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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. UN Recommendations. HIV- women or HIV status unknown

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Update on HIV and infant feeding

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  1. Update on HIV and infant feeding Peggy Henderson and Constanza Vallenas Department of Child and Adolescent Health and Development, WHO Rome, 25 February 2007

  2. UN 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

  3. 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

  4. Balancing risksfor HIV-positive women HIV transmission IF BREASTFEEDING Mortality Infectious diseasesMalnutrition IF NOT BREASTFEEDING

  5. 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%

  6. Balancing risks – 2Relative risk of infectious disease mortality among non-breastfed infants 5.8 Relative risk 4.1 2.6 1.8 1.4 Age (months) WHO Collaborative Study Team, Lancet, 2000

  7. Balancing risks – 3Mixed feeding carries higher risk of HIV transmissionthan exclusive breastfeeding Hazard ratio Coovadia et al., Lancet, in press

  8. Balancing Risks - 4No Difference in 18-Month mortality/HIV infection between Formula and Breastfed Infants FF: 33 infected, 62 deaths BF: 53 infected, 48 deaths p=0.60 p=0.86 p=0.08 % HIV-Infected or Dead Thior et al., JAMA, 2006

  9. 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

  10. High EXCLUSIVE breastfeeding rates achievable with good quality counselling and support Median duration of EBF = 159 days Coovadia et al., Lancet, in press

  11. Emerging 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

  12. Infant infections by feeding mode Vertical Transmission Study, in Press

  13. Emerging 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

  14. Emerging 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

  15. 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

  16. 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

  17. Implications 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

  18. Updating 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)

  19. THANK YOU

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