Infant and young child nutrition in the context of HIV

Rene Ekpini ESenior Adviser

UNICEF, New York

Vienna , 18 July 2010

Mother-to-Child transmission in 100 infants born to HIV-positive mother by

timing of transmission

63

uninfected

15

15

7

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

Exclusive BF

Non-exclusive BF

4.0%

10.1%

P=0.002

Exclusive breastfeeding associated withlower postnatal transmission; Zambia

Thea D et al. 14th CROI, 2007, Los Angeles, CA Abs. LB

Adverse effects of abstinence from breastfeeding are greater in programmes

than in clinical trials

0-6 monthsBotswana Clinical Trial

0-12 monthsRakai, Uganda programme

2X

6X

Kagaayi J, Gray RH, Brahmbhatt H. et al. PLoS ONE 2008; Dec 3: e3877

Thior I, Lockman S, Smeaton LM et al. JAMA 2006; 296: 794-805

Rates of exclusive breastfeeding in HIV-infected women in resource-limited

settings

Stopped breastfeeding

Continued breastfeeding

No overall benefit in HIV-free survivalto early cessation vs. continued breastfeedingThea D et al. 14th CROI, 2007, Los Angeles, CA Abs. LB

p = 0.21

Overall HIV-free survival among children without HIV and still breastfeeding at age 4 Months of age by group assignment (abrupt vs standard cessation)

Increased diarrhea-related hospitalizations and deaths among the weaned

Fawzy A, Arpadi S, Aldrovandi G et al. IAS Conference Cape Town July 2009

Stopped Breastfeeding

Continued Breastfeeding

Early cessation of breastfeeding particularlyharmful for children who became HIV-infectedThea D et al. 14th CROI, 2007, Los Angeles, CA Abs. LB

p = 0.01

Survival of HIV-infected Children with Positive Results before Age 4 Months by Group Assignment (Abrupt vs Standard Weaning)

Maternal HAART studies to prevent HIV postnatal transmission and cumulative

MTCT Between age 4-6 weeks and 6-7 months HIV transmission rates

% T

R a

t 6

mon

ths

4 non-randomized-controlled studies show reduced HIV breastfeeding transmission

6 mo EBF 6 mo EBF 6 mo EBF 6 mo EBFCourtesy: Lynne Mofenson

6.4%7.6%

3%

4.7%

1.8%

2.9%

0.01.02.03.04.05.06.07.08.09.0

10.0

Transmission at 6 mo Death at 6 mo

Control Maternal LPV/r Inf NVP

Breastfeeding, Antiretroviral and Nutrition (BAN) study

Infa

nt H

IV tr

ansm

issi

on

and

mor

talit

y ra

tes %

p=0.001

p=0.003

3 Arms: 1) Control2) Mothers receive LPv/r for 28 wks throughout BF 3) Breastfeeding infants received daily NVP for 6 mths

PEPI-Malawi Infant Prophylaxis Trial:Postnatal HIV Infection Rates at Age 14 Weeks in

Infants Uninfected at Birth by Maternal CD4 CategoryMofenson L et al. IAS,Capetown, South Africa, July 2009 Abs.

TuPEC053

CD4 <200 CD4 200-350 CD4 >350% Postnatal

infection (95% CI)

Relative Risk (95% CI)

[% Efficacy]% Postnatal

infection (95% CI)

Relative Risk(95% CI)

[% Efficacy]

% PostnatalInfection (95% CI)

RelativeRisk

(95% CI)[% Efficacy]

Control 17.6%(12.2-25.2)

1.0 9.0%(5.9-13.8)

1.0 5.5%(3.8-7.9)

1.0

Extended NVP

5.8%(3.0-10.8)

0.33(0.16-0.68)

[67%]

3.4%(1.7-6.7)

0.37(0.17-0.84)

[63%]

1.4%(0.7-3.0)

0.25(0.12-0.59)

[75%]Extended NVP+AZT

6.1%(3.3-12.4)

0.36 (0.17-0.78)

[64%]

3.2%(1.3-6.3)

0.32(0.13-0.78)

[68%]

2.3%(1.3-4.1)

0.42(0.22-0.83)

[58%]

Extended Infant Prophylaxis is Effective in Reducing Postnatal Infection in all Maternal CD4 Cell Count Strata

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)

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

Recommendation 1:

Ensuring mothers receive the care they needMothers known to be HIV-infected should be provided with lifelong antiretroviral therapy or antiretroviral prophylaxis interventions to reduce HIV transmission through breastfeeding according to WHO recommendations

2009 WHO recommendations

Recommendation 2:

Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV 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

2009 WHO recommendations

Are we there yet?

National policy level

• Evidence-informed policy development

Management and

Coordination

• Management and planning capacity at national and sub-national level

Service delivery

level

• Capacity of health care workers, counselors and community cadres to deliver services

System approach including civil society and communities

Qua

lity

data

for

act

ion

Translating the policy discourse into effective programme - 1

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

• 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)

Translating the policy discourse into effective programme - 3

Cost of scenarios - 10,000 HIV mothers (US$)Assume eligibility criteria for ART <350

Balancing cost and outcomes

Beyond the multitude of mountains there is

a shinning sun of hope