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HIV and
Replacement Feeding
Adapted from :
WHO Infant and Young Child Feeding Counseling:
An Integrated Course
At the end of the session the participants
will be able to:
1. Discuss the importance of counseling HIV
positive women on infant feeding options;
2. Discuss the benefits of BF to newborns and to
mother
3. Enumerate the different factors associated
with HIV transmission through BF
4. Identify the recommended feeding options for
different scenarios
5. Discuss how to stop BF
6. Determine the feeding options after cessation
of BF
Global
summary
of the
HIV/AIDS
epidemic
Western Europe
520,000 – 680,000
North Africa & Middle
East
470,000 – 730,000
Sub-Saharan Africa
27.0 – 29.2 million
Eastern Europe
& Central Asia
1.2 – 1.8 million
South &
South-East Asia
5.6 – 9.2 million
Australia
& New Zealand
12,000 – 18,000
North America
790,000 – 1.2 million
Caribbean
350,000 – 590,000
Latin America
1.3 – 1.9 million
East Asia & Pacific
800,000 – 1.3 million
Adults and children estimated to be living with HIV and AIDS
as of end of 2011 Total: 33 (32.6 – 38.1) million
HIV & AIDS Situationer
Office of the WHO Representative in the Philippines
Office of the WHO Representative in the Philippines
Is HIV Problem in the Philippines Real?
The Current HIV
Situation
63 countries reported.
The Philippines is
one of only 7countries
with increasing HIV cases
HIV Situation in the
Philippines
Estimated number of People
living with HIV 2011 (15-49 yr
old): 19,022
7,884 cumulative cases reported
(1984 – 2011)
By 2015, estimated HIV
population: 35,941
5yrs ago: 210 new cases/yr
This year: 1500 new cases
In 5yrs: 9,800 new cases/yr
Total: 35,000 PLHIV
DEMOGRAPHIC FIGURES 1984-2012
Demographic Data January 2012 Cumulative Data: 1984- 2012
Total Reported Cases 212 8,576
Asymptomatic Cases 208 7,601
AIDS Cases 4 975
Males 203 7,093
Females 9 1,472
Youth 15-24yo 57 1,974
Children < 15yo 1 59
Reported Deaths due to
AIDS
1 342
Office of the WHO Representative in the Philippines
Sentinel
Sites
Baguio City
Angeles City
Quezon City
Pasay City
Iloilo City
Cebu City
Cagayan de Oro City
Davao City
Gen. Santos City
Zamboanga City
In 2007…
National adult HIV
prevalence = 0.0168%
Estimated Number of
PLHIV: 7,490
in 2009…
10x increase!
Treatment Hubs 13 (+ 3)
Gov. Celestino Gallares
Mem Hosp (VII)
Jose B. Lingad
Memorial Medical
Center (III)
Cagayan Valley
Medical Center (II)
Makati Med Cntr
The Medical City
Office of the WHO Representative in the Philippines
Results
• HIV epidemic in the Philippines
expanding
• 10x increase in the number of HIV +
cases
• Evidence of rapid growth rate in some
geosites, among specific most-at-risk
groups (MSM and PWID)
• NO Most-at-risk group is off the hook
• 50% of infection transmitted in the past 5
months (BED Assay)
Office of the WHO Representative in the Philippines
2009: TWO new cases a day!
Average Number of Cases per Month
2007: One new case a day
2000: One new case every
3 days
N A T I O N A L E P I D E M I O L O G Y C E N T E R
2011 : 5-6 new cases a day!
HIV Transmission
• Exchange of HIV-infected body fluid such as
semen, vaginal fluid or blood during unprotected
sexual intercourse
• HIV-infected blood transfusions
• Percutaneous (contaminated needles or other
sharp instruments) or mucous membrane exposure
to contaminated blood and other body fluids
• Mother to Child Transmission (MTCT) during
pregnancy, labor and delivery Breastfeeding
TRANSMISSION
Transmission Risk:
 Unprotected vaginal intercourse M to F 0.1%
 Unprotected vaginal intercourse F to M 0.05%
 Unprotected anal intercourse 0.56%
 Needle share/ IV drug use 67%
 Needle stick 0.3%
 Mother to child transmission 13-48%
 Blood products 90%
MMWRJanuary 21, 2005 / 54(RR02);1-20adapted
TREATMENT: Drugs to treat HIV
 Antiretroviral drugs or ARVs
 use to reduce the amount of HIV in the body
 given at the end of pregnancy and at the time of
delivery
 Combination antiretroviral therapy has been
shown to be more effective than monotherapy (3
drugs given whenever possible)
 Drugs
 azidothymidine (AZT)
 zidovudine (ZDV)
 nevirapine
Philippine HIV/AIDS Registry
January 1984-Nov 2011 (N= 8,096)
Reported modes of Transmission cases
Sexual Transmission/Contact 7,408
Blood/Blood products 20
Injecting drug use 235
Needle prick injuries 3
Mother-to-Child 55
No Data Available 375
Mother-To-Child Transmission
(MTCT) of HIV
Young children who get HIV are usually
infected through their mother
- during pregnancy across the placenta
- at the time of labour and birth through
blood and secretions
- through breastfeeding
17/3
Estimated risk and timing of MCTC
transmission of HIV in the absence of interventions
Timing of MTCT of HIV Transmission Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
_____________________________________________________________________
Overall without breastfeeding 15-25%
Overall with breastfeeding to 6 months 20-35%
Overall with breastfeeding to 18–24 months 30-45%
17/4
Assume prevalence of
HIV infection among
women in the area is
20 %
Q. How many of these
women are likely to be
HIV-positive ?
100 mothers and babies
Of the 100 mothers and babies
(Only 20 mothers may have HIV)
17/6
++ + + +
+ + +
++ + +
+ + + + +
+ + +
If the prevalence of HIV infection is 20%, 20% of 100 = 20
The MCTC during
pregnancy is 15-25%
(Using 25%) ,
how many of these
infants were infected
before or during
delivery ?
20 mothers are likely to be HIV positive
Timing of MTCT of HIV Transmission Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
________________________________________________
Overall without breastfeeding 15-25%
Overall with breastfeeding to 6 months 20-35%
Overall with breastfeeding to 18–24 months 30-45%
++ + + +
+ + +
+++ +
+ + + + +
+ + +
Of the 20 mothers who may have the HIV...
ONLY 5 infants are likely to be infected during pregnancy and
delivery
17/6
+
+ + + +
+ + +
++ + +
+ + + + +
+ + +
25% of 20 = 5
The transmission rate
during breastfeeding is
5-20% …
(using 15%) , assuming
all babies are breastfed
how many will be
infected ?
20 mothers who are likely to be HIV positive
Timing of MTCT of HIV Transmission Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
________________________________________________
Overall without breastfeeding 15-25%
Overall with breastfeeding to 6 months 20-35%
Overall with breastfeeding to 18–24 months 30-45%
++ + + +
+ + +
+++ +
+ + + + +
+ + +
100 mothers and babies
Only 20 mothers may have HIV
(About 3 of the infants of HIV positive mothers are likely to be infected by
breastfeeding)
17/6
++ + + +
+ + +
++ + +
+ + + + +
+ + +
15% of 20 = 3
Factors which affect
mother-to-child transmission of HIV
Recent infection with HIV
Severity of disease
Sexually transmitted infections
Obstetric procedures
Duration of breastfeeding
Exclusive breastfeeding or mixed feeding
Condition of the breasts
Condition of the baby’s mouth
17/13
Recent infection with HIV
Woman infected with HIV during
pregnancy or while breastfeeding
 higher levels of virus in her blood
 infant is more likely to be infected
Unprotected extramarital sex exposes
men to infection with HIV
Severity of HIV infection
Mother is ill with HIV-related disease or
AIDS
Mother not treated with drugs
More virus in the body
= Transmission to the baby is more likely
Duration of breastfeeding
Virus can be transmitted any time
during breastfeeding
The longer the duration of
breastfeeding, the greater the risk of
transmission
Exclusive breastfeeding or mixed feeding
Risk of transmission is greater if
infant given any other foods or drinks
Risk is less if exclusive breastfeeding
Other foods may cause diarrhea and
damage the gut
Condition of the breasts
Nipple fissure, mastitis or breast
abscess may increase risk of HIV
transmission
Good breastfeeding technique helps
• prevent these conditions
• reduce transmission of HIV
Condition of the baby’s mouth
• Mouth sores or thrush may enter the
damaged skin
1. Mothers known to be HIV-infected and whose
infants are HIV uninfected or of unknown HIV status.
• This infant feeding option can be observed in the following
situations:
• The mother was started on ARV treatment.
• The mother received zidovudine (AZT) as prophylaxis
during pregnancy and that the baby will be given daily
dose of nevirapine up to 1 week after all exposure to
breastmilk has ended.
• (Dose of Nevirapine (once daily): Birth-6weeks if
<2,500gm – 10mg , if > 2,500 gm – 15 mg ; > 6
weeks-6 months – 20mg; >6-9months – 30mg ;
>9months to end of breastfeeding – 40mg)
2. Mothers known to be HIV infected with an
HIV positive child
• Since the child is already known to be (+),
preventing transmission is no longer a
concern in determining the appropriate
feeding option.
• For this scenario, the best feeding option is
exclusive BF for 6 months and continue BF
up to 12 months of age
Counselling for infant feeding
in relation to HIV
Pregnant or recently-delivered woman
in contact with the health services
Unknown
HIV status
Tested
negative
Tested
positive
Encourage
testing
Counsel and
encourage
breastfeeding
Counsel on
infant feeding
Discuss all
options
available
18/2
• a. safe water and sanitation are assured
at the household level and in the
community
• b. the mother, or other caregiver can
reliably provide sufficient infant formula
milk to support normal growth and
development of the infant
CONDITIONS when to give
Replacement Feeding to infant with
HIV:
c the mother or caregiver can prepare it
cleanly and frequently enough so that it
is safe and carries a low risk of diarrhoea
and malnutrition.
d. the mother or caregiver can, in the
first six months, exclusively give infant
formula milk
• d. the mother or caregiver can, in the
first six months, exclusively give infant
formula milk
• e. the family is supportive of this
practice
• f. the mother or caregiver can access
health care that offers comprehensive
child health services.
• These descriptions are intended to
give simpler and more explicit
options and meaning to the concept
of AFASS (acceptable, feasible,
affordable, sustainable, safe)
Infant feeding options from
0-6 months
for HIV-positive women
Infant feeding options from 0-6 months
Replacement feeding
when requirements
are fulfilled
• Commercial infant
formula
• Home modified
animal milk with a
micronutrient
supplement
Exclusive
breastfeeding
Other breast-milk
options:
• Expression and heat-
treatment
• [Milk banks]
Early cessation
when RF
requirements
are fulfilled
18/3
ADVANTAGES of Exclusive
breastfeeding for an HIV-infected mother
Breast milk is the perfect food for babies
- complete nutrition including water
- no need for any liquid or food
Breast milk gives protection against
common childhood infections, especially
diarrhea and pneumonia
Breast milk is free, always available and
does not need any special preparation
Advantages of exclusive breastfeeding for
an HIV-infected mother
Exclusive breastfeeding reduces
the risk of HIV transmission,
compared to mixed feeding
Exclusive breastfeeding helps
mothers recover from childbirth
and protects them from getting
pregnant too soon
DISADVANTAGES of exclusive
breastfeeding for an HIV-infected mother
As long as the mother breastfeeds, her
baby is exposed to HIV
People may pressure mother to mix feed
which increases the risk of HIV and other
infections
Mother will need support to exclusively
breastfeed until it is possible for her to
use another feeding option
Early cessation of breastfeeding
Reduces the risk of HIV transmission
- by reducing the length of time the
infant is exposed to the virus in breast
milk
- for HIV+ = 12 months is maximum
length of time to breastfed; whereas for
healthy babies continue up to 2 years
Early cessation of breastfeeding
Mothers may consider other breast milk
substitute such as expressing and heat-
treating breast milk from six months
onwards
How to stop breastfeeding
• HIV infected mothers who decided to stop BF
at any time should discontinue it gradually
within a month.
• Infants who are receiving prophylaxis (daily
Nevirapine) should continue taking the drugs
up to one week after the cessation of
breastmilk exposure.
• For HIV infected mothers who decided to stop
BF, the health provider must counsel them on
other infant feeding alternatives.
Breastfeeding by another
woman who is HIV-negative
Wet nursing – a woman breastfeeding
a baby to whom she did not give
birth
Donor breast milk – milk expressed by
another woman for another baby
Pointers about wet-nursing
A woman breastfeeding another infant
need to have sufficient rest, food and
water
Baby’s own mother should provide as
much care as possible to the child by
cuddling, changing, washing, massaging,
and giving other foods
Pointers about wet-nursing
To protect the baby from HIV, wet-nurse
must be HIV-negative
Wet-nurse should protect self from HIV
infection the entire time she is breastfeeding
• Not having sex or using condom
• Have sex with only one partner who is
also faithful to her
• Not sharing razors, needles or other
piercing objects
Heat-treated expressed milk
Heat-treated breast milk is another option to
consider if
• Mother wishes to give her baby her own
milk
• Alternative milks are too expensive
• Sick or low-birth-weight infants are more
at risk from artificial feeding
Heat-treated expressed milk
Heat-treatment destroys HIV in breast milk
Heat-treatment reduces the level of some
anti-infective components of breast milk
Heat-treated milk remains superior to
breast-milk substitute
HOW to heat-treat and store breast milk
Before heating gather the following
Clean containers with wide necks and
covers, enough to store the milk
A small pot to heat the milk
A large container of cool water
A small cup for feeding the baby
Fuel to heat the milk
Soap and clean water to wash the
equipment
How to heat-treat and store breast milk
Follow these steps
- Wash all the pots, cups and containers with soap
and water
- Only heat enough expressed milk for one feed
- Place container with breastmilk inside a wider
pot with boiling water . When the breastmilk is
rolling boil, remove and
- Place the pot in a container of cold water so
that it cools quickly or let the milk stand until it
cools
- Store the boiled milk in clean, covered container
1. ADVANTAGES
 Giving only formula carries no risk of
transmitting HIV to the baby
 Most of the nutrients a baby needs have
already been added to the formula.
 Other responsible family members can
help feed the baby.
ADVANTAGES AND DISADVANTAGES OF
COMMERCIAL INFANT FORMULA
II. DISADVANTAGES of artificial formula
Formula does not contain antibodies that
protect a baby from infections.
A formula-fed baby is more likely to get
seriously sick from diarrhoea, chest
infections and malnutrition, especially if the
formula is not prepared correctly.
A mother should stop breastfeeding
completely or the risk of transmitting HIV
will continue.
People may wonder why a mother is
using formula instead of breastfeeding,
and this could cause them to suspect
she is HIV- positive.
Mother needs fuel, clean water, utensils,
soap etc.
Time consuming
Expensive
Have to teach baby to drink from cup
Mom may get pregnant soon
DISADVANTAGES OF COMMERCIAL FORMULA
Summary
If a mother who is HIV-positive decides to
breastfeed as the best option, she should
be supported to establish and maintain it
If a mother breastfeeds, she should make
sure that her infant is well-attached to the
breast, to prevent nipple fissure and
mastitis, which may increase the risk of
transmission of HIV
Summary
A mother who is HIV-positive should
breastfeed exclusively, no other foods or
fluids
Other breast milk options include :
exclusive breastfeeding and stopping early,
expression, and heat-treatment of breast
milk
“HIV-infected mothers should receive
counselling which includes provision of
general information about the risks and
benefits of various infant feeding
options, and specific guidance in
selecting the option most likely to be
suitable for their situation. Whatever a
mother decides, she should be
supported in her choice”
WHO 2010 Guideline on HIV and Infant Feeding
CASE STUDY NO. 1
• Marian, 28 year old HIV positive
woman, has delivered a baby boy.
During her pregnancy, she was given
AZT as early as 28 weeks of pregnancy.
• As part of post-delivery counseling,
what advice will you give to Marian on
infant feeding?
• During post-delivery counseling, the health provider should
encourage Marian to BF her baby exclusively provided that the
baby will be given daily dose of nevirapine.
• The health provider can explain to Marian that there is risk of
transmission of the HIV virus through BF. However, this risk can
be reduced by providing ARV prophylaxis to her baby since she
has already taken AZT during pregnancy.
• The health provider should also advise her that in case she
would stop BF for whatever cause, daily dose of nevirapine
taken by the baby can only be discontinued one week after the
cessation of BF
CASE STUDY NO. 2
• Helen, 32 year old positive woman that is on
zidovudine, lamivudine and nevirapine, came
to your clinic as part of her antenatal check
up. She is pregnant at 37 weeks age of
gestation. She asked you as her attending
physician if she can breastfeed her baby right
after delivery. Helen said that she has
browsed the internet and found out that HIV
can be transmitted through breast milk.
• What advice will you give to Helen regarding
her concerns?
• The health provider can explain to Helen that
there is risk of transmission of HIV to the
baby because the HIV virus in CD4 cells is
present in breast milk.
• However, antiretroviral drugs can reduce
the risk of transmission.
• The health provider can assure Helen that
she can breastfeed her baby after delivery as
long as she will continue taking her
antiretroviral drugs.
CASE STUDY NO. 3
• Micah, 26 year old woman, is breastfeeding her
4 month old baby when she found out that she
is HIV positive. She submitted herself and her
3 month old baby to HIV testing after the result
of the HIV test of her husband turned out to be
positive. Her baby also turned out to be
positive. During post HIV test counseling,
Micah asked if she can still continue
breastfeeding her baby.
• How will you advise Micah regarding her
concerns.
• Since both Micah and her baby are known to be HIV
positive, risk of transmission is no longer a major
concern.
• In this case, the health provider can advise Micah to
continue breastfeeding exclusively up to 6 months
and at six months, introduce complementary foods.
• Breastfeeding can be continued like the
recommendation for the general population which is
up to 2 years of age.

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  • 1.
  • 2. HIV and Replacement Feeding Adapted from : WHO Infant and Young Child Feeding Counseling: An Integrated Course
  • 3. At the end of the session the participants will be able to: 1. Discuss the importance of counseling HIV positive women on infant feeding options; 2. Discuss the benefits of BF to newborns and to mother 3. Enumerate the different factors associated with HIV transmission through BF 4. Identify the recommended feeding options for different scenarios 5. Discuss how to stop BF 6. Determine the feeding options after cessation of BF
  • 4. Global summary of the HIV/AIDS epidemic Western Europe 520,000 – 680,000 North Africa & Middle East 470,000 – 730,000 Sub-Saharan Africa 27.0 – 29.2 million Eastern Europe & Central Asia 1.2 – 1.8 million South & South-East Asia 5.6 – 9.2 million Australia & New Zealand 12,000 – 18,000 North America 790,000 – 1.2 million Caribbean 350,000 – 590,000 Latin America 1.3 – 1.9 million East Asia & Pacific 800,000 – 1.3 million Adults and children estimated to be living with HIV and AIDS as of end of 2011 Total: 33 (32.6 – 38.1) million HIV & AIDS Situationer Office of the WHO Representative in the Philippines
  • 5. Office of the WHO Representative in the Philippines Is HIV Problem in the Philippines Real? The Current HIV Situation
  • 6. 63 countries reported. The Philippines is one of only 7countries with increasing HIV cases
  • 7. HIV Situation in the Philippines Estimated number of People living with HIV 2011 (15-49 yr old): 19,022 7,884 cumulative cases reported (1984 – 2011) By 2015, estimated HIV population: 35,941
  • 8. 5yrs ago: 210 new cases/yr This year: 1500 new cases In 5yrs: 9,800 new cases/yr Total: 35,000 PLHIV
  • 9. DEMOGRAPHIC FIGURES 1984-2012 Demographic Data January 2012 Cumulative Data: 1984- 2012 Total Reported Cases 212 8,576 Asymptomatic Cases 208 7,601 AIDS Cases 4 975 Males 203 7,093 Females 9 1,472 Youth 15-24yo 57 1,974 Children < 15yo 1 59 Reported Deaths due to AIDS 1 342
  • 10. Office of the WHO Representative in the Philippines Sentinel Sites Baguio City Angeles City Quezon City Pasay City Iloilo City Cebu City Cagayan de Oro City Davao City Gen. Santos City Zamboanga City In 2007… National adult HIV prevalence = 0.0168% Estimated Number of PLHIV: 7,490 in 2009… 10x increase!
  • 11. Treatment Hubs 13 (+ 3) Gov. Celestino Gallares Mem Hosp (VII) Jose B. Lingad Memorial Medical Center (III) Cagayan Valley Medical Center (II) Makati Med Cntr The Medical City
  • 12. Office of the WHO Representative in the Philippines Results • HIV epidemic in the Philippines expanding • 10x increase in the number of HIV + cases • Evidence of rapid growth rate in some geosites, among specific most-at-risk groups (MSM and PWID) • NO Most-at-risk group is off the hook • 50% of infection transmitted in the past 5 months (BED Assay)
  • 13. Office of the WHO Representative in the Philippines 2009: TWO new cases a day! Average Number of Cases per Month 2007: One new case a day 2000: One new case every 3 days N A T I O N A L E P I D E M I O L O G Y C E N T E R 2011 : 5-6 new cases a day!
  • 14. HIV Transmission • Exchange of HIV-infected body fluid such as semen, vaginal fluid or blood during unprotected sexual intercourse • HIV-infected blood transfusions • Percutaneous (contaminated needles or other sharp instruments) or mucous membrane exposure to contaminated blood and other body fluids • Mother to Child Transmission (MTCT) during pregnancy, labor and delivery Breastfeeding
  • 15. TRANSMISSION Transmission Risk:  Unprotected vaginal intercourse M to F 0.1%  Unprotected vaginal intercourse F to M 0.05%  Unprotected anal intercourse 0.56%  Needle share/ IV drug use 67%  Needle stick 0.3%  Mother to child transmission 13-48%  Blood products 90% MMWRJanuary 21, 2005 / 54(RR02);1-20adapted
  • 16. TREATMENT: Drugs to treat HIV  Antiretroviral drugs or ARVs  use to reduce the amount of HIV in the body  given at the end of pregnancy and at the time of delivery  Combination antiretroviral therapy has been shown to be more effective than monotherapy (3 drugs given whenever possible)  Drugs  azidothymidine (AZT)  zidovudine (ZDV)  nevirapine
  • 17. Philippine HIV/AIDS Registry January 1984-Nov 2011 (N= 8,096) Reported modes of Transmission cases Sexual Transmission/Contact 7,408 Blood/Blood products 20 Injecting drug use 235 Needle prick injuries 3 Mother-to-Child 55 No Data Available 375
  • 18. Mother-To-Child Transmission (MTCT) of HIV Young children who get HIV are usually infected through their mother - during pregnancy across the placenta - at the time of labour and birth through blood and secretions - through breastfeeding 17/3
  • 19. Estimated risk and timing of MCTC transmission of HIV in the absence of interventions Timing of MTCT of HIV Transmission Rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% _____________________________________________________________________ Overall without breastfeeding 15-25% Overall with breastfeeding to 6 months 20-35% Overall with breastfeeding to 18–24 months 30-45% 17/4
  • 20. Assume prevalence of HIV infection among women in the area is 20 % Q. How many of these women are likely to be HIV-positive ? 100 mothers and babies
  • 21. Of the 100 mothers and babies (Only 20 mothers may have HIV) 17/6 ++ + + + + + + ++ + + + + + + + + + + If the prevalence of HIV infection is 20%, 20% of 100 = 20
  • 22. The MCTC during pregnancy is 15-25% (Using 25%) , how many of these infants were infected before or during delivery ? 20 mothers are likely to be HIV positive Timing of MTCT of HIV Transmission Rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% ________________________________________________ Overall without breastfeeding 15-25% Overall with breastfeeding to 6 months 20-35% Overall with breastfeeding to 18–24 months 30-45% ++ + + + + + + +++ + + + + + + + + +
  • 23. Of the 20 mothers who may have the HIV... ONLY 5 infants are likely to be infected during pregnancy and delivery 17/6 + + + + + + + + ++ + + + + + + + + + + 25% of 20 = 5
  • 24. The transmission rate during breastfeeding is 5-20% … (using 15%) , assuming all babies are breastfed how many will be infected ? 20 mothers who are likely to be HIV positive Timing of MTCT of HIV Transmission Rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% ________________________________________________ Overall without breastfeeding 15-25% Overall with breastfeeding to 6 months 20-35% Overall with breastfeeding to 18–24 months 30-45% ++ + + + + + + +++ + + + + + + + + +
  • 25. 100 mothers and babies Only 20 mothers may have HIV (About 3 of the infants of HIV positive mothers are likely to be infected by breastfeeding) 17/6 ++ + + + + + + ++ + + + + + + + + + + 15% of 20 = 3
  • 26. Factors which affect mother-to-child transmission of HIV Recent infection with HIV Severity of disease Sexually transmitted infections Obstetric procedures Duration of breastfeeding Exclusive breastfeeding or mixed feeding Condition of the breasts Condition of the baby’s mouth 17/13
  • 27. Recent infection with HIV Woman infected with HIV during pregnancy or while breastfeeding  higher levels of virus in her blood  infant is more likely to be infected Unprotected extramarital sex exposes men to infection with HIV
  • 28. Severity of HIV infection Mother is ill with HIV-related disease or AIDS Mother not treated with drugs More virus in the body = Transmission to the baby is more likely
  • 29. Duration of breastfeeding Virus can be transmitted any time during breastfeeding The longer the duration of breastfeeding, the greater the risk of transmission
  • 30. Exclusive breastfeeding or mixed feeding Risk of transmission is greater if infant given any other foods or drinks Risk is less if exclusive breastfeeding Other foods may cause diarrhea and damage the gut
  • 31. Condition of the breasts Nipple fissure, mastitis or breast abscess may increase risk of HIV transmission Good breastfeeding technique helps • prevent these conditions • reduce transmission of HIV Condition of the baby’s mouth • Mouth sores or thrush may enter the damaged skin
  • 32. 1. Mothers known to be HIV-infected and whose infants are HIV uninfected or of unknown HIV status. • This infant feeding option can be observed in the following situations: • The mother was started on ARV treatment. • The mother received zidovudine (AZT) as prophylaxis during pregnancy and that the baby will be given daily dose of nevirapine up to 1 week after all exposure to breastmilk has ended. • (Dose of Nevirapine (once daily): Birth-6weeks if <2,500gm – 10mg , if > 2,500 gm – 15 mg ; > 6 weeks-6 months – 20mg; >6-9months – 30mg ; >9months to end of breastfeeding – 40mg)
  • 33. 2. Mothers known to be HIV infected with an HIV positive child • Since the child is already known to be (+), preventing transmission is no longer a concern in determining the appropriate feeding option. • For this scenario, the best feeding option is exclusive BF for 6 months and continue BF up to 12 months of age
  • 34. Counselling for infant feeding in relation to HIV Pregnant or recently-delivered woman in contact with the health services Unknown HIV status Tested negative Tested positive Encourage testing Counsel and encourage breastfeeding Counsel on infant feeding Discuss all options available 18/2
  • 35. • a. safe water and sanitation are assured at the household level and in the community • b. the mother, or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant CONDITIONS when to give Replacement Feeding to infant with HIV:
  • 36. c the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition. d. the mother or caregiver can, in the first six months, exclusively give infant formula milk
  • 37. • d. the mother or caregiver can, in the first six months, exclusively give infant formula milk • e. the family is supportive of this practice • f. the mother or caregiver can access health care that offers comprehensive child health services.
  • 38. • These descriptions are intended to give simpler and more explicit options and meaning to the concept of AFASS (acceptable, feasible, affordable, sustainable, safe)
  • 39. Infant feeding options from 0-6 months for HIV-positive women Infant feeding options from 0-6 months Replacement feeding when requirements are fulfilled • Commercial infant formula • Home modified animal milk with a micronutrient supplement Exclusive breastfeeding Other breast-milk options: • Expression and heat- treatment • [Milk banks] Early cessation when RF requirements are fulfilled 18/3
  • 40. ADVANTAGES of Exclusive breastfeeding for an HIV-infected mother Breast milk is the perfect food for babies - complete nutrition including water - no need for any liquid or food Breast milk gives protection against common childhood infections, especially diarrhea and pneumonia Breast milk is free, always available and does not need any special preparation
  • 41. Advantages of exclusive breastfeeding for an HIV-infected mother Exclusive breastfeeding reduces the risk of HIV transmission, compared to mixed feeding Exclusive breastfeeding helps mothers recover from childbirth and protects them from getting pregnant too soon
  • 42. DISADVANTAGES of exclusive breastfeeding for an HIV-infected mother As long as the mother breastfeeds, her baby is exposed to HIV People may pressure mother to mix feed which increases the risk of HIV and other infections Mother will need support to exclusively breastfeed until it is possible for her to use another feeding option
  • 43. Early cessation of breastfeeding Reduces the risk of HIV transmission - by reducing the length of time the infant is exposed to the virus in breast milk - for HIV+ = 12 months is maximum length of time to breastfed; whereas for healthy babies continue up to 2 years
  • 44. Early cessation of breastfeeding Mothers may consider other breast milk substitute such as expressing and heat- treating breast milk from six months onwards
  • 45. How to stop breastfeeding • HIV infected mothers who decided to stop BF at any time should discontinue it gradually within a month. • Infants who are receiving prophylaxis (daily Nevirapine) should continue taking the drugs up to one week after the cessation of breastmilk exposure. • For HIV infected mothers who decided to stop BF, the health provider must counsel them on other infant feeding alternatives.
  • 46. Breastfeeding by another woman who is HIV-negative Wet nursing – a woman breastfeeding a baby to whom she did not give birth Donor breast milk – milk expressed by another woman for another baby
  • 47. Pointers about wet-nursing A woman breastfeeding another infant need to have sufficient rest, food and water Baby’s own mother should provide as much care as possible to the child by cuddling, changing, washing, massaging, and giving other foods
  • 48. Pointers about wet-nursing To protect the baby from HIV, wet-nurse must be HIV-negative Wet-nurse should protect self from HIV infection the entire time she is breastfeeding • Not having sex or using condom • Have sex with only one partner who is also faithful to her • Not sharing razors, needles or other piercing objects
  • 49. Heat-treated expressed milk Heat-treated breast milk is another option to consider if • Mother wishes to give her baby her own milk • Alternative milks are too expensive • Sick or low-birth-weight infants are more at risk from artificial feeding
  • 50. Heat-treated expressed milk Heat-treatment destroys HIV in breast milk Heat-treatment reduces the level of some anti-infective components of breast milk Heat-treated milk remains superior to breast-milk substitute
  • 51. HOW to heat-treat and store breast milk Before heating gather the following Clean containers with wide necks and covers, enough to store the milk A small pot to heat the milk A large container of cool water A small cup for feeding the baby Fuel to heat the milk Soap and clean water to wash the equipment
  • 52. How to heat-treat and store breast milk Follow these steps - Wash all the pots, cups and containers with soap and water - Only heat enough expressed milk for one feed - Place container with breastmilk inside a wider pot with boiling water . When the breastmilk is rolling boil, remove and - Place the pot in a container of cold water so that it cools quickly or let the milk stand until it cools - Store the boiled milk in clean, covered container
  • 53. 1. ADVANTAGES  Giving only formula carries no risk of transmitting HIV to the baby  Most of the nutrients a baby needs have already been added to the formula.  Other responsible family members can help feed the baby. ADVANTAGES AND DISADVANTAGES OF COMMERCIAL INFANT FORMULA
  • 54. II. DISADVANTAGES of artificial formula Formula does not contain antibodies that protect a baby from infections. A formula-fed baby is more likely to get seriously sick from diarrhoea, chest infections and malnutrition, especially if the formula is not prepared correctly. A mother should stop breastfeeding completely or the risk of transmitting HIV will continue.
  • 55. People may wonder why a mother is using formula instead of breastfeeding, and this could cause them to suspect she is HIV- positive. Mother needs fuel, clean water, utensils, soap etc. Time consuming Expensive Have to teach baby to drink from cup Mom may get pregnant soon DISADVANTAGES OF COMMERCIAL FORMULA
  • 56. Summary If a mother who is HIV-positive decides to breastfeed as the best option, she should be supported to establish and maintain it If a mother breastfeeds, she should make sure that her infant is well-attached to the breast, to prevent nipple fissure and mastitis, which may increase the risk of transmission of HIV
  • 57. Summary A mother who is HIV-positive should breastfeed exclusively, no other foods or fluids Other breast milk options include : exclusive breastfeeding and stopping early, expression, and heat-treatment of breast milk
  • 58. “HIV-infected mothers should receive counselling which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. Whatever a mother decides, she should be supported in her choice” WHO 2010 Guideline on HIV and Infant Feeding
  • 59.
  • 60. CASE STUDY NO. 1 • Marian, 28 year old HIV positive woman, has delivered a baby boy. During her pregnancy, she was given AZT as early as 28 weeks of pregnancy. • As part of post-delivery counseling, what advice will you give to Marian on infant feeding?
  • 61. • During post-delivery counseling, the health provider should encourage Marian to BF her baby exclusively provided that the baby will be given daily dose of nevirapine. • The health provider can explain to Marian that there is risk of transmission of the HIV virus through BF. However, this risk can be reduced by providing ARV prophylaxis to her baby since she has already taken AZT during pregnancy. • The health provider should also advise her that in case she would stop BF for whatever cause, daily dose of nevirapine taken by the baby can only be discontinued one week after the cessation of BF
  • 62. CASE STUDY NO. 2 • Helen, 32 year old positive woman that is on zidovudine, lamivudine and nevirapine, came to your clinic as part of her antenatal check up. She is pregnant at 37 weeks age of gestation. She asked you as her attending physician if she can breastfeed her baby right after delivery. Helen said that she has browsed the internet and found out that HIV can be transmitted through breast milk. • What advice will you give to Helen regarding her concerns?
  • 63. • The health provider can explain to Helen that there is risk of transmission of HIV to the baby because the HIV virus in CD4 cells is present in breast milk. • However, antiretroviral drugs can reduce the risk of transmission. • The health provider can assure Helen that she can breastfeed her baby after delivery as long as she will continue taking her antiretroviral drugs.
  • 64. CASE STUDY NO. 3 • Micah, 26 year old woman, is breastfeeding her 4 month old baby when she found out that she is HIV positive. She submitted herself and her 3 month old baby to HIV testing after the result of the HIV test of her husband turned out to be positive. Her baby also turned out to be positive. During post HIV test counseling, Micah asked if she can still continue breastfeeding her baby. • How will you advise Micah regarding her concerns.
  • 65. • Since both Micah and her baby are known to be HIV positive, risk of transmission is no longer a major concern. • In this case, the health provider can advise Micah to continue breastfeeding exclusively up to 6 months and at six months, introduce complementary foods. • Breastfeeding can be continued like the recommendation for the general population which is up to 2 years of age.