Risk of mortality is greater among women without access to hygiene, sanitation,water

1. Risk of mortality is greater among women without access to hygiene, sanitation,water RR of Infant Mortality by Feeding Mode and Health Environment Habicht et al., 1988

2. Percent of Total Population with Access to Safe Water UNICEF, 2002

3. Percent of Total Population with Access to Adequate Sanitation UNICEF, 2002

4. Breastfeeding exclusive breastfeeding heat-treated breast milk wet-nursing milks banks early cessation of breastfeeding (as soon as feasible) Replacement feeding commercial infant formula home prepared infant formula (modified, with additional nutrients) enriched family diet with BMS/MN supplements after 6 months Feeding Options Currently Recommended by WHO (1998)

5. What do we know about the feasibility of exclusive breastfeeding? (BFHI/MCH/IMCI) -1 % infants breastfed exclusively in previous 24 hours @ 3 months @ 5 months < 6 months < 4 months

6. EBF rates at 6 weeks - over time and after the introduction of an education and counseling program on safer breastfeeding practices in Harare, Zimbabwe (n=9,931) Education and counseling intervention began ZVITAMBO data

7. Exclusive breastfeeding rates in PMTCT programs with infant feeding counseling - Barcelona AIDS abstracts Methodologies and ages at measurement varied

8. Methods used for measuring exclusive breastfeeding produce different rate estimates n=970 mothers exposed to infant feeding counseling ZVITAMBO data

9. Potential risks for infant Dehydration Anorexia Later behavior problems Malnutrition Illness or death Potential risks for mother Engorgement Mastitis Increased risks of pregnancy Depression Stigma Possible reversion to breastfeeding What do we know about the feasibility of early/rapid breastfeeding cessation? -1 Piwoz et al, 2002

10. What do we know about the feasibility of early breastfeeding cessation?-2 Barcelona AIDS Conference • Early, rapid cessation is possible (Uganda, Zambia, Botswana) • Problems encountered • breast engorgement; mastitis; babies crying, trouble sleeping, appetite loss, diarrhea; financial constraints with replacement feeding; family objections • more problems when cessation < 6 months (Botswana) • Trained counselors were able to help mothers overcome problems • Provision of replacement feeds, family support facilitated process • Impact on HIV transmission, survival not yet known

11. Breast milk contributes > 50% of the nutrient intake of children > 6 months in developing countries and won’t be easy to replace Adapted from WHO, 1998; Dewey and Brown, 2002 using data from Bangladesh, Ghana, Guatemala, Peru

12. What do we know about the feasibility of other breastfeeding options? • Heat-treated breast milk • heating milk to 56-62.5 degrees C for 12-15 min inactivates HIV in human milk (Jeffreys et al 2001) • no data on feasibility of daily use from birth • may be practical during transition period with early cessation • Use of wet nurse - no data • monitoring HIV status of wet nurse a challenge • practice may be less common because of HIV • Milk banks - no data • may be feasible in some settings (Brazil, LA Region)

13. What do we know about the feasibility of commercial formula? • High acceptance/adherence in some countries with access to clean water, health care, subsidized cost • Thailand, Brazil, South Africa, Botswana • Adherence with exclusive use may be higher than for exclusive BF (Botswana) • Stigma associated with its use widely reported in Africa • Access to safe water, health care needed • Proper instruction on safe preparation, feeding • Cost - > 6 months supply

14. Formula use in selected programs where providedfree Barcelona AIDS Conference

15. Uptake of Infant Formula in PMTCT program sites in SA McCoy et al, 2002

16. Evidence of Spillover?Infant feeding patterns in PMTCT vs.non-PMTCT sites in Botswana (< 6 months, 24 hr recall) EBF is lower, mixed feeding is higher in PMTCT sites P< 0.001 MOH/UNICEF, 2002

17. What do we know about the feasibility of home prepared formula? • Nutritional adequacy and cost studied in KwaZulu Natal, SA • Fresh and powdered full-cream milk • Findings: • intakes of vitamins E, C, folic acid, pantothenic acid < 33% of adequate intake (AI) • intakes of zinc, copper, selenium, vitamin A < 80% AI • intakes of EFA were < 20-60% AI • cost was $9.80/month or 20% of average monthly income • preparation time was 20-30 minutes for 120 ml Papathakis et al, 2002

18. Challenges for the Future • Policy issues: • Can we reframe the debate on breastfeeding versus replacement feeding? • What is the role of commercial infant formula? • Implementation: • How do we implement October 2000 guidance/scale up? • Research: • Risk analysis and counseling hampered by uncertainty • Can breastfeeding or replacement feeding be made safer for HIV+ women? • Learning from ALL our experience

19. Can we reframe our thinking and discussion on this issue? -1 • Let’s talk about improving HIV-free survival instead of reducing HIV transmission • reflects higher objective • resolves conflicting strategies • Let’s talk about reducing postnatal transmission instead of HIV transmission through breastfeeding • more accurate • less emotional • less burdened with the weight of history

20. Can we reframe our thinking and discussion on this issue? -2 • Focus on maternal health & nutrition • Keeping HIV+ mothers well may be among the most important things we can do to prevent P/N transmission • BF transmission was ~2% between 6 w-24 months in WA study among women with CD4 >500 (Leroy et al, 2002) • Nutrition depletion, weight loss during BF may increase risk of maternal mortality (Nduati et al, 2001) • Keeping mothers alive will improve child’s chances for survival (Nduati et al, 2001) • ARV use during BF now being studied

21. Can we make breastfeeding safer for HIV+ women? -1 • Enhance health/nutrition care for women • Provide adequate lactation counseling and support, involving families/communities • increase adherence to exclusive breastfeeding • promote good breastfeeding techniques • 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 • may be most important in early month(s)

22. Can we make breastfeeding safer for HIV+ women? -2 • Assist families with early breastfeeding cessation • assess health status of mother and infant • prepare for the process so that the transition is safe (cup-feeding, safe preparation/hygiene, stigma) • heat treat breast milk if weaning is gradual • could prevent sizeable fraction of BF transmission • Provide adequate nutrition after breastfeeding ends • appropriate breast milk substitutes and/or multi-nutrient supplements should be provided to prevent malnutrition

23. HIV and Infant Feeding Risk Analysis in Setting where IMR=89/1000: Improving maternal health & safer BF practices Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%; IMR=89/1000

24. HIV and Infant Feeding Risk Analysis in Setting where IMR=100/1000: Improving maternal health & safer BF practices Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%;

25. HIV and Infant Feeding Risk Analysis in Setting where IMR=135/1000: Improving maternal health & safer BF practices Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%;

26. What is the role of commercial formula for replacement feeding? • It is the best option for RF if conditions can be met • formulated specially for humans, nutritionally fortified • safe water, access to health care, training in safe preparation, feeding required to make it safe • postnatal follow-up also required (monitor growth, ensure adequate access/availability) • cost will make it NOT affordable for poor families to purchase • cost may make it NOT sustainable for governments • Code of Marketing of BMS protects against misuse if enacted/enforced • But “spillover” may be unavoidable if BF support for HIV-negative and status unknown mothers is not adequate

27. Can we make replacement feeding safer for HIV+ women? • Provide safe water & environmental conditions • Family support, community understanding • Postnatal follow-up and enhanced care • essential child health interventions • Screen mothers, target use to those most at risk • Take measures to prevent unnecessary use of RF • We must strengthen, not abandon, our efforts to support optimal infant feeding for all because of HIV. The need is even greater when PMTCT programs provide infant formula to HIV+ women.

28. Thank you