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Meeting the Challenge of Infant Feeding in the Context of HIV

Meeting the Challenge of Infant Feeding in the Context of HIV. Dr. JP Dadhich MD Coordinator, BPNI Taskforce on Research and Interventions Co-coordinator, IBFAN Asia Pacific WG on HIV & Infant Feeding New Delhi, India. 10 th IWHM, September 2005, New Delhi. Outline.

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Meeting the Challenge of Infant Feeding in the Context of HIV

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  1. Meeting the Challenge of Infant Feeding in the Context of HIV Dr. JP Dadhich MD Coordinator, BPNI Taskforce on Research and Interventions Co-coordinator, IBFAN Asia Pacific WG on HIV & Infant Feeding New Delhi, India 10th IWHM, September 2005, New Delhi

  2. Outline • Magnitude of HIV/AIDS • Global response • Risk factors for transmission from parents to child • Challenges in HIV and IF • Partnership

  3. Magnitude of HIV/AIDS Pandemic • By the end of 2003, an estimated 38 million people were infected with HIV • Over 95 % were in developing countries • Approximately 17 million people with HIV are women • 2.1 million are children under 15

  4. Known Routes of HIV transmission India NACO, 2002

  5. Situation of PTCT in India 27 million pregnancies per year 108,000 infected pregnancies Annual Cohort of 32,000 infected newborns 0.4% prevalence 30% transmission

  6. Overview of HIV Transmission to Children

  7. Timing of Parent-to-child Transmission Early Postpartum (0-6 months) Late Postpartum (6-24 months) Early Antenatal (<36 wks) Labor and Delivery Breastfeeding Pregnancy Late Antenatal (36 wks to labor) 5-10% 10-20% 10-20% Adapted from N Shaffer, CDC

  8. PTCT in 100 HIV+ Mothers by Timing of Transmission Uninfected: 63 Breastfeeding: 15 Delivery: 15 Pregnancy: 7

  9. Risk Factors For PTCT • Feeding method • Immune/health status of mother • Plasma viral load • Breast inflammation (mastitis, abscess, bleeding nipples)

  10. Early Mixed Breastfeeding Cumulative HIV transmission Durban, SA Coutsoudis et al, 1999; 2001

  11. Exclusive Breastfeeding Falls Rapidly From First Month Onwards (NFHS-II-1999)

  12. Maternal Virus Load and Perinatal Transmission Garcia BM. NEJM, 1999

  13. Maternal Immune Status Leroy et al 2003

  14. Breast Pathology Prevalence of breast pathologies on clinical exam.In HIV+ women in Africa • Mastitis: 7-11% • Nipple lesions:11-13% • Breast abscesses:12% (Embree et al; John et al; Semba et al)

  15. Technical and Programmatic Guidance • Global strategy on infant and young child feeding(2002) • HIV & infant feeding: framework for priority action(who/UNICEF/UNFPA/UNAIDS/world bank/UNHCR/WFP/FAO/IAEA) • HIV & infant feeding: guidelines for decision-makers(WHO/UNICEF/UNFPA/UNAIDS) • HIV & infant feeding: A guide for health care managers and supervisors(WHO/UNICEF/UNFPA/UNAIDS) • WABA/UNICEF colloquium at Arusha 2002 • IBFAN/BPNI/UNICEF colloquium at new Delhi 2003

  16. Unique Global Consensus • 9 UN agencies ratified in 2003 • 5 priority actions, first being development of policy and plans for IYCF including HIV, promotion of exclusive breastfeeding for ALL babies

  17. WHO/UNAIDS/UNICEF Guidelines on HIV&IF (1997-2005) HIV- or status unknown • Exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for 2 years HIV+ • When replacement feeding is acceptable, feasible, affordable, safe and sustainable, avoidance of all breastfeeding is recommended.Otherwise EBF is recommended for the first months of life

  18. Feeding Options for First 6 Months • Replacement feeding: • Commercial infant formula • Home-modified animal milk • Breastfeeding: • Exclusive with early cessation • Breast-milk feeding options: • Expressed and heat-treated BM • Wet-nursing • BM banks

  19. Summary of Background • Major public health problem with socio-economic dimensions • Global guidelines are available • Fair knowledge about the mode and various risk factors for PTCT

  20. Challenges in HIV and IF

  21. Challenges…. Implementation of UN tools and inclusion of PTCT in national programs is not a priority

  22. HIV IF – Status at National Level5 Country Assessment IBFAN-AP, WABA; 2005

  23. Challenges…. • Information to parents and community is negligible, inadequate and improper • Training of health workers and counselors is lacking or inadequate

  24. Where HIV+ Women Receive Counseling and Free Infant Formula, Its Use Is Not Optimal

  25. Bacterial Contamination and Improper Preparation of Commercial Infant Formula in a PMTCT Program (Durban, South Africa) Contamination of milk samples • 64% E Coli • 26% Enterococci Over dilution of milk samples • 22% for infants <= 12 months • 78% for children > 12 months Bergström, 2003

  26. Assessment of PPTCT CounselorsBPNI, NACO -2004 • Inadequate, Biased Knowledge • Inappropriate Practices • Insufficient Skill Transfer

  27. Challenges…. Keeping mothers healthy is not a priority action

  28. Focus on Maternal Health & Nutrition • Keeping HIV+ mothers well may be among the most important things we can do to prevent P/N transmission and maternal survival • BF transmission was ~2% between 6 w-24 months in women with CD4 >500 (Leroy et al, 2003) • No programmatic intervention to ensure maternal health

  29. Expanding Use of ARVs • Legitimate demand for a single standard of care regardless of socioeconomic conditions  currently HAART for mother, peri-natal ARV therapy • Lower prices, wider variety of available regimens, easier logistics,  expanding postnatal use and availability of ARVs

  30. Challenges…. • Infant feeding is linked with child survival, but ignored in context to HIV • Paucity of research directed towards HIV free survival • Available research is not being disseminated

  31. Proportion of All < 5 Yrs Deaths That Could Be Prevented With Infant Feeding Interventions * *Estimate would be 15% without effects of HIV Jones et al, 2003, Lancet

  32. Risks of artificial feeding(in developing countries risks are elevated above these levels) Increased levels of accute illness: • Respiratory infections • Middle ear infection: 3-4x risk • Gastroenteritis: 3-4x risk (developing countries 17-25x) • Bacterial infection requiring hospitalization: 10x risk • Meningitis: 4x risk • Higher mortality from sudden infant death syndrom (SIDS)

  33. HIV/Infant feeding is about Assessing the risks

  34. Model for Per 1000 HIV-Positive Mothers (IMR 96) Ross and Labbok, AJPH, 2004 Ross J et al. 2004, AJPH

  35. Feeding Mode and Survival • Multi-centric trial from Ghana, India, Peru • Published in bulletin of WHO • Non-breastfed infants had a higher risk of dying V/V breastfed infants Bahl et al. 2005

  36. Challenges…. Making feeding safer is not seen as an option to prevent PTCT

  37. Strengthen Approaches for Making Breastfeeding Safer for ALL Women • Provide adequate lactation counseling and support, involving families/communities • Increase adherence to exclusive breastfeeding • Prevent cracked nipples, maintain breast health • Immediate treatment for mastitis, other systemic infections that could affect viral load in BM • Could prevent a sizeable fraction of BF transmission • Safe sex/condom use for prevention of fresh inf

  38. Make Breastfeeding Safer for HIV+ Women • Avoid mixed feeding,ensure exclusive breastfeeding • Prevent breast problems • Minimize maternal viral load • Improve maternal immunity • Provide ARVs to mother and child

  39. Make Replacement Feeding Safer for HIV+ Women • Provide safe water & environmental conditions • Adequate sustained supply • Ensure hygiene • Family support, community understanding – take care of stigma

  40. Challenges…. Policy makers, planners, health care providers and counselors are not sensitized on gender issues

  41. Gender Issues in HIV and Infant Feeding • The terminology used “mother to child transmission” (MTCT) puts the blame on the mother, the woman – who is already often a victim of the HIV epidemic • Stigma and discrimination against the women is much stronger • Often seen as a vector, blamed for spread • Risks violence, abandonment, neglect, destitution

  42. Gender Issues in HIV and Infant Feeding • Information from health system almost always directed at mothers/women • Women/mothers are tested, women are made responsible for feeding, caring etc • Men are not targeted as equally responsible

  43. Issues for Partnership • Gender sensitizationof policy makers, planners, health care providers, media and counselors • Universalizing preventive serviceslike VCT, skilled counseling on feeding options • Empowering parentsto choose interventions which ensures improved HIV free survival • Publicizingavailable research and knowledge

  44. Thanks !!! Thanks !!!!

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