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

1. Infant and young child nutrition
in the context of HIV
Rene Ekpini E
Senior Adviser
UN I CEF, N ew York
Vienna , 18 July 2010

2. Mother-to-Child transmission in 100
infants born to HIV-positive mother by
timing of transmission
63
uninfected
15
15
7

3. Significant breakthroughs in
interventions to reduce postnatal HIV
transmission
• Appropriate infant feeding counselling and
support for safer infant feeding practices
• Lifelong antiretroviral therapy for women in
need of treatment for their own health
• Triple ARV prophylaxis continued through
breastfeeding in HIV-positive mothers
• Extended ARV prophylaxis to infants through
breastfeeding

4. Exclusive breastfeeding associated with
lower postnatal transmission; Zambia
Thea D et al. 14th CROI , 2007, Los Angeles, CA Abs. LB
10.1%
Non-exclusive BF
4.0%
Exclusive BF
P=0.002

5. Adverse effects of abstinence from
breastfeeding are greater in programmes
than in clinical trials
0-6 months 0-12 months
Botswana Clinical Trial Rakai, Uganda
programme
6X
2X
Thior I, Lockman S, Smeaton LM et Kagaayi J, Gray RH, Brahmbhatt H. et
al. JAM A 2006; 296: 794-805 al. PLoS ONE 2008; Dec 3: e3877

6. Rates of exclusive breastfeeding in HIV-
infected women in resource-limited
settings

7. No overall benefit in HIV-free survival
to early cessation vs. continued breastfeeding
Thea D et al. 14 th CROI , 2007, Los Angeles, CA Abs. LB
Stopped breastfeeding
Continued breastfeeding
Overall HIV-free survival among children
without HIV and still breastfeeding at age 4
Months of age by group assignment (abrupt vs
standard cessation)
p = 0.21

8. Increased diarrhea-related hospitalizations
and deaths among the weaned
Fawzy A, Arpadi S, Aldrovandi G et al. IAS Conference Cape Town July 2009

9. Early cessation of breastfeeding particularly
harmful for children who became HIV-infected
Thea D et al. 14th CROI , 2007, Los Angeles, CA Abs. LB
Survival of HIV-infected Children with Positive Results before Age 4 Months
by Group Assignment (Abrupt vs Standard Weaning)
Continued Breastfeeding
Stopped Breastfeeding
p = 0.01

10. Maternal HAART studies to prevent HIV
postnatal transmission and cumulative
MTCT
Between age 4-6 weeks and 6-7 months HIV transmission rates
4 non-randomized-controlled studies show reduced
HIV breastfeeding transmission
% TR at 6 months
6 mo EBF 6 mo EBF 6 mo EBF 6 mo EBF
Courtesy: Lynne Mofenson

11. Breastfeeding, Antiretroviral and Nutrition
(BAN) study
3 Arms: 1) Control
2) Mothers receive LPv/r for 28 wks throughout BF
3) Breastfeeding infants received daily NVP for 6 mths
10.0 Control Maternal LPV/r Inf NVP
9.0
Infant HIV transmission
and mortality rates %
8.0 7.6%
7.0 6.4%
6.0 p=0.001
4.7%
5.0 p=0.003
4.0 2.9%
3%
3.0
1.8%
2.0
1.0
0.0
Transmission at 6 mo Death at 6 mo

12. PEPI-Malawi Infant Prophylaxis Trial:
Postnatal HIV Infection Rates at Age 14 Weeks in
Infants Uninfected at Birth by Maternal CD4 Category
M ofenson L et al. I AS,Capetow n, South Africa, July 2009 Abs.
TuP EC053
CD4 <200 CD4 200-350 CD4 >350
% Postnatal Relative Risk Relative Risk % Relative
infection (95% CI) % Postnatal (95% CI) Postnatal Risk
(95% CI) [% Efficacy] infection [% Efficacy] Infection (95% CI)
(95% CI) (95% CI) [% Efficacy]
Control 17.6% 1.0 9.0% 1.0 5.5% 1.0
(12.2-25.2) (5.9-13.8) (3.8-7.9)
Ex tended 5.8% 0.33 3.4% 0.37 1.4% 0.25
NVP (3.0-10.8) (0.16-0.68) (1.7-6.7) (0.17-0.84) (0.7-3.0) (0.12-0.59)
[67%] [63%] [75%]
Ex tended 6.1% 0.36 3.2% 0.32 2.3% 0.42
NVP+AZT (3.3-12.4) (0.17-0.78) (1.3-6.3) (0.13-0.78) (1.3-4.1) (0.22-0.83)
[64%] [68%] [58%]
Extended Infant Prophylaxis is Effective in Reducing
Postnatal Infection in all Maternal CD4 Cell Count Strata

13. Summary of existing evidence on
the use of ARVs for PMTCT
• Starting ART if maternal CD4 < 350 is critical for the
health of mothers and their infants
• For mothers with CD4 >350:
– Efficacy of maternal HAART vs short AZT/sdNVP
appears similar for preventing in utero MTCT
(Kesho Bora)
– Longer AP duration (AZT or HAART) is more
effective
– Both maternal HAART and infant prophylaxis
prevent postnatal infection (BAN, Kesho Bora)
– Different maternal HAART regimens appear
equivalent for prevention (Mma Bana)

14. 2009 WHO guidelines refer to two
key approaches
1. Lifelong antiretroviral therapy for all pregnant
women in need of treatment for their own health
2. Maternal or infant ARV prophylaxis beginning as
early as 4 weeks of gestation or as soon as possible
thereafter until cessation of all breastfeeding

15. 2009 WHO recommendations
Recommendation 1:
Ensuring mothers receive the care they need
M others k now n to be HI V-infected should be provided
with lifelong antiretroviral therapy or antiretroviral
prophylaxis interventions to reduce HIV transmission
through breastfeeding according to WHO
recommendations

16. 2009 WHO recommendations
Recommendation 2:
M others k now n to be HI V-infected (and w hose infants
are HI V uninfected or of unk now n HI V status) should
exclusively breastfeed their infants for the first 6
months of life, introducing appropriate complementary
foods thereafter, and continue breastfeeding for the
first 12 months of life.
Breastfeeding should then only stop once a
nutritionally adequate and safe diet without breast
milk can be provided.
When HIV-infected mothers decide to stop
breastfeeding (at any time) they should do so
gradually within one month

17. Are we there yet?

18. Translating the policy discourse into
effective programme - 1
Quality data for action
• Evidence-informed policy development
National
policy level
• Management and planning capacity at
Management
and
national and sub-national level
Coordination
• Capacity of health care workers, counselors
Service and community cadres to deliver services
delivery
level
System approach including civil
society and communities

19. Translating the policy discourse into
effective programme - 2
• To define what integration means on the ground
– Integration is a 'mantra' without definition – not
clearly understood what interventions
should/can be integrated and how
• Policy advocacy for a shift toward “HIV-free
survival” and, improved maternal health and
survival as the preferred metric for effectiveness of
PMTCT programmes
• Strengthening the evidence (M&E – Operational
research ) to inform policy formulation and
programming around infant feeding, and maternal
and child nutrition

20. Translating the policy discourse into
effective programme - 3
• Define the minimum IF package’ closely linked with
delivery of ARVs and translate concepts (e.g. AFASS) into
meaningful routine counselling practices aroung infant
feeding and nutrition
• Implementing IF and nutrition counselling and support as
an integral component of continuum of care of pregnant
women, mothers and their children (including routine
immunization, cotrimoxazole prophylaxis, early infant
diagnosis)
• Involving individuals, families and communities as
partners and clients
• Promoting and supporting innovations (e.g. Rapid SMS)

21. Balancing cost and outcomes
Cost of scenarios - 10,000 HIV mothers (US$)
Assume eligibility criteria for ART <350

22. Beyond the multitude
of mountains there is
a shinning sun of hope