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Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding

Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding Jean R. Anderson, MD Director Johns Hopkins HIV Women’s Health Program Benefits of Breastfeeding to Newborn Provides complete nutrition for first 4 – 6 months of life

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Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding

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  1. Care of Women with HIV Living in Limited-Resource SettingsHIV and Breastfeeding Jean R. Anderson, MDDirector Johns Hopkins HIV Women’s Health Program

  2. Benefits of Breastfeeding to Newborn • Provides complete nutrition for first 4–6 months of life • Provides significant protection from infectious morbidity and mortality • Gastrointestinal infections • Lower respiratory infections • Otitis media • Meningitis • Lack of breastfeeding is associated with 3–5 fold increase in newborn mortality • Reduces exposure to waterborne pathogens in areas with unsafe water supply

  3. Benefits of Breastfeeding to Mother • Delays return of fertility • Promotes child spacing • Allows maternal recovery from blood loss • Promotes mother-newborn bonding • Is low in cost

  4. Objectives • Discuss evidence linking breastfeeding to mother-to-child transmission (MTCT) of HIV • Explain possible effects of breastfeeding on health of HIV-positive mothers • Describe interventions to reduce risk of transmission through breastfeeding

  5. Estimated Timing and Risk of MTCT of HIV (Absolute Rates) Source: DeCock et al 2000.

  6. Cumulative MTCT Rates in Selected Breastfeeding Populations in Africa

  7. Risk of Transmission • International pooled analysis of four African and four European/American breastfeeding studies (n=902) • Rate of transmission 3.2 per 100 child-years of breastfeeding • Underestimates breastfeeding transmission in first 2.5 months of life • Most transmissions occurred after 6 months of breastfeeding Source: Leroy 1998.

  8. Risk of Transmission continued • Prospective cohort breastfeeding study in Malawi (n=672) • Rate of transmission 6.9 per 100 child-years of breastfeeding • Underestimates breastfeeding transmission in first month of life • Risk highest in first months of breastfeeding but continued throughout entire breastfeeding period Source: Miotti 1999.

  9. HIV Transmission During Breastfeeding in Women with Acute HIV Infection • Higher plasma HIV levels during acute infection • Transmission rate approximately 29% with acute infection • Implications • Importance of prevention counseling after negative HIV test early in pregnancy • Need to reinforce use of male or female condoms during pregnancy and breastfeeding Source: Dunn 1992.

  10. Variables Associated with Breastmilk Transmission • Maternal factors • New HIV infection • Advanced HIV infection • Plasma viral load, CD4 count • Breastmilk viral load • Inflammatory breast conditions • Mastitis • Breast abscess • Cracked nipples • Vitamin A deficiency

  11. Variables Associated with Breastmilk Transmission continued • Newborn factors • Oral thrush • Other mucosal lesions due to trauma or other infection • Preterm birth or low birth weight • Nutritional deficiencies • Breastfeeding characteristics • Colostrum versus mature milk • Timing • Highest in first months • Increases with longer duration of breastfeeding • Pattern of breastfeeding • Exclusive breastfeeding versus mixed or replacement feeding

  12. HIV Transmission Through Breastfeeding Source: Miotti 1999.

  13. Breastfeeding versus Formula Feeding • Setting • Nairobi, Kenya • Study participants • Mother-newborn pairs randomized to breastfeeding (n=197) versus formula feeding (n=204) • Results • Compliance with assigned feeding group • Breastfeeding – 96% • Formula – 70% (p<.001) • Cumulative risk of HIV infection (24 months) • Breastfeeding – 36.7% • Formula – 20.5% (p=.001) Source: Nduati 2000.

  14. Breastfeeding versus Formula Feeding • Results continued • 44% of HIV infection in breastfeeding group due to breastmilk • 75% of infection difference between two groups occurred by 6 months • Mortality rate at 2 years similar in breastfed (24.4%) and formula newborns (20.0%) (p=.30) • HIV-uninfected survival rate at 2 years significantly higher with formula feeding (70%) versus breastfeeding (58%) (p=.02) Source: Nduati 2000.

  15. Exclusive Breastfeeding Versus Mixed Feeding • Mixed feeding means feeding newborns with mixture of breastmilk and other foods or liquids • Water or glucose-water solution • Weak tea • Formula • Cereal or porridge • Fruits and vegetables • Exclusive breastfeeding is associated with reduced incidence of diarrhea, respiratory illness, allergy, and neonatal mortality Source: Perera 1999 Cesar 1999 Oddy 1999 Leach 1999.

  16. Exclusive Breastfeeding versus Mixed Feeding: Risk of HIV Transmission • Setting • Durban, South Africa • Objective • To determine risk of HIV transmission by newborn feeding practice • Study participants • 551 HIV-positive pregnant women and their newborns • Comparisons • Never breastfed newborns (n=157) • Newborns exclusively breastfed x 3 months or more (n=118) • All other breastfed newborns (n=276) Source: Coutsoudis et al 2001.

  17. Exclusive Breastfeeding versus Mixed Feeding: Risk of HIV Transmission continued • Results • Newborns exclusively breastfeeding had no excess risk of MTCT of HIV over 6 months as compared to never-breastfed newborns (cumulative risk of infection 19.4% in both groups) • Newborns fed with mixture of breastmilk and other foods and liquids at greatest risk for MTCT (cumulative risk of infection 26.1% at 6 months, 35.9% at 15 months) • After exclusive breastfeeding ended, new infections began to occur in newborns still breastfeeding (cumulative risk of infection 24.7% at 15 months) Source: Coutsoudis et al 2001.

  18. Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women • HIV-positive women participating in randomized clinical trial of breastfeeding versus formula feeding in Kenya (197 breastfeeding, 200 formula feeding) • Assignment to breastfeeding group associated with over 3-fold increased mortality rate during 2 years of followup • After controlling for HIV status in newborn, newborns of mothers who died had 8-fold increase in likelihood of subsequent death Source: Nduati et al 2001.

  19. Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued • HIV-positive women enrolled in randomized Vitamin A supplementation study in Durban, South Africa • Data analyzed by chosen method of newborn feeding, average followup of 11 months • No evidence of increased mortality or morbidity in ever- versus never-breastfed group Source: Coutsoudis et al 2001.

  20. Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued • What is the role of nutritional status? • Higher prevalence of anemia in Kenya study than in South African study • Women in breastfeeding group had greater weight loss than formula group; significant relationship between weight loss during followup and mortality (Kenya) • Combined metabolic demands of HIV and breastfeeding (energy, nutrient stores) may result in increased nutritional impairment, especially in women already malnourished

  21. Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued • What is the role of immune status? • Maternal deaths associated with lower CD4 counts and higher viral load at enrollment (Kenya) • Mortality was related to HIV status • Baseline immune status better in South African study subjects

  22. Newborn Mortality Per 100 Live Birthsby Maternal HIV Status Source: World Bank 1999.

  23. Interventions to Prevent HIV Transmission by Breastfeeding • Primary prevention of HIV in childbearing women • Safer sexual and drug-using practices during pregnancy and lactation • Identification of HIV in women who are pregnant or considering pregnancy • Voluntary counseling and testing

  24. Recommendations for Feeding • HIV-negative women and women of unknown status • Exclusive breastfeeding for 6 months • HIV-positive women • Avoid all breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe • Provide guidance and support to HIV-positive mothers who choose not to breastfeed to ensure adequate nutrition • If breastfeeding chosen, encourage exclusive breastfeeding up to 6 months of infant’s life • Teach proper attachment of newborn to nipples and frequent breast emptying • Teach prevention and recognition and encourage prompt treatment of mastitis, breast abscess, cracked nipples and oral thrush or other oral lesions in newborns Source: WHO 2001.

  25. Recommendations for Feeding continued • Promote hygiene and food safety for maternal health and safety of replacement feeding • Improve the nutritional status of pregnant and lactating mothers • Vitamin E supplements reduced mastitis risk in Tanzanian study • Maternal iron status

  26. Recommendations for Feeding continued • Keep period of transition from breastfeeding to full replacement feeding (weaning) as short as possible • Provide guidance after stopping breastfeeding to ensure adequate newborn nutrition • Counsel and give support to maintain breast health and decrease psychological consequences of rapid weaning

  27. Cumulative MTCT Rates in Selected Breastfeeding Populations Receiving Short Course Antiretrovirals

  28. Stigma of Not Breastfeeding • Women who do not breastfeed may face social stigma • Not breastfeeding may arouse suspicion or even violence • Strong cultural pressures to breastfeed along with desire to protect newborn by not breastfeeding may increase practice of mixed feeding by HIV-positive mothers

  29. Further Directions for Research • Role of antiretroviral therapy for newborn and/or mother in prevention of MTCT through breastfeeding • Feasibility and safety of heat treating breastmilk expressed at home to inactivate HIV • Role of immune-based interventions • Passive immune therapy • Vaccines

  30. Summary • All HIV-positive mothers should receive counseling • Information about risks and benefits of newborn feeding options • Specific guidance in selecting option most suitable for individual situation • Support for maternal choice • Local assessments should be conducted to identify range of newborn feeding options that are acceptable, feasible, affordable, sustainable and safe in different locations • Information and education on transmission of HIV through breastfeeding should be directed to the general public, communities and families to reduce stigma of not breastfeeding

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