Update on HIV and infant feeding

Update on HIV and infant feeding

Peggy Henderson and Constanza Vallenas

Department of Child and Adolescent Health and Development, WHO

Rome, 25 February 2007

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UN RecommendationsUN Recommendations

HIV- women or HIV status unknown

Exclusive breastfeeding for 6 months and continued breastfeeding for 2 years or beyond

HIV+ women

Most appropriate infant feeding option for HIV-exposed infant depends on individual circumstances, including consideration of health services, counselling and support

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Selecting an option:AFASS

Selecting an option:AFASS

To be a better option for the individual than exclusive breastfeeding, replacement feeding has to be AFASS:

Acceptable

Feasible

Affordable

Sustainable AND

Safe

For the mother and baby

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Balancing risksfor HIV-positive women

Balancing risksfor HIV-positive women

HIV transmission

IF BREASTFEEDING

Mortality Infectious diseasesMalnutrition

IF NOT BREASTFEEDING

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Balancing risks - 1 HIV transmission

Balancing risks - 1 HIV transmission

Risk of HIV transmission with full package of MTCT prevention Interventions (HAART, replacement feeding, caesarean section) < 2%

Risk of HIV transmission through breastfeeding:

Exclusive breastfeeding (6 weeks – 6 months) ~ 4%

Breastfeeding as usual (varying duration) 5 to 20%

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1

2

3

4

5

6

7

<2 m 2 - 3 m 4 - 5 m 6 - 8 m 9 - 11 m

Rela

tive r

isk

Age (months)

WHO Collaborative Study Team, Lancet, 2000

Balancing risks – 2Relative risk of infectious disease mortality

among non-breastfed infants

5.8

4.1

2.6

1.81.4

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1

3

5

7

9

11

13

BF+formula BF+solids EBF

Haz

ard

rat

io

Coovadia et al., Lancet, in press

Balancing risks – 3Mixed feeding carries higher risk of HIV transmission

than exclusive breastfeeding

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Balancing Risks - 4No Difference in 18-Month mortality/HIV infection

between Formula and Breastfed Infants

Balancing Risks - 4No Difference in 18-Month mortality/HIV infection

between Formula and Breastfed Infants

13.9%12.5%8.9%

15.1%12.9%

6.1%

0%

10%

20%

30%

1 Month 7 Months 18 MonthsInfant age

Formula Breast + AZT

p=0.60p=0.86

p=0.08

FF: 33 infected, 62 deathsBF: 53 infected, 48 deaths

% H

IV-I

nfe

cte

d o

r D

ea

d

Thior et al., JAMA, 2006

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Supporting a mother to choose and implementan option:

Before delivery and in the first months

Supporting a mother to choose and implementan option:

Before delivery and in the first months

Counselling based on broad definition of AFASS for her and her baby

2 main options (replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interested

Support for choice

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High EXCLUSIVE breastfeeding rates achievable with good quality counselling and support

High EXCLUSIVE breastfeeding rates achievable with good quality counselling and support

66.50%

40.10%

81.90%

0

20

40

60

80

100

6 weeks ≥ 3 months 6 monthsAge

% e

xclu

sive

ly b

reas

tfed

Median duration of EBF = 159 days

Coovadia et al., Lancet, in press

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Emerging evidenceEmerging evidence

Early BF cessation associated with increased morbidity and mortality in HIV-exposed infants

Providing free infant formula from birth does not necessarily lead to better HIV-free survival compared to EBF

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Infant infections by feeding modeInfant infections by feeding mode

HRp95% CI

EBF1.0

BM + fluid1.56 0.308 0.66-3.69

BM + solids10.870.0181.51-78.00

BM+FF (@12wks)1.820.0570.98-3.36

EBF1.0

MBF pre-3/121.54 0.011 1.10-2.15

MBF post-3/121.53 0.021 1.07-2.20

Vertical Transmission Study, in Press

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Emerging evidenceEmerging evidence

HIV-positive infants benefit from continued BF

Availability of health system support important in assessing AFASS

Severity of disease in mother important, but AFASS criteria still more critical

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Emerging evidenceEmerging evidence

● Improved adherence, longer duration of exclusive breastfeeding achieved in HIV-infected and HIV-uninfected mothers given consistent messages and frequent, high quality counselling

● Not enough evidence re ARVs and breastfeeding to draw firm conclusions, but HIV-infected mothers who need ARVs should have them

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Supporting a mother at key decision points in first months

Supporting a mother at key decision points in first months

If mother breastfeeding: Early testing (PCR):

Baby HIV-negative: replacement feeding if AFASS Baby HIV-positive: continue breastfeeding

Improvement in financial/social/support situation: re-assess AFASS to consider replacement feeding

Mother on ARVs: Risk of transmission low, but replacement feeding if AFASS

Continued support for choice for all mothers

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Supporting a mother when practiceschange at 6 months

Supporting a mother when practiceschange at 6 months

If still breastfeeding: if other milks, animal source-foods available – cease all breastfeeding

and give other foods no such foods available – risk of mixed feeding for a few months

probably less than risk of severe malnutrition

If breastfeeding already stopped: Continue with milk of some kind and complementary foods

Continued support for choice

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Implications for scaling-up in countriesImplications for scaling-up in countries

Good quality infant feeding counselling and support for mothers (training, motivation, supervision)

Protection, promotion and support for infant feeding for all women to help HIV-positive women who breastfeed

Where breast-milk substitutes provided, safe and appropriate use and prevention of spillover

Link infant feeding with effective reproductive and child health services

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Updating guidanceUpdating guidance

Consensus Statement from 2006 Technical Consultation (new evidence and experience, updated recommendations

Full consultation report (1st quarter 2007)

Update of Review of transmission (1st quarter 2007)

Technical update (2nd quarter 2007)

Minimal revision of existing tools (as reprinted)

Complete revisions when more evidence on ARVs and breastfeeding available (~2008-9)

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THANK YOUTHANK YOU