The big debate: Infant feeding and HIV

Dr. S. Katyayan

M.B.B.S. (HONS),M.D. (Paed.), P.G.D.M.L.S.(Pune)

Transmission of HIV from Mother to the Baby

• 100,000 HIV + Indian women become pregnant every year

• 30,000 children become HIV + every year

SO WHAT ARE THE INFANT AND YOUNG CHILD NUTRITION(IYCN)

WHO Norms

Timing of MTCTThe risk of HIV transmission through breast milk & transmission during

pregnancy

How does transmission occur during breastfeeding

• Exact mechanism is unknown HIV virus in blood passes into milk

– Cell free, cell associated virus observed in milk– Virus sheds intermittetently (Undetectable 25 -30%)– Levels vary between breasts of samples taken at the same time– Infant consumes HIVEnters and infects thru permeable mucous membranes, lymphoid tissues

and lesions in the mouth and gutAlthough the baby may consume 500,000 virons, and >25, 000 infected

cells per day majority don’t become infected– Immune factors in BM may play a role

– Lewis X component (LECTIN) in human milk binds DC-SIGN and inhibits HIV-1 transfer to CD4+ T-lymphocytes (present in the tonsils of the baby)

Risk Factors for Postnatal Transmission

Mother• Immune status • Plasma Viral load• Breast milk Virus• Breast Infection (mastitis,

abscess, sore and bleeding nipples)

• New HIV infection• Viral characteristics

• Infant• Breastfeeding duration• Non exclusive breast

feeding• Age (first months)• Lesions in the mouth,

intestine• Prematurity• Infant immune response

Risk factors for postnatal transmisson: Maternal Immune

Status • HIV transmission from 6 wks to 24 months in West Africa by

maternal baseline CD4• The higher the CD4 count( >500) the less the transmission• Therefore the maternal immune status is important

0

5

10

15

CD4<500 CD4>=500

Cum

ula

tive H

IV

Tra

nsm

issi

on (

%)

14

1.4

Risks factors for postnatal Transmission: Breast milk Viral Load

1w 1 mo 3 mo 6 mo

4

3

2

1

0

Mean

Log

10

HIV

RN

A

CD4<500 CD4 >= 500

Pillay ct al , 2000

BM viral load was consistently higher in women with low CD4 counts (p<0.01). BM RNA was associated with increased MTCT,

ofter adjusting for maternal DC 4 (or = 2.82)

Risks factors for postnatal Transmission: Maternal Viral Load

• Viral RNA can be a important predictor of intra partum MTCT

• Plasma viral load may also be a risk factor in Breastfeeding

• Higher risk in of transmission in women infected postnatally (Early Viraemia)

Preavalance of Breast Patholgies in HIV +ve women

• Mastitis(Clinical and subclinical) Subclinical mastitis is associated with higher viral load Mastitis associated with higher risk of transmission

• Nipple lesions Nipple lesions and breast abscesses are also

associated with an increased risk of transmission

• Breast abscess

Risks factors for postnatal Transmission Breast health II

• 18-20% of overall MTCT may be attributed to mastitis – If BF accounts for 40% of all transmission

then mastitis (Breast health problems) may account for 50% of all transmission

Risks factors for postnatal Transmission: Duration of breastfeeding

• Risk of breastfeeding persists as long as BF is practiced

• Risk of HIV transmission is higher in first 6 months

• Several possible explanations– Higher prevalance of mastitis– Infant gut more immature– More breast milk consumed

4

8

16

0

2

4

6

8

10

12

14

16

Risk of transmission

6 months

12 months

2 years

Note: results represent worst case scenario as these populations were mixed breastfed with no lactation mx to prevent breast problems

Cumulative probability of HIV among 549 children born to HIV+

women by type of feedsCoutsoudis et al. AIDS 2001, 15:379-87

• Exclusively breastfed group ( ) is statistically significantly different from mixed fed ( ), but is not statistically significantly different from never breastfed ( )group until 15 months, controlling for 15 variables.

0

5

10

15

20

25

30

35

40

45

TYPE OF FEEDSRisk of HIV infection over time in 157 children never

breastfed; 118 EBF; and 276 mixed breastfeeders

0

5

10

15

20

25

30

35

40

Birth 6 Mths 12 mths 15 mths

Never brfExcl brfMixed Brf

Infant mortality among children born to HIV+ mothers by early feeding Pattern (0-3months) in

Harare, Zimbawe (n-892 in 2002)

0

50

100

150

200

250

EBF PredominantBF

Partial BF BM + NHM

deat

hs/1

000

Adjusted HR for BM + NHM VS EBF = 5.97 (P, 0.001) : Predominant BF vs EBF=2.52 (P=0.04) ; Partial BF vs EBF=2.84 (p=0.02)

Postnatal Risk of Transmission of HIV: Infant Oral Lesions

• Disruption of skin and muccousmembrane of mouth and gut associated with incrase risk of Transmission– Epithelial integrity – Infant oral thrush associated with increased

risk of transmission

So what should HIV+ mothers in resource poor settings do?

Infants who do not breast feed have an increased risk of dying in

the first year

0 - 1 2 - 3 4 - 5 6 - 8 9 - 11

Age in months

Pooled Odds Ratios

Ross J et al. 2004, AJPH

Cumulative HIV-free Survival

600.0

650.0

700.0

750.0

800.0

850.0

900.0

0 6 12 18 24

Age (months)

HIV

-free

sur

vivo

rs/1

000

live

birt

hs

No postnatalintervention/Status Quo BFpatterns (B24)

No BF by HIV-infected mothers(B0)

Short duration (6 months) BFby HIV-infected mothers (B6)

Short duration "safer" BF (6months) by HIV-infectedmothers (SB6)

"Safer" BF (24 months) by HIV-infected mothers (SB24)

Model for Per 1000 HIV-Positive Mothers

(IMR 96)

Where IMR>40, this model indicates that EBF might be the best choice feeding option for HIV+ Moms

Ross and Labbok, AJPH, 2004

So what are the risks of not breastfeeding?

Not breastfeeding increases mortalityRR of infectious disease mortality among non-breastfed infants

0

1

2

3

4

5

6

WHO, Lancet 20005.8

4.1

2.6

1.81.4

<2Age (months)

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

Not breastfeeding in the first 2 months significantly increases morbidity in infants born to HIV infected women

Durban VITA/breastfeeding study

% of infants who had an illness episode in the first 2 months

0

5

10

15

20

25

30

35

40

never brf breastfed

Coutsoudis et al. in press, Acta Paediatr, Aug 2003.

HIV infected children who were not breastfed had significantly more morbidity

Durban breastfeeding study

% of infants who had 3 or more morbidity episodes

0

10

20

30

40

50

60

never brf breastfed

Coutsoudis et al. in press, Acta Paediatr, Aug 2003

0

2

4

6

8

10

12

14

16

Per

cen

tag

e

Non breastfedBreastfed

HIV infected children who were not breastfed HIV infected children who were not breastfed had significantly more recurrent diarrhoea had significantly more recurrent diarrhoea Frederick et al, Los Angeles Study 1997Frederick et al, Los Angeles Study 1997 (138 HIV infected children, 43% (138 HIV infected children, 43% breastfed)breastfed)

Facts:

0

10

20

30

40

50

60

70

80

Non-breastfed

breastfed

HIV infected children who were not breastfed HIV infected children who were not breastfed progressed to AIDS more quicklyprogressed to AIDS more quickly Frederick et al, Los Angeles Study Frederick et al, Los Angeles Study 19971997 (138 HIV infected children, 43% breastfed)(138 HIV infected children, 43% breastfed)

Facts:

Where HIV+ women receive counseling and free infant formula, its use is not

optimal

100% 98%89%

33%

46%

0%

20%

40%

60%

80%

100%

120%

Brazil

Thailand

Botswana

Uganda

Cote d"I voire

If you answer no to any of these questions, formula feeding may not be the best option•Do you have easy access to clean safe water•Do you have easy facilities to boil water •Do you have facilities to sterilise bottles etc.•Do you have a fridge with regular electricity•Do you have a guaranteed income of R150/month to spend on formula, bottles, teats, sterilising fluid etc.•Does your family know your status & will they support you to formula feed•Will it be acceptable to give f/feeds at night or when baby is crying in public•Do you have easy access to clinic/hospital if child gets diarrhea

Feeding options currently recommended by the WHO

• Breastfeeding – exclusive breastfeeding

– Heat-treated breast milk

– wet-nursing

– milks banks

– early cessation of breastfeeding (as soon as)

– Treatment & prophylaxis of mother and baby

• Replacement feeding – commercial infant

formula – home prepared infant

formula (modified, with additional nutrients)

– enriched family diet with BMS/MN supplements after 6 months

Can we make breastfeeding safer for HIV+ women

• Assist families with early breasfeeding cessation – Access 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

Key Messages

• Help mother to stay healthy• Help baby to stay healthy• Constant updating of knowledge about IYCN and HIV• Good Counseling Skills• Respect wishes of mother after Counseling s• Exclusive Breastfeeding for six months is the best option

in our setting• Consider each point of AFASS in depth before advising

replacement feeds• Rapid weaning with home cooked food as replacement

at six months or before.• Treatment of the mother with NRV’s

Replacement Feeds must be

• acceptable, A

• feasible, F

• affordable, A

• safe and S

• Sustainable S

Thank youDr. S. Katyayan

MBBS, MD, PGDMLS.