies from Madagascar, Honduras, and India demonstrate positive impacts of community-based approaches.
This document provides guidance on communicable disease control in emergency situations. It covers topics such as rapid assessment, prevention, surveillance, outbreak control, and the prevention and control of specific diseases. The document was edited by M.A. Connolly and published by the World Health Organization in 2005. It aims to provide public health workers with the information needed to effectively respond to communicable disease outbreaks during humanitarian emergencies.
Here are the key steps to assess for an airway or breathing problem:
1. Look at the child's chest - is it rising and falling with each breath? Listen at the child's mouth and nose for sounds of breathing.
2. Check for central cyanosis - a bluish color of the tongue and lips caused by lack of oxygen in the blood. Cyanosis is an emergency sign.
3. Observe the child's breathing pattern - is it fast (over 60 breaths per minute for infants under 2 months, over 50 breaths per minute for children 2 months to 1 year, over 40 breaths per minute for children 1 to 5 years)? Is there chest indrawing? These are signs of respiratory distress and an
Epidemiology and management of common skin diseases in children in developing...Paul Mark Pilar
This document reviews the epidemiology and management of common skin diseases in children in developing countries. It finds that skin diseases are very prevalent, with pyoderma, scabies, tinea capitis, viral infections and dermatitis being most common. Data shows high rates of these diseases in children and rural areas. There is a lack of standardized treatment guidelines and public health strategies for managing skin diseases in developing areas. Improved primary healthcare and basic hygiene promotion may help address some of the major skin conditions.
A guide to family planning for community health workers and their clientsPaul Mark Pilar
This document provides guidance for community health workers and their clients on family planning methods. It aims to help clients choose the method that best suits their needs and to provide health workers with the information required for effective counseling. The tool compares different family planning methods and covers topics such as choosing a method, method instructions, special health situations, frequently asked questions, and counseling checklists.
health, community leaders; review of existing records
3. Data analysis
Identification of priority health problems
Estimation of morbidity and mortality rates
Identification of risk factors and vulnerable groups
Identification of gaps in services and resources
4. Report writing
Presentation of findings
Recommendations for priority interventions
Estimation of resources needed
Identification of lead agency
5. Dissemination of findings
Feedback to agencies and authorities
Coordination of response
6. Monitoring and evaluation
Follow-up assessment
Monitoring of interventions
Evaluation of impact
1.1 Objectives
The objectives of a rapid health assessment are to:
- Identify the main communicable disease threats, including those with
epidemic potential;
-
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
Hiv transmission thru breastfeeding
1. This publication is an update of the review of current knowledge on HIV transmission through
breastfeeding, with a focus on information made available between 2001 and 2007. It re-
HIV Transmission Through
views scientific evidence on the risk of HIV transmission through breastfeeding, the impact
of different feeding options on child health outcomes, and conceivable strategies to reduce
HIV transmission through breastfeeding with an emphasis on the developing world.
Breastfeeding
For further information, please contact:
World Health Organization
Department of Child and Adolescent Health and Development (cah@who.int) or
Department of HIV/AIDS (hiv-aids@who.int) or
Department of Nutrition for Health and Development (nutrition@who.int)
20 Avenue Appia, 1211 Geneva 27, Switzerland
website: http://www.who.int
UNICEF
Nutrition Section – Programme Division
3 United Nations Plaza
A REVIEW OF AVAILABLE EVIDENCE
New York, New York 10017, United States of America 2007 Update
Tel +1 212 326 7000
ISBN 978 92 4 159659 6
4. Table of contents
Preface v
Acknowledgements vii
Acronyms viii
Glossary ix
Executive summary 1
Introduction 3
Mother-to-child transmission of HIV 5
HIV infection in women 5
Rates of, and risk factors for, overall mother-to-child transmission 5
Prevention of mother-to-child transmission of HIV 6
HIV transmission through breastfeeding 9
Pathogenesis and mechanisms of breastfeeding transmission 9
Risk of postnatal transmission through breastfeeding 10
Timing of postnatal transmission through breastfeeding 10
Early postnatal transmission through breastfeeding 10
Late postnatal transmission through breastfeeding 11
Factors associated with risk of transmission through breastfeeding 12
Maternal factors 12
Infant factors 16
Benefits of breastfeeding 19
Health benefits of breastfeeding in the general population 19
Maternal health benefits 19
Child health benefits 19
Health benefits of breastfeeding in children born to HIV-infected mothers 21
HIV-exposed children, regardless of HIV status 21
HIV-infected children 21
Global breastfeeding practices 22
Strategies to reduce HIV transmission through breastfeeding 23
Primary prevention of HIV in women of childbearing age 23
Framework to assess interventions to prevent postnatal transmission 24
iii
5. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
Modifying infant feeding options for HIV-infected women: replacement feeding 24
Adverse outcomes of alternatives to breastfeeding practices 25
Social acceptability of feeding practices 25
HIV-infection 32
HIV-free survival 32
Discussion 32
Strategies for HIV-infected women who breastfed 33
Exclusive breastfeeding 33
Early cessation of breastfeeding 35
Heat treatment or pasteurization of expressed breast milk. 36
Microbicide treatment of expressed breast milk 36
Antiretroviral therapy during breastfeeding 37
Immunization of breastfed newborns 39
From research to public health recommendations on infant feeding:
consequences for practice 39
Ongoing or planned research addressing the breastfeeding period 41
Conclusion 43
References 44
iv
6. Preface
T his Review was originally prepared as a back
ground paper for the Technical Consulta-
tion on HIV and Infant Feeding that took place
acquisition without gains for survival. It remains
important to identify means of making breastfee-
ding safer for HIV-infected women who have no
in Geneva in October 2006. It was updated dur- choice other than to continue breastfeeding.
ing 2007 to include relevant new information.
In a study on mastitis in Zambia (abstract
As the Review was going to print at the begin- #650), breast milk samples were collected from
ning of 2008, several trials were underway to 38 women who had clinical symptoms of masti-
assess use of extended maternal or infant tis. The study found that during mastitis, eleva-
antiretrovirals to reduce transmission among tions of breast milk viral load are restricted to
HIV-exposed breastfed infants. Relevant find- the mastitic breast and eventually return to base-
ings were presented at the 15th Conference on line levels, supporting current recommendations
Retroviruses and Opportunistic Infections for women with mastitis to breastfeed from the
(CROI) held from 3 to 5 February 2008 and are unaffected breast.
summarized here.1
Maternal outcomes and infant feeding
Postnatal HIV transmission, infant practices
outcomes and infant feeding practices In the Ditrame-Plus cohort study in Abidjan
In a pooled analysis of individual data from (abstract #73), the risk of pregnancy before 12
a South African and a West African cohort months post-partum was comparable in replace-
study (abstract #46), the overall risk of post- ment feeding and breastfeeding groups: 4%. Be-
natal HIV infection was 3.9% among children tween 12 and 24 months post-partum, the risk
breastfed for <6 months and 8.7% among chil- of pregnancy was significantly lower among re-
dren breastfed for >6 months (adjusted hazard placement feeders than breastfeeders. Replace-
ratio: 1.8). Breastfeeding duration, as well as ment feeding was not responsible for a greater
maternal immune status, appear to be major incidence of pregnancies in this West African
determinants of HIV transmission. The risk did urban context, probably due to the systematic
not differ between exclusively and predominantly offer and the frequent use of contraceptive serv-
breastfed children. Exposure to breastfeeding ices.
mixed with solids during the first 2 months in-
creased the postnatal risk of acquisition of HIV Antiretrovirals in breastfeeding women
(adjusted hazard ratio: 2.9). The Kisumu Breastfeeding Study in Kenya
(abstract #45LB) was an observational prospec-
In the Vertical Transmission Study in South tive cohort of children of lactating women tak-
Africa (abstract #636), 18-month HIV-free sur- ing antiretroviral treatment (ART) to prevent
vival of children of HIV-infected women shows mother-to-child transmission (MTCT). Overall
that breastfeeding of HIV-uninfected infants transmission rates were 3.9% at 6 weeks, 5% at
beyond 6 months of age increases the risk of HIV 6 months, 5.9% at 12 months and 6.7% at 18
1
CROI abstracts are available at http:/www.retroconference. org, accessed February 15, 2008.
v
7. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
months. There was no difference in HIV trans- well below levels required for treatment, suggest-
mission by baseline maternal CD4 count. For ing minimal risk for drug toxicity. Lamivudine
those infants who became infected during the (3TC) and nelfinavir exposure in infants would
first 6 weeks of life, resistance was initially not suggest minimal risk for resistance in HIV-in-
detected (abstract #84LB), but emerged during fected children; however, low-level nevirapine
the breastfeeding period. (NVP) exposure via breast milk may predispose
HIV-infected infants to resistance.
In the MASHI trial in Botswana (abstract
#637), the MTCT rate at one month was 1.2% Antiretrovirals in breastfed children
among breastfeeders and 1.1% among formula The PEPI-Malawi Study (abstract #42LB)
feeders. The authors concluded that evaluated in a randomized controlled trial if 14
breastfeeding was not a risk for MTCT within weeks of extended daily infant antiretroviral
the first month of life for children exposed to prophylaxis with NVP (group 2) or NVP+ZDV
maternal ART and receiving infant antiretroviral (group 3) with breastfeeding cessation from age
prophylaxis. 4-6 months would reduce postnatal transmission
of HIV compared to controls receiving single dose
The preliminar y results of the non- (sd) NVP and one week ZDV (group 1). At age
randomized part of the Kesho-Bora study 9 months, the risk of HIV infection was 10.6%
being conducted in five African sites (ab- in group 1, 5.2% in group 2 and 6.4% in group
stract #638) showed that the HIV transmis- 3. However, at 18 months, the HIV rate reach
sion rate at 12 months was 7.6% in women with 13.9% in group 1, 10.1% in group 2 and 10.2%
<200 CD4 with no significant difference accord- in group 3. Postnatal transmission occurred af-
ing to infant feeding pattern; the rate was 5.8% ter NVP cessation among breastfed children.
among women with >500 CD4 count, respec- Post-exposure prophylaxis in breastfed children
tively 7.5% and 0% in ever and never breastfed could reduce postnatal transmission but should
infants. be maintained over the entire breastfeeding du-
ration.
In the Dream cohort in Mozambique (ab-
stract #369), 341 mother-infant pairs were fol- In the SWEN randomized controlled Trial
lowed from pregnancy until 12 months post conducted in Ethiopia, India and Uganda
partum; mothers breastfed while receiving ART (abstract #43), an extended infant post-expo-
until 6 months post delivery. ART continued sure prophylaxis with daily NVP for 6 weeks in
beyond 6 months in women who initiated it for breastfed infants of HIV-infected mothers was
their own health. The HIV MTCT rates were: assessed. The 6-week HIV transmission rate in
1.2% (4) at birth, 1.9% (6) at 6 months, and the extended-NVP arm was 2.5% versus 5.3%
2.8% (8) at 12 months. Four late post-natal HIV- in the sd NVP arm (p=0.009), but the 6-month
1 infections (>1 month of age) were observed in HIV rate was 6.9% in the extended-NVP arm
this cohort; 15% were lost to follow-up. versus 9.0% in the sd NVP arm (p=0.16). The
extended-NVP arm was safe, but postnatal trans-
The Breastfeeding, Antiretroviral and Nutri- mission occurred after stopping NVP in breastfed
tion (BAN) Study in Malawi (abstract #648) children with a reduction of long term efficacy.
reports on antiretroviral concentrations. Infants' Occurrence of resistance to NVP in infected chil-
plasma concentrations for all antiretrovirals were dren was very high (11/12).
vi
8. Acknowledgements
T his review was updated by Valériane Leroy
(INSERM U593, Institut de Santé
Publique, Epidémiologie et Développement,
useful information on synthesis of the technical
consultation. We would like to especially thank
Rajiv Bahl, Renaud Becquet, André Briend,
Université Victor Segalen, Bordeaux, France). It Anirban Chatterjee, Anna Coutsoudis, François
is based on an original review on HIV transmis- Dabis, Mary Glenn Fowler, Peggy Henderson,
sion through breastfeeding prepared by Marie- Lida Lhotska, Jose Martines, Ellen Piwoz, Felic-
Louise Newell (Institute of Child Health, ity Savage, Constanza Vallenas and Isabelle de
London) for WHO in 2003. The 2003 review Vincenzi for reviewing the report and giving help-
was updated in 2005 by the WHO Department ful comments. Finally, we would like to acknowl-
of Nutrition for Health and Development as a edge the contributions of Coralie Thore,
background paper for a consultation on Nutri- Christian Weller and Evelyne Mouillet from the
tion and HIV. ISPED library in Bordeaux for their help in re-
We are very grateful to Marie-Louise Newell searching papers.
for helping in structuring the early draft of this Kai Lashley performed the final copy-edit of
review and to Lynne Mofenson for providing the text.
vii
9. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
Acronyms
3TC lamivudine
AIDS acquired immunodeficiency syndrome
ANRS Agence Nationale de Recherches sur le SIDA (France)
ARV antiretroviral
ART antiretroviral therapy
AZT azidothymidine
BF breastfeeding
CI confidence interval
D4T stavudine
ddI didanosine
DNA deoxyribonucleic acid
EBF exclusive breastfeeding
FF formula feeding
HIVIGLOB HIV hyperimmune globulin
HIV human immunodeficiency virus
HR hazard ratio
MF mixed feeding
MTCT mother-to-child transmission of HIV
NVP nevirapine
OR odds ratio
PCR polymerase chain reaction
PMTCT prevention of mother-to-child transmission of HIV
RF replacement feeding
RNA ribonucleic acid
SLPI secretory leukocyte protease inhibitor
SDS sodium dodecyl sulfate
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNGASS/AIDS United Nations General Assembly Special Session on HIV/AIDS
UNICEF United Nations Children’s Fund
WHO World Health Organization
ZDV zidovudine
viii
10. Glossary
ART, an abbreviation for antiretroviral therapy, Complementary food means any food, wheth-
is a combination of three or more different er manufactured or locally prepared, used as a
antiretroviral drugs used in the treatment of complement to breast milk or to a breast-milk
those infected with HIV to reduce viral load. substitute, when either becomes insufficient
to satisfy the nutritional requirements of the
Breast-milk substitute refers to any food be-
infant.
ing marketed or otherwise represented as a
partial or total replacement for breast milk, DNA, an abbreviation for deoxyribonucleic acid,
whether or not suitable for that purpose. is the carrier of genetic information found in
cell nuclei.
CD4 cells (also known as T4 or helper T cells)
are lymphocytes (a type of white blood cell), Exclusive breastfeeding means an infant re-
which are key in both humoral and cell-medi- ceives no other food or drink, not even water,
ated immune responses. These are the main other than breast milk (which can include ex-
target cells for HIV. Their numbers decrease pressed breast milk), with the exception of
during HIV infection, and their level is used drops or syrups consisting of vitamins, miner-
as a marker of progression of the infection. al supplements or medicines.
CD8 cells are a subtype of T lymphocytes,
Formula feeding involves the use of commer-
which also play an important role in fighting
cial infant formula that is formulated indus-
infections. Their numbers may be increased
trially in accordance with applicable Codex
during HIV infection.
Alimentarius standards to satisfy the nutri-
Cell-associated virus refers to HIV which lives tional requirements of infants during the first
inside the cell, measured as HIV-DNA. months of life up to the introduction of com-
plementary foods.
Cell-free virus refers to parts of the virus (viri-
ons) not associated with a cell, measured as Human immunodeficiency virus (HIV) refers
HIV-RNA. to HIV-1 in this review. Cases of mother-to-
child transmission of HIV-2 are rare.
Cessation of breastfeeding means completely
stopping breastfeeding, which includes no Immunoglobulins are any of the five distinct
more suckling at the breast. antibodies present in the serum and external
secretions of the body (IgA, IgD, IgE, IgG and
Colostrum is the thick yellow milk secreted by
IgM).
the breasts during the first few days after de-
livery, which gradually evolves into mature Incidence density means the incidence rate of
milk at 3–14 days postpartum. It contains an event, i.e. HIV infection or death per per-
more antibodies and white blood cells than son-time (months or years).
mature breast milk.
Infant refers to a child from birth to 12 months
Commercial infant formula means a breast- of age.
milk substitute formulated industrially in ac-
Intrapartum means the period during labour
cordance with applicable Codex Alimentarius
and delivery.
standards to satisfy the nutritional require-
ments of infants during the first months of
life.
ix
11. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
Lamivudine, or 3TC, is an antiretroviral drug Peripartum transmission is mother-to-child
often used in combination with zidovudine, transmission of HIV occurring around the time
ZDV also known as azidothymidine, AZT.
, of delivery (i.e. late in pregnancy, during or
immediately after delivery).
Late postnatal HIV transmission means trans-
mission that takes place after about six weeks Postnatal transmission is mother-to-child
of life, the earliest time at which it is possible transmission of HIV after delivery, during the
to determine that transmission did not take breastfeeding period.
place during delivery.
Predominant breastfeeding means breastfeed-
Lipid means any one of a widely varying group ing is the main source of nourishment, but an
of fats and fat-like organic substances. infant is also given small amounts of non-nu-
tritious drinks, such as tea, water and water-
Macrophage is a large ‘wandering’ phagocytic
based drinks.
white blood cell that ingests foreign matter,
and plays an important role in resisting infec- Replacement feeding means the process of feed-
tion. ing a child who is not receiving any breast milk
with a diet that provides all the nutrients the
Mature breast milk is milk produced from about
child needs until the child is fully fed on fam-
14 days postpartum until the cessation of
ily foods.
breastfeeding.
RNA, an abbreviation for ribonucleic acid, is a
Mixed feeding refers to breastfeeding with the
substance found in the nucleus of all living
addition of fluids, solid foods and/or non-hu-
cells and in many viruses. An intermediate of
man milks such as formula.
DNA, it is the medium by which genetic in-
Mother-to-child transmission (MTCT) indi- structions from the nucleus are transmitted
cates instances of transmission of HIV to a to the rest of the cell. RNA viral load, ex-
child from an HIV-infected woman during pressed as copies of RNA per ml of plasma or
pregnancy, delivery or breastfeeding. The term other body fluid, reflects the amount of ac-
is used in this document because the immedi- tively replicating virus in the body. High viral
ate source of the child’s HIV infection is the RNA levels occur (temporarily) immediately
mother. Use of the term mother-to-child trans- after acquisition of infection and later with
mission implies no blame, whether or not a progression of disease, and are associated with
woman is aware of her own infection status. higher rates of transmission.
Neonatal describes the period immediately fol- Virion refers to those parts of the virus that are
lowing birth through the first 28 days of life. able to replicate HIV.
Nevirapine, or NVP, is an antiretroviral drug Wet-nurse refers to the breastfeeding of an infant
commonly used as a treatment regimen, ei- by someone other than the infant’s mother.
ther alone or in combination with other drugs,
Zidovudine, or ZDV is an antiretroviral drug
,
to prevent MTCT.
which inhibits HIV replication. It was the first
Partial breastfeeding means giving a baby some drug licensed to treat HIV infection. Today it
breastfeeds and some artificial feeds, either is frequently used in combination with other
milk or cereal, or other food. antiretroviral drugs and, alone or in combina-
PCR means polymerase chain reaction, a labo- tion, it is used in the prevention of mother-
ratory method in which the genetic material to-child transmission of HIV (It is also known
.
(DNA or RNA) of the virus is detected and as retrovir or azidothymidine, AZT.)
amplified. It can be both qualitative and quan-
titative.
x
12. Executive summary
B reastfeeding is best for infants, and
is an effective method of reducing the risk
of common childhood morbidity, particularly
their infants during pregnancy or delivery in
about 15-25% of cases; and an additional 5-20%
of infants may become infected postnatally dur-
gastrointestinal and respiratory infections, and ing breastfeeding, for an overall risk of 30-45%.
of promoting child survival and maternal health Breastfeeding may thus be responsible for one
through child spacing. In 2001, the World Health third to one half of HIV infections in infants
Assembly endorsed the recommendation that when interventions are not available.
infants should be exclusively breastfed for the HIV has been detected in breast milk in cell-
first six months of life to achieve optimal growth, free and cell-associated compartments and there
development and health. Thereafter, infants is now evidence that both compartments are in-
should receive nutritionally adequate and safe volved in transmission of HIV through breast
complementary foods while breastfeeding con- milk. Following ingestion of HIV infected breast
tinues to 24 months or beyond. milk, infant gut mucosal surfaces are the most
While breastfeeding carries significant health likely site at which transmission occurs.
benefits to infants and young children, HIV can The rate of late postnatal transmission (that
be transmitted during breastfeeding from an is, after six weeks of age) can be better quanti-
HIV-infected mother to her infant. Reducing this fied in 2007 than previously. Data from a meta-
transmission while ensuring improved HIV-free analysis show that the cumulative probability of
survival1 is one of the most pressing public health late postnatal transmission at 18 months is 9.3%
dilemmas confronting researchers, health-care (95% confidence interval, CI, 3.8-14.8%). Late
professionals, health policy-makers and HIV-in- postnatal transmission, therefore, could contrib-
fected women in many areas of the world, espe- ute as much as 42% to the overall rate of MTCT.
cially in developing countries. Analysis indicates that late postnatal transmis-
In 2007, 2.5 million children aged less than sion risk is around 1% per month of breastfeeding
15 years worldwide were living with HIV and an and is constant over time from between four and
estimated 420 000 children aged less than 15 six weeks to 18 months. Transmission can take
years were newly infected with HIV in 2007 place at any point during breastfeeding, and the
alone, nearly always through mother-to-child longer the duration of breastfeeding, the greater
transmission (MTCT). HIV/AIDS is an increas- the cumulative risk.
ingly important cause of mortality in those aged The risk of postnatal transmission through
less than five years in Africa. Before the breastfeeding is associated with clinical, immu-
antiretroviral therapy (ART) era, child mortal- nological and virological maternal factors and
ity due to HIV was estimated to be 35.2% by infant feeding patterns. Maternal seroconversion
age one year and 52.5% by two years of age. during breastfeeding, low maternal CD4 cell
Mother-to-child transmission of HIV can oc- count, increased maternal RNA viral load in
cur during pregnancy, labour or delivery, or plasma and breast milk and a lack of persistence
through breastfeeding. Without specific interven- of HIV-specific IgM in breast-milk at 18 months
tions, HIV-infected women will pass the virus to are strongly associated with increased risk of
1
HIV-free survival refers to young children who are both alive and HIV-uninfected at a given point in time, usually 18
months.
1
13. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
transmission through breastfeeding. Breast low-up with repeated growth measurements is
pathologies such as clinical and subclinical mas- also crucial to this support, as is nutritional coun-
titis, nipple bleeding, and abscesses, fissures or selling, particularly around the period of
lesions are also associated with a higher risk of breastfeeding cessation.
transmission through breastfeeding. Exclusive Early cessation of breastfeeding could also
breastfeeding for up to six months, however, is prevent a sizable proportion of postnatal HIV
associated with a three to fourfold decreased risk infections but several studies in Africa have re-
of transmission of HIV compared to non-exclu- ported that it was associated with an increased
sive breastfeeding; mixed feeding, therefore, ap- risk of infant morbidity (especially diarrhoea)
pears to be a clear risk factor for postnatal and mortality in HIV-exposed children. Recent
transmission. One study found that about 4% data from Zambia and Botswana show that pro-
of exclusively breastfed infants became infected longed breastfeeding of children already infected
through exclusive breastfeeding from six weeks with HIV is associated with improved survival
to six months. compared to early cessation of breastfeeding.
The incidence of HIV infection among women It is also important to identify approaches to
during the postpartum period is high in Africa. treating expressed breast milk to eliminate the
The overall risk of MTCT is increased in recently- risk of transmission while preserving the milk's
infected lactating women and estimated to be nutritional content and protective qualities. With
29% (95% Cl, 16–42%), illustrating the impor- this aim, expressed heat-treated breast milk and
tance of prevention of primary infection through- microbicides to treat HIV-infected breast milk
out the breastfeeding period. may have a role to play in shortening the dura-
The most appropriate infant feeding option tion of breastfeeding and allowing for a safe tran-
for an HIV-infected mother depends on her in- sition period to other types of foods.
dividual circumstances, including her health sta- More research is required to provide practical
tus and the local situation. The health services tools that can be used routinely – especially
available and the counselling and support she is around the time of early breastfeeding cessation
likely to receive should be considered. The World – to contribute to the assessment of the nutri-
Health Organization (WHO) recommends HIV- tional adequacy of complementary feeding and
infected women breastfeed their infants exclu- guide efficiently the nutritional counselling of
sively for the first six months of life, unless children exposed to HIV.
replacement feeding is acceptable, feasible, af- Other possibilities for preventing HIV from
fordable, sustainable and safe for them and their being transmitted through breast milk are emerg-
infants before that time. When those conditions ing. These include giving ART to women during
are met, WHO recommends avoidance of all breastfeeding (whether or not necessary for the
breastfeeding by HIV-infected women. mother's health) and post-exposure prophylaxis
To help HIV-positive mothers make the best to the infant. Recent studies have sought to de-
choice, they should receive appropriate counsel- termine the effects of the former, and several
ling that includes information about the risks studies on the latter are ongoing; both are dis-
and benefits of various infant feeding options cussed in this review. Finally, passive and active
based on local assessments, and guidance in se- immunization strategies of breastfed newborns
lecting the most suitable option for their own are increasingly being studied. Further research
situation. Counselling, information provision and on their potential role in reducing MTCT of HIV
support during the antenatal period is key for is needed and ongoing.
women to make informed choices. Postnatal fol-
2
14. Introduction
D espite substantial progress in reducing child
morbidity and mortality and promoting
family health in recent decades, there are still
timated 420 000 children aged less than 15 years
were newly infected in 2007 (UNAIDS 2006).
There were also an estimated 380 000 deaths
unacceptable disparities in maternal and child due to AIDS among children. Africa has the high-
health worldwide (Black et al. 2003; WHO est prevalence: 90% of both new infections and
2005). While child mortality has declined in the AIDS-related deaths among children occur there,
past decades in many regions, progress on key particularly in southern Africa (UNAIDS 2007).
indicators has begun to slow down. In parts of MTCT is the most significant source of HIV
sub-Saharan Africa, child mortality is on the rise infection in young children. The virus may be trans-
(Black et al. 2003). About 9.7 million children mitted during pregnancy, labour or delivery, or
under five die each year (WHO mortality data through breastfeeding (De Cock et al. 2000). With-
bank, access on request), mainly from prevent- out specific interventions, HIV-infected women will
able causes and almost all in poor countries. In pass the virus to their infants during pregnancy or
the period between 2000 and 2003, four causes delivery in about 15–25% of cases; and an addi-
accounted for over 80% of the then estimated tional 5–20% of infants may become infected post-
10.6 million yearly deaths in children aged less natally during breastfeeding (De Cock et al. 2000;
than five years: pneumonia (19%), diarrhoea Nduati et al. 2000). About two thirds of infants
(17%), malaria (8%), and neonatal conditions born to HIV-infected mothers will not be infected.
(37%). Among neonatal deaths, 36% were due Breastfeeding may thus be responsible for one third
to infections including sepsis, pneumonia, teta- to one half of HIV infections in infants and young
nus and diarrhoea, 28% were due to being pre- children in African settings (De Cock et al. 2000).
term and 23% were due to asphyxia (Bryce et HIV/AIDS is an increasingly important cause of
al. 2005). Undernutrition is an underlying cause mortality in children aged less than five years in
of more than half of all deaths in children aged Africa (Dabis & Ekpini 2002; Walker et al. 2002).
less than five years, and is associated with infec- Before the antiretroviral therapy (ART) era, child
tious diseases (Bryce et al. 2005). It is also the mortality due to HIV was estimated to be 35.2%
leading underlying cause of disability and illness by age one year and 52.5% by two years of age
worldwide, particularly so in countries with high among HIV-infected children in a meta-analysis,
infant mortality, where suboptimal feeding prac- which pooled information from the African clini-
tices are a major cause of underweight (Bryce et cal trials that aimed to assess the efficacy of inter-
al. 2005). Promotion of breastfeeding has played ventions to reduce MTCT. Mortality varied by
an important role in protecting infants and young geographical region, and was associated with ma-
children, since breastfeeding provides optimal nu- ternal death, maternal CD4 cell counts <200μl,
trition, protects against common childhood in- and infant HIV infection and its timing. In HIV-
fections, reduces mortality significantly, and has infected children, mortality was significantly lower
child-spacing effects (Nicoll et al. 2000a; WHO for those with late infection than those with early
Collaborative Study Team 2000). Exclusive infection (Newell et al. 2004). These findings high-
breastfeeding is therefore recommended until six light the need for effective prevention of MTCT,
months of age (WHO 2001). early paediatric HIV diagnosis and antiretroviral
In 2007, 2.5 million children aged less than care and support for HIV-infected children and all
15 years worldwide were living with HIV. An es- members of affected families.
3
15. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
Prevention of MTCT of HIV using available priate care and highlights missed sexual and re-
antiretroviral interventions can be achieved, even productive health opportunities (UNAIDS
in breastfeeding populations. Considerable effort 2006). To meet international goals for reductions
is ongoing to scale-up these interventions to in child mortality, efforts must continue to focus
reach a wider population (WHO 2006). How- on preventing MTCT, but must also prevent un-
ever, in settings where breastfeeding beyond one dernutrition and strengthen health systems and
year is the norm, postnatal transmission through programmes that can deliver available interven-
breastfeeding reduces the impact of perinatal tions for the other major diseases killing chil-
antiretroviral interventions (Leroy et al. 2002). dren in the developing world (Bryce et al. 2006a).
While breastfeeding carries the risk of HIV trans- The fourth Millennium Development Goal
mission, not breastfeeding carries other signifi- (MDG) calls for a two thirds reduction between
cant health risks to infants and young children, 1990 and 2015 in deaths of children aged less
such as an increased risk of diarrhoea and pneu- than five years (http://www.un.org/millenniumgoals).
monia morbidity and mortality (Nicoll et al. Achieving this goal will require widespread use
2000a; WHO Collaborative Study Team 2000; of effective interventions for preventing deaths,
Thior et al. 2006). and is also linked to MDG5 on maternal mor-
The prevention of HIV transmission should tality, as infant health and survival is closely
be balanced against the risk of other morbidity linked to maternal health (Bryce & Victora
and mortality risks, including malnutrition. The 2005; Costello & Osrin 2005; Mason 2005;
reduction of HIV transmission through the Bryce et al. 2006b).
breastfeeding period is one of the most pressing This report is an update of the review of current
public health dilemmas confronting researchers, knowledge on HIV transmission through
health-care professionals, health policy-makers breastfeeding (WHO/UNICEF/UNFPA/UNAIDS
and HIV-infected women in many areas of the 2004) with a focus on information made available
world, especially in developing countries. Preven- between 2001 and 2007. It reviews recent scien-
tion of HIV transmission during breastfeeding tific evidence on the risk of HIV transmission
should be considered in a broad context that through breastfeeding, the impact of different feed-
takes into account the need to promote ing options on child health outcomes, and con-
breastfeeding of infants and young children ceivable strategies to reduce HIV transmission
within the general population. Countries need through breastfeeding with a specific emphasis on
to develop (or revise) comprehensive national the developing world. This review further informs
feeding policies of infants and young children to guidance on HIV prevention and infant feeding
consider the risks of HIV transmission during strategies (WHO 2006).
infant feeding, while continuing to protect, pro- To update this review, published and unpub-
mote and support breastfeeding for infants of lished literature contributing to recent evidence
HIV-negative women and women whose HIV about children affected and infected by HIV/
infection status is unknown. AIDS and infant feeding patterns since 2001 was
The Declaration of Commitment endorsed at consulted. Medline, one of the main biblio-
the United Nations General Assembly Special graphic scientific databases, was used, facilitat-
Session on HIV (UNGASS) in 2001 set the goal ing a wide variety of studies to be selected,
of reducing the proportion of infants infected ranging from randomized clinical trials to epide-
with HIV by 20% by 2005 and 50% by 2010 miological cohort studies (investigating HIV/
(Harwood & Planetwire.org 2001; UN 2001). AIDS-related morbidity and mortality among
A further goal was ensuring that 80% of preg- children, MTCT and infant feeding patterns),
nant women who receive antenatal care have to demographic and national surveillance surveys
access to HIV prevention services. However, the (infant feeding indicators). The most relevant
Joint United Nations Programme on HIV/AIDS references have been included in this review, in-
(UNAIDS) reports that less than 10% of HIV- cluding other systematic reviews.
infected pregnant women have access to appro-
4
16. Mother-to-child transmission of HIV
HIV infection in women Rates of, and risk factors for overall
S exual contact continues to be the major mode
of HIV transmission, leading to high preva-
lence of HIV infection in women making access
mother-to-child transmission of HIV
In HIV-infected pregnant women, MTCT can
occur before, during or after delivery, but trans-
to sexual and reproductive health services essen- mission in early pregnancy is rare (Rouzioux et
tial (Schmid et al. 2004). al. 1993). Without specific interventions aimed
The prevalence of HIV infection varies con- at reducing the risk of transmission, estimated
siderably from region to region. Children in sub- rates of MTCT range from 15% to 25% in Eu-
Saharan Africa are disproportionately affected, rope and the United States of America and from
with nearly nine in every 10 newly-infected chil- 25% to 45% in developing countries (The Work-
dren worldwide living in this region (UNAIDS ing Group on Mother-to-Child Transmission of
2007). In West and Central Africa, HIV preva- HIV 1995). The additional risk posed by
lence in pregnant women currently reaches up breastfeeding as commonly practised in devel-
to about 7% in some urban areas, with generally oping countries ranges from 5% to 20%, with
lower rates in rural areas. Prevalence in East Af- an attributable risk of 40% (Table 1) (De Cock
rica is up to about 9% in urban areas, while in et al. 2000). These breastfeeding practices ac-
Southern Africa antenatal seroprevalences of count for a large part of the estimated differences
about 16-39% have been reported. In the Carib- in the risks of MTCT between developing and
bean, Central America and South America, rates developed countries (where breastfeeding is less
among pregnant women are generally below 1%. common). The overall risk of MTCT is increased
In Asia, seroprevalence rates in some cities or immediately after HIV is acquired, due to the
provinces of Cambodia, India, Indonesia and initially high levels of maternal viral load. There-
Thailand range from less than 1% up to about fore, when a woman contracts HIV during preg-
5%. In Eastern Europe, where there has been an nancy or the breastfeeding period, the risk of
exceptionally rapid increase in the number of virus transmission is increased. There is some
HIV-infections, the estimated antenatal preva- evidence of an increased risk of acquisition of
lence is still less than 1% (UNAIDS 2007). HIV during pregnancy (Gray et al. 2005).
The incidence of HIV among women during The overall risk of MTCT is associated with
the postpartum period is also high in Africa. The factors related to the virus, the mother and the
HIV incidence rate was 3.5/100 women-years infant (Newell 2001). Maternal RNA viral load
(95% confidence interval, CI, 1.9–5.0) in early in plasma has been strongly associated with the
1990 in Rwanda (Leroy et al. 1994). In Zimba- risk of MTCT (European Collaborative Study
bwe in late 1990, among the 9562 women who 1996; European Collaborative Study 1997;
were HIV-negative at the time of giving birth, Mayaux et al. 1997; Simonds et al. 1998; Shaffer
3.4% (95% CI 3.0–3.8) and 6.5% (95% CI 5.7– et al. 1999b; Leroy et al. 2001). However, al-
7.4) acquired HIV infection over 12 and 24 though the risk of transmission increases sub-
months postpartum, respectively (Humphrey et stantially with increasing viral load, transmission
al. 2006). As 85% of women still breastfeed at of the virus to the fetus or infant can occur, al-
15 months and 30% at 21 months in this popu- beit rarely, even with very low, or undetectable,
lation, new postpartum infections subsequently viral load levels. Similarly, at very high levels of
increase the number of children exposed to HIV. HIV RNA, transmission does not always occur.
5
17. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
TABLE 1. Estimated absolute rates of MTCT of HIV by timing of transmission, without interventions
HIV transmission rate (%)
Timing of HIV transmission No breastfeeding Breastfeeding through Breastfeeding through 18
six months to 24 months
During pregnancy 5 to 10 5 to 10 5 to 10
During labour 10 to 15 10 to 15 10 to 15
During breastfeeding 0 5 to 10 15 to 20
Overall 15 to 25 20 to 35 30 to 45
Nevertheless, women with a low CD4 cell count gest that a highly-active combination
near the time of delivery (below 200 cells per antiretroviral treatment regimen, given during
mm3) and those who have been diagnosed with and after pregnancy, is able to significantly re-
severe clinical disease are more likely to trans- duce HIV RNA viral load in both plasma and
mit the virus than those who are less severely breast milk. This suggests there may be a role
affected by HIV infection (European Collabora- for ART prophylaxis in mothers as a means to
tive Study 2001; Leroy et al. 2002). HIV has reduce breastfeeding-associated transmission
been recovered from vaginal and cervical secre- (Giuliano et al. 2007).
tions of pregnant women (Nielsen et al. 1996;
John et al. 1997; Kovacs et al. 2001) and from Prevention of mother-to-child
gastric secretions of infants born to HIV-serop- transmission of HIV
ositive women (Mandelbrot et al. 1999), consti-
The United Nations strategy to prevent the
tuting independent risk factors for MTCT. There
transmission of HIV to infants and young chil-
is also evidence that malaria could increase the
dren involves: 1) prevention of HIV infection in
risk of MTCT (Ayouba et al. 2003; Mwapasa et
general, especially in women and young people;
al. 2004), although the interaction between pla-
2) prevention of unwanted pregnancies among
cental malaria and MTCT appears to be vari-
HIV-infected women; 3) prevention of HIV
able and complex (Ayisi et al. 2004). Delivery
transmission from HIV-infected women to their
factors such as vaginal delivery and duration of
infants; and 4) provision of care, treatment and
delivery, which increase contact between the in-
support to HIV-infected women, their infants
fant and HIV-infected maternal body fluids
and family. Guidance for implementing pro-
(cervico-vaginal secretions and blood) have been
grammes at national scale is available (WHO/
linked with increased risk of MTCT (European
UNICEF, 2007).
Collaborative Study 1996; European Collabora-
In developed countries, the rate of MTCT has
tive Study 1997).
declined substantially in the past ten years. With
The increasing use of ART in pregnancy in
the use of antiretroviral combinations, elective
developed countries has resulted in a growing
caesarean section delivery and avoidance of
proportion of women achieving undetectable lev-
breastfeeding, rates below 2% have been reported
els of the virus by the time of delivery, which
in American and European populations (Euro-
has had a substantial impact on vertical trans-
pean Collaborative Study 2001; Dorenbaum et
mission. Several studies are currently under way
al. 2002; Newell 2006). In developing countries,
in breastfeeding populations in resource-poor
shorter, simpler peripartum antiretroviral
settings to evaluate the use of ART for mothers
prophylaxis interventions have been shown to
during pregnancy and postnatally, and for
be effective in reducing transmission risk, but
uninfected infants during the breastfeeding pe-
their application in populations where
riod. (Thorne & Newell 2007). Results from the
breastfeeding is commonly practised poses con-
DREAM study carried out in Mozambique sug-
siderable challenges (Dabis et al. 2000).
6
18. MOTHER-TO-CHILD TRANSMISSION OF HIV
Early randomized clinical trials from 1998 in six to eight weeks, in comparison with NVP, only
Africa and Thailand demonstrated the short- the longest combination of ZDV and 3TC is sig-
term efficacy of several antiretroviral regimens nificantly more effective, leading to a 61% ad-
administered around the time of deliver y justed reduction (p=<0.0005). These results
(peripartum) to prevent transmission (Dabis et suggest that there exists an equivalence of choice
al. 1999; Guay et al. 1999; Saba 1999; Shaffer between single-dose NVP and short-course ZDV .
et al. 1999a; Wiktor 1999). This short-term ef- They confirm that a combination of ZDV and
ficacy was measured by comparing infant HIV 3TC from 36 weeks of gestation has a greater
infection status at six and eight weeks of age efficacy in reducing early transmission than the
between groups receiving different antiretroviral same combination starting during labour and
interventions or a placebo. These regimens in- delivery or than any single antiretroviral prophy-
volved three different ARV drugs, used alone or laxis (short-course ZDV or single-dose NVP).
in combination: zidovudine (ZDV), lamivudine There is no doubt that even lower peripartum
(3TC) and nevirapine (NVP). transmission rates, comparable to those obtained
The NVP prophylactic regimen is particularly in developed countries, could be achieved
easy to use with one single dose given to the through enhanced short-course antiretroviral
woman at the onset of labour, and one dose of regimens. In the ANRS 1201/1202 Ditrame Plus
syrup administered to the baby within 72 hours cohort in Abidjan, Côte d’Ivoire, transmission
of delivery, reducing transmission by around rates at six to eight weeks postpartum were 6.5%
40%, from a rate of 20% to 12% at six to eight (95% CI 3.9–9.1%) with ZDV plus single-dose
weeks postpartum (Guay et al. 1999). Transmis- NVP, a relative 72% reduction compared with
sion rates at six to eight weeks of 15% have been ZDV alone (95% CI 52–88%, p=0.0002 ad-
reported when ZDV is given to the mother from justed on maternal CD4 cell count, clinical stage
week 36 of gestation (Dabis et al. 1999; Wiktor of infection and breastfeeding status) (Dabis et
1999). Peripartum ZDV efficacy has been re- al. 2005). The overall rate was 4.7% (95% CI
ported as greater in women with higher CD4 cell 2.4–7.0%) when mothers were given both ZDV
counts, even at six weeks postpartum (Leroy et and 3TC from week 32 of gestation, continued
al. 2002). In another regimen, ZDV given in for one week postpartum (for both mother and
combination with 3TC to the mother from weeks child), in addition to single-dose NVP to mother
28–36 of gestation until one week postpartum, and infant. Despite these considerable advances,
while the newborn receives ZDV prophylaxis several problems remain to be addressed, which
during one week, reduced transmission to be- are detailed elsewhere (WHO 2006).
tween 6% and 9% (Saba et al. 2002). Single-dose NVP given to women and infants
The respective efficacy of these different reduces mother-to-child HIV transmission and
antiretroviral regimens was compared in a recent is easy to use, but NVP resistance develops in a
pooled analysis using a standardized definition large percentage of women, raising concerns for
of peripartum HIV infection (Leroy et al. 2005). future maternal treatment (Eshleman et al.
This study included 4125 singleton live births 2004a; Eshleman et al. 2004b; Jourdain et al.
from six African trials, which adjusted MTCT 2004; Eshleman et al. 2005). Alternatives to
rates at six to eight weeks for other maternal NVP are being considered, but this problem can
and child determinants. In comparison with pla- be avoided to a considerable extent by a post-
cebo, the adjusted relative reduction in MTCT partum three-day to one week regimen of AZT
reached 77% for the combination of ZDV and and 3TC.
3TC administered antepartum, intrapartum and Residual MTCT rates remain high in mothers
seven days postpartum; 51% for the combina- who have advanced HIV disease (Leroy et al.
tion of ZDV and 3TC during the intrapartum 2002). Antiretroviral therapy is now recom-
and postpartum periods only; 45% for ZDV only, mended for these women (WHO 2006). More
administered antepartum, intrapartum and post- recent cohort studies in Côte d’Ivoire and Mo-
partum; and 40% for single-dose NVP. Thus, at zambique indicate that when three-drug combi-
7
19. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
nation antiretroviral therapy (i.e. ART) is given where prolonged breastfeeding is the norm (Leroy
to HIV-infected pregnant women either univer- et al. 2003). In the West African trials, the 24-
sally – irrespective of CD4 cell count (Giuliano month efficacy of short-course ZDV to mothers
et al. 2007) – or only to those who require it for was still significant, giving a 26% reduction, with
their own health (Tonwe-Gold 2007), MTCT a residual MTCT rate of 22.5% in the ZDV arm
rates below 5% can be achieved at four weeks compared to 30.2% in the placebo arm (Leroy
postpartum. et al. 2002). In the NVP trial, the 18-month
Women presenting late for delivery without efficacy was sustained with a residual MTCT rate
knowing their HIV status, which frequently hap- of 15.7% in the NVP arm, a 41% significant re-
pens in resource-constrained settings, do not re- duction (Jackson et al. 2003). In the PETRA trial,
ceive the ante and intrapartum components of although the six-week efficacy of the combined
these regimens. In this context, the efficacy of a ZDV+3TC long-course (ante, intra and postpar-
simple neonatal-only antiretroviral post-exposure tum/postnatal) regimen and the ZDV+3TC
prophylactic regimen has been demonstrated in medium-course (intra- and postpartum/postna-
Malawi. The overall MTCT rate at six to eight tal) regimen was significantly effective, the 18-
weeks was 15.3% in 484 babies who received month long-term efficacy was lost mainly
NVP and ZDV and 20.9% in 468 babies who because of postnatal transmission (Saba et al.
received NVP only in the NVAZ trial conducted 2002). However, this trial lacked statistical power
in Malawi (p=0.03) (Taha et al. 2003). In South to address differences at 18 months.
Africa, single-dose NVP given to newborns ex- Given the considerable advances that have
posed to HIV tended to reduce MTCT. The rate been made in the past ten years, peripartum HIV
at 12 weeks was 14.3% in 518 babies who re- transmission rates below 5% can be achieved,
ceived NVP, and 18.1% in 533 babies who re- even in African breastfeeding populations, with
ceived ZDV during six weeks postnatally relatively inexpensive, easy-to-use and feasible
(p=0.4). Among newborns who were not in- short-term antiretroviral combinations (WHO
fected at birth, the 12-week MTCT rate was 2006). The introduction of short-course
7.9% in the NVP arm and 13.1% in the ZDV antiretroviral regimens to prevent MTCT in less-
arm (p=0.06) (Gray et al. 2005). developed countries should be accompanied by
All these short-course peripartum antiretro- interventions to minimize the risk of subsequent
viral regimens have lower field efficacy when tak- transmission through breastfeeding (Leroy et al.
ing into account the subsequent risk of postnatal 2003). Postnatal transmission will be detailed
transmission of HIV in African populations in the next section.
8
20. HIV transmission through
breastfeeding
T ransmission of HIV through breastfeeding
has been well documented since 1985. The
first reports indicating the possibility of HIV
not be predicted from the analysis of circulating
viral populations (Becquart et al. 2002).
The origin of HIV in breast milk is still not
transmission through breast milk were in well understood. There is now evidence that both
breastfed infants of women who had acquired cell-free and cell-associated HIV in breast milk
infection postnatally through blood transfusions are responsible for breast-milk transmission
or through heterosexual exposure (Ziegler et al. (Koulinska et al. 2006). Studies have demon-
1985; Hira et al. 1990; Van de Perre et al. 1991; strated the presence of cell-free virus and latent
Palasanthiran et al. 1993). There were also re- (non-productive) infected cells, but not produc-
ports of infants – with no other known exposure tive HIV infective cells. Cells, including
to HIV – who were infected through being wet- macrophages and lymphocytes, and cell-free vi-
nursed and through pooled breast milk (Nduati rus may migrate from the systemic compartment
et al. 1994). There is a theoretical risk of oral to breast milk. Recently, it has been reported that
transmission from infant to wet-nurse, with cases infected CD4 cells demonstrate a greater capac-
having been reported (Visco-Comandini et al. ity to enter into a viral replication cycle in the
2005). breast-milk compartment compared with blood
(Petitjean et al. 2006).
Pathogenesis and mechanisms of Following ingestion of HIV infected breast
breastfeeding transmission milk, infant gut mucosal surfaces are the most
likely site at which transmission occurs. Cell-free
HIV has been detected in breast milk in cell-free
or cellular HIV may penetrate to the submucosa
and cell-associated compartments. To date most
through mucosal breaches or lesions, via
studies have used DNA or RNA polymerase
transcytosis through M cells or enterocytes ex-
chain reaction assays to evaluate breast milk for
pressing galactosyl ceramide (Gal Cer) or Fc
HIV. In an early study from Kenya, breast milk
receptors. In vitro models suggest that secretory
HIV RNA was detected in 39% of 75 specimens
IgA or IgM may inhibit transcytosis of HIV
(Lewis et al. 1998). In this study viral levels in
across enterocytes (Bomsel 1997; Bomsel et al.
breast milk were about one log lower than in
1998). Breast-milk HIV immunoglobins may
plasma. However, there were some cases that
play a role in protection from transmission by
suggested compartmentalization of virus to
coating infant mucosal surfaces: in a cohort of
breast milk with higher levels in breast milk than
lactating women infected with HIV in Rwanda,
plasma. Viral variants in blood and breast milk
anti-HIV antibodies of the IgG isotype were more
were found to be distinct, with some major vari-
frequently detected in breast milk followed by
ants in breast milk not detected in blood. This
secretory IgM (Van de Perre et al. 1993). Tonsils
finding would suggest that some virus in breast
may also be a portal of entry for HIV in breast-
milk replicates independently, in the mammary
milk transmission. Tonsils include M cells in close
compartment. The observation of a compart-
proximity to lymphocytes and dendritic cells, and
mentalization of HIV between peripheral blood
tonsillar M cells are capable of HIV replication
and breast milk highlights that postnatal trans-
(Frankel et al. 1997).
mission of HIV can occur with variants that may
9
21. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
Risk of postnatal transmission through sion beyond four to six weeks ranging from 4%
breastfeeding to 12% was reported from these trials (Ekpini et
al. 1997; Saba et al. 2002; Jackson et al. 2003;
The risk attributable to transmission of HIV
Leroy et al. 2003). Differences need to be inter-
through breastfeeding has been difficult to meas-
preted according to the risk factors for postnatal
ure because of the difficulty in distinguishing
transmission. However, there is strong evidence
intrapartum transmission from early transmis-
of a continued increase in cumulative transmis-
sion through breastfeeding.
sion risk as long as the child is breastfed (Leroy
Based on an assessment of the limited data
et al. 1998; Miotti et al. 1999; Leroy et al. 2003;
available in the early 1990s, the additional risk
The Breastfeeding and HIV International Trans-
of transmission from breast milk – above that
mission Study Group (BHITS) 2004; Iliff et al.
occurring during pregnancy and delivery – among
2005).
women with established HIV infection was esti-
mated to be approximately 15% when
breastfeeding continued for two years or more. Timing of postnatal transmission
When the mother acquires HIV postnatally, the through breastfeeding
estimated risk of transmission is estimated to be Transmission of HIV through breastfeeding can
29% (95% Cl: 16–42%) (Dunn et al. 1992). take place at any time during lactation. There is
Subsequent data, including the results of a insufficient information available to estimate the
randomized clinical trial, confirm these initial exact association between duration of breast-
findings in HIV-infected pregnant women. In the feeding and the timing of transmission. How-
clinical trial in Nairobi, HIV-infected pregnant ever, there is some evidence that there is an
women were randomly allocated to either breast increased early postnatal risk within the first six
(n=212) or formula (n=213) feeding groups in to eight weeks. This still remains uncertain, how-
the absence of any preventive antiretroviral in- ever; a late postnatal risk beyond six to eight
tervention (Nduati et al. 2000). Compliance with weeks has been better characterized recently
assigned feeding modality was 96% in the (The Breastfeeding and HIV International Trans-
breastfeeding arm and 70% in the formula arm. mission Study Group (BHITS) 2004).
Median duration of breastfeeding was 17
months. The cumulative probability of HIV in- Early postnatal transmission through
fection at 24 months of age was 36.7% in the breastfeeding
breastfeeding arm and 20.5% in the formula- Data suggest that the first six to eight weeks of
feeding arm, with 44% of HIV infection in the breastfeeding could be a high risk period for
breastfeeding arm attributable to breastfeeding. transmission of HIV. However, it is difficult to
Most breastfeeding transmission occurred early, investigate for technical reasons, and thus diffi-
although transmission continued throughout the cult to draw any conclusions about the relative
duration of exposure (Nduati et al. 2000). Al- risk of transmission through colostrum and ma-
though exclusive breastfeeding was recom- ture breast milk (Van de Perre et al. 1993; Ruff
mended in this trial it was likely not always et al. 1994; Lewis et al. 1998). First, colostrum
exclusive in this population. Furthermore, infor- and mature breast milk contain different types
mation on the mode of breastfeeding was not of cells and varying levels of immune-modulat-
collected. ing components (e.g. vitamin A, immunoglobu-
Other estimations of the rate of transmission lins and lactoferrin). Second, the total volume
through breastfeeding can be inferred from the of colostrum ingested by the infant is much
results of trials in which a peripartum interven- smaller than that of mature breast milk. Third,
tion to reduce MTCT risk was evaluated both in the infant’s immune system is less well-devel-
the short-term (four to six weeks) and in the long- oped during the first few days of lactation than
term, after the end of breastfeeding exposure at in later lactation, while younger infants have an
18–24 months. Additional postnatal transmis- increased blood concentration of maternal anti-
10
22. HIV TRANSMISSION THROUGH BREASTFEEDING
bodies. There is no evidence to suggest that load in plasma. Of note, the probability of infec-
avoidance of colostrum would reduce the risk of tion through breastfeeding per day of exposure
breastfeeding transmission to the infant. was not significantly different for children aged
Based on statistical modelling using data from less than four months versus those older than
studies with a limited duration of breastfeeding, this (0.00015 versus 0.00031, p=0.4).
it appears that the highest risk period for trans- In the SAINT trial in South Africa, although
mission is within the first four to eight weeks of not randomized on infant feeding modalities, the
life, and that infectivity may vary in populations proportion of new infections having occurred
at different stages of the disease (Dunn 1998). between birth and six to eight weeks increased
Evidence remains weak to detail the percentage to 5.6% when comparing breastfed infants to
of transmission occurring early. In the rando- formula-fed infants (Moodley et al. 2003).
mized clinical trial of breast milk versus formula
carried out in Nairobi, Kenya, 10% of the total Late postnatal transmission through
16% cumulative difference in infection rates be- breastfeeding
tween infants in the breastfed and formula-fed Late postnatal risk of HIV transmission
arms apparently occurred by week six of age. The through breastfeeding can be reliably estimated
cumulative rate of HIV infection in the formula- among children born to infected mothers who
feeding arm was approximately half that of the tested negative at four to six weeks postpar-
breastfeeding arm at birth (3.1% versus 7.0%, tum. These children are followed until after
p=0.35). Although not statistically significant, they cease breastfeeding to determine their rate
this differential between arms raised concern of acquisition of HIV infection through
about the true comparability of the two arms at breastfeeding. The time at which the exposure
birth, with women in the breastfeeding arm hav- starts is determined by the age at which in-
ing more advanced disease than in the formula- fants are tested. This is now usually around
feeding arm (Bulterys 2000). four to six weeks of age, but in earlier studies
Additionally, the breastfeeding women were was between three and six months of age. These
likely more ill as evidenced by the much higher different ‘starting points’ may explain differ-
than expected mortality in this group compared ent estimates of rates of late postnatal trans-
to the women giving formula to their children mission between studies (Table 2).
(Nduati et al. 2001). In the Kenya trial, the pro- The best evidence on the risk of late postna-
portion of new HIV infections between birth and tal transmission comes from a meta-analysis of
six to eight weeks was 6.3% (from 3.1% to 9.7% a large number of data relating to breastfeeding
in formula-fed versus 7.0% vs19.9% in breastfed and postnatal transmission of HIV from
babies, p=0.005) (Nduati et al. 2000). Seventy- randomized controlled trials of peripartum in-
five per cent of the risk difference between the terventions conducted in sub-Saharan Africa.
two arms occurred by six months of age, although Early transmission was defined as a positive HIV
transmission continued throughout the duration test before four weeks, and late postnatal trans-
of exposure (Nduati et al. 2000). In a subsequent mission as a negative diagnostic test at or after
analysis of this data, 75% of the risk difference four weeks of age, followed by a subsequent posi-
between the two arms occurred by six months of tive test result (The Breastfeeding and HIV In-
age, although transmission continued through- ternational Transmission Study Group (BHITS)
out the duration of exposure (Nduati et al. 2000). 2004). Of 4085 children (breastfed singletons
In a subsequent analysis of this trial data, the for whom HIV testing was performed) from nine
probability of transmission through breastfeeding eligible trials, 993 (24%) were definitively in-
was estimated to be 0.00064 per litre of breast fected (placebo arms, 25.9%; treatment arms,
milk ingested and 0.00028 per day of 23.4%, p=0.08). The time of infection was un-
breastfeeding (Richardson et al. 2003). Breast- known for 454 children. Of 539 children where
milk infectivity was significantly higher for moth- the time of infection was known, 225 (42%) were
ers with low CD4 cell counts and high RNA viral infected during the late postnatal period. Late
11
23. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
TABLE 2. Estimated rates of late postnatal transmission of HIV in African cohorts
Study location Age at nega- Median Infection inci- Cumulative Cumulative
(citation) tive test duration of dence per 100 percentage of percentage of
(determining breastfeeding child-years of infants in- infants in-
denominator) breastfeeding fected by 12 fected at last
(%) months follow-up
Malawi (Miotti et al. 1999) 1 month >12 months 6.9 8.9 10.3 (18 months)
Africa (Leroy et al. 1998) 3 months 16 months 3 2.5 9.2 (36 months)
West Africa(Leroy et al. 4 weeks 12 months 8.6 9.5 13.1 (18
2003) months); 13.1
(24 months)
Africa BHITS (The 4 weeks 10 months 8.9 7 9.3 (18 months)
Breastfeeding and HIV
International Transmission
Study Group (BHITS)
2004)
Zvitambo, Zimbabwe (Iliff 6 weeks >18 months 9.2 7.7 12.1 (18 months)
et al. 2005) EBF: 3.42 EBF: 6.94
PBF: 7.29 PBF: 8.56
MF: 8.41 MF: 13.92
South Africa, the Vertical 4-8 weeks 6 months 10.7 (EBF only) NA EBF: 4.04 (6
Transmission Study months)
(Coovadia et al. 2007)
Côte d’Ivoire, the ANRS 4 weeks 5 months 3.8 NA NA
1201/1202 Ditrame Plus EBF: 5.9
study (Leroy et al. 2004) PBF: 11.3
MF: 31.6
NA, not available; EBF, exclusive breastfeeding; PBF, predominant breastfeeding; MF, mixed feeding (breast milk and other
fluids, foods and/or formula).
postnatal transmission occurred throughout sion Study Group (BHITS) 2004). Analysis of
breastfeeding. The cumulative probability of late how transmission rates vary with time from birth
postnatal transmission at 18 months was 9.3% indicated that late postnatal transmission risk is
(95% CI 3.8-14.8%). The overall risk of late around 1% per month of breastfeeding and is
postnatal transmission was 8.9 transmissions per constant over time from four to six weeks and
100 child-years of breastfeeding (95% CI 7.8- 18 months, i.e. between 0.8 and 1.2 per 100
10.2 per 100 child-years) follow-up (Table 2). child-months of breastfeeding. The longer the
Late postnatal transmission could contribute as duration of breastfeeding, the higher the cumu-
much as 42% to the overall rate of MTCT (The lative risk of postnatal transmission of HIV.
Breastfeeding and HIV International Transmis-
12
24. HIV TRANSMISSION THROUGH BREASTFEEDING
In conclusion, the rate of late postnatal trans- HIV infection, when the rate of postnatal trans-
mission is now better characterized than previ- mission has been estimated to be nearly 30%
ously and is estimated to be around 1% per (Dunn et al. 1992). In a study in Kenya, the
month of breastfeeding and constant over time. relative risk of MTCT was increased about six-
When breastfeeding is prolonged to 18-24 fold during primary infection of the mother
months or beyond, the additional cumulative (Embree et al. 2000).
postnatal risk of transmission through
breastfeeding varies from 4% to 16% according HIV-related immune status
to the study (Miotti et al. 1999; Nduati et al. More data are now available on the association
2000; Jackson et al. 2003; Leroy et al. 2003). between maternal immune status (CD4 cell
counts) and MTCT through breastfeeding. Ma-
Factors associated with risk of ternal immunosuppression defined by low CD4
transmission of HIV through cell count, although strongly correlated with
plasma RNA viral load, is an independent risk
breastfeeding factor for breastfeeding transmission in all stud-
There is reliable quantification of the effect of
ies with available information. In an analysis of
risk factors associated with an increased or de-
pooled data from two West African ZDV trials
creased likelihood of transmission of the virus
(Leroy et al. 2002; Leroy et al. 2003), maternal
through breastfeeding. Clinical, immunological
CD4 cell counts below 500 cells per mm3 in
and virological factors in mothers, as well as in-
plasma close to time of delivery was associated
fant feeding patterns, affect postnatal transmis-
with a threefold increase in risk of late postnatal
sion (Table 3).
transmission compared to women with CD4 cell
counts equal to or greater than 500 per mm3
Maternal factors (Leroy et al. 2003). In the BHITS meta-analysis
Maternal seroconversion during breastfeeding
of data from nine intervention trials in sub-Sa-
HIV maternal seroconversion during breastfee-
haran Africa, the risk of late postnatal acquisi-
ding constitutes a high risk factor for postnatal
tion of infection after four weeks of age was
HIV transmission; it is higher than among
strongly associated with maternal CD4 cell
women who have been infected previous to
count. Transmission increased eightfold when
breastfeeding (Van de Perre et al. 1991; Dunn et
CD4 cell counts were below 200 per ml, and 3.7-
al. 1992). High levels of virus in plasma, and
fold where CD4 cell counts were between 200
probably also in breast milk, are seen in primary
and 500 per ml, compared to the reference group
Table 3. Factors associated with transmission of HIV through breastfeeding
Maternal Infant
Younger maternal age, lower parity Factors associated with the immune system
Maternal seroconversion during lactation Pattern of infant feeding (exclusive breastfeeding versus
Clinical and/or immunological (CD4 cell count) disease mixed)
progression Morbidity leading to less vigorous suckling, milk stasis and
RNA viral load in plasma increased leakage of virus across milk ducts (oral thrush)
RNA viral load in breast milk
Local immune factors in breast milk
Breast health (subclinical or clinical mastitis, abscess,
cracked nipples) (indirect factor)
Maternal nutritional status
Duration of breastfeeding
Source: Adapted from John-Stewart et al. (2004).
13
25. HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007
of CD4 cell count above 500 per ml (The understood. In particular, viral load rebound (i.e.
Breastfeeding and HIV International Transmis- increased levels of the virus after cessation of
sion Study Group (BHITS) 2004). In the Verti- antiretrovirals) in breast milk after discontinua-
cal Transmission Study in South Africa, infants tion of peripartum antiretrovirals is of concern
born to mothers with CD4 cell counts less than (Van de Perre et al. 1997). An increase in the
200 cells per mm3 were almost four times more levels of HIV RNA in breast milk from day eight
likely to acquire HIV or die than were those born to day 45 after delivery was associated with
to mothers with CD4 cell counts greater than maternal short-course ZDV prophylaxis com-
500 cells per mm3; and those born to mothers pared to the placebo group in the Ditrame Plus
with CD4 cell counts between 200 and 500 cells ANRS 049a trial (Manigart et al. 2004). In this
per mm3 were 2.2 times more likely to acquire West African trial, breast-milk HIV-RNA from
HIV or die (Coovadia et al. 2007). 28 women who transmitted HIV postnatally and
from 130 women who did not transmit HIV was
RNA viral load in plasma and breast milk compared. Levels of HIV RNA in breast milk at
Increased maternal RNA viral load in plasma and day eight after delivery and its increase from day
breast milk are both strongly associated with eight to days 45-90 postpartum were both inde-
increased risk of transmission through pendently associated with postnatal transmission
breastfeeding. In West Africa, the rate of late (Manigart et al. 2004). Although HIV transmis-
postnatal transmission increased 2.6-fold for sion continues after cessation of peripartum
every one log10 increase in plasma RNA viral antiretroviral therapy, there is no clinical evidence
load (measured in late pregnancy) (Leroy et al. to suggest that stopping antiretroviral therapy
2001; Leroy et al. 2003). Breast-milk HIV RNA in this early period is associated with an increased
levels cor relate with systemic viral load rate of breastfeeding transmission due to viral
(Willumsen 2003), and are likely to be associ- rebound after cessation of antiretrovirals. Indeed,
ated with risk of breast-milk HIV transmission in the pooled analysis of the West African trials
(Semba et al. 1999a; Willumsen 2003). In Ma- using short-course perinatal ZDV prophylaxis,
lawi, the risk of transmission increased fivefold the cumulative postnatal transmission risks were
when RNA virus had been detected in breast- similar in the ZDV (9.8%, n=254) and placebo
milk samples taken at six weeks postpartum groups (9.1%, n=225) at age 24 months (Leroy
(Semba et al. 1999a). In Nairobi, breast-milk et al. 2003). The long-term overall efficacy of
RNA levels were assessed in serial samples up to this peripartum ZDV regimen was reduced in
two years after delivery (John et al. 2001). In both groups. Global recommendations on
analyses comparing 92 infected infants with 187 antiretrovirals during pregnancy are available
infants who were uninfected at two years, ma- (WHO, 2006).
ternal plasma RNA, mastitis and breast abscess
were associated with late transmission (occur- Anti-infective properties of breast milk in HIV-
ring after two months postpartum). Median RNA infected women
load in colostrum and early milk was higher than Breast milk contains maternal antibodies, with
in mature milk collected more than 14 days af- all basic forms of immunoglobulins IgG, IgM,
ter delivery. Breast-milk RNA load was signifi- IgA, IgD, and IgE present. The most abundant
cantly associated with transmission through is usually secretory IgA (Lawrence & Lawrence
breastfeeding. In a study conducted in Durban, 2004). The role of breast-milk HIV-specific an-
South African women with detectable RNA vi- tibodies in inhibiting HIV transmission through
ral load in breast milk at any time during the breastfeeding has been investigated ( Van de Perre
first six months postpartum were more likely to et al. 1993, Kuhn et al. 2006). The breast milk
transmit than those with undetectable RNA vi- of women with established HIV infection has
ral load (Pillay et al. 2000). been found to have HIV-specific IgG, with its
The evolution of HIV RNA in breast milk af- wide spectrum of activity against HIV proteins,
ter peripartum antiretrovirals needs to be better comparable to HIV-specific IgG in serum. The
14