HIV & Infant Feeding

Transcription

1 Updated on 14 March 2007 HIV & Infant Feeding Exclusive breastfeeding for the first six months of life is the most effective preventive measure available for reducing child mortality in developing countries, and not breastfeeding increases the risk of morbidity and mortality for infants. However, breastfeeding is one of the ways in which HIV can be passed from a woman with HIV to her infant or young child. UN agencies have developed recommendations which recognize this dilemma and help in balancing the risks, to achieve the goal of both increasing child survival and reducing HIV transmission. HIV-infected women need counselling and support to decide on the infant feeding option most likely to lead to the best outcome for them and their babies. facts & figures Without interventions and depending on duration, about 5-20% of HIV-infected women will transmit HIV through breastfeeding The risk of transmission through exclusive breastfeeding up to six months of life (measured from 6 weeks) is about 4% About 94% of infants in the world are ever breastfed, 79% of infants continue breastfeeding at one year of age, and 52% at two years of age Globally, about one-third of infants in developing countries are exclusively breastfed up to the recommended age of 6 months Non-breastfed infants have about a 6 fold increased risk of mortality from diarrhoeal diseases in the first two months of life compared to breastfed infants Maternal risk factors associated with mother-to-child transmission during breastfeeding include maternal seroconversion during breastfeeding, clinical and/or immunological disease progression (e.g. CD4+ cell count), RNA viral load in plasma and breast milk, local immune factors in breast milk and breast health. Infant risk factors include pattern of infant feeding (exclusive vs mixed), immune factors and perhaps oral thrush. Possible interventions to decrease the risk of transmission during breastfeeding include safer infant feeding practices, short-course prophylactic ARV regimens for the mother and/or infant, HAART to the mother during the breastfeeding period, and infant immunization. For mothers who choose to breastfeed, evidence shows that exclusive breastfeeding up to six months carries a lower risk of HIV transmission than mixed feeding, that is breastfeeding and giving other fluids or foods. Programme data indicate that maternal HAART for treatment-eligible women may reduce postnatal HIV transmission; follow-up trial data on the safety and efficacy of this approach, and on infant prophylaxis trials, are awaited. Until further evidence is available on this subject, ARV use is not recommended as a public health intervention to reduce postnatal transmission, and the current recommendations on HIV and infant feeding are valid even for women receiving ARV treatment for their own health.

2 Reducing the risk of HIV transmission through breastfeeding: Safer infant feeding practices If a woman chooses to breastfeed: Exclusively breastfeed up to six months. Prevent mastitis and other breast conditions through good attachment and positioning Identify and treat breast problems early Replacement feed and avoid breastfeeding completely Anti-retroviral drugs If woman needs it for her own health, benefit of maternal HAART during breastfeeding period outweighs risk to infant, and likely to reduce risk of HIV transmission through breastfeeding If not needed for mother's health, benefits and risks unclear, being addressed by ongoing research Peripartum regimens achieve some reduction in breastfeeding transmission Evidence for post-partum infant interventions not yet conclusive Immunization of infant Initial trial in Uganda More evidence awaited Key Operational Considerations and Steps Since mothers need specific guidance and support to make the best choice of infant feeding for their situations, countries need to put in place adequate counselling and support on infant feeding for HIV-positive women, but also including activities aimed at supporting feeding practices in the general population. Infant follow-up needs to continue up to at least two years of age, throughout the time that feeding practices are changing, and including the critical period at six months when either breast milk or formula is no longer enough and other foods should be introduced. The UN HIV and Infant Feeding Framework for Priority Action describes the types of activities that countries should be undertaking. These include: 1. Develop or revise (as appropriate) a comprehensive national infant and young child feeding policy, which includes HIV and infant feeding. 2. Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions. 3. Intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of a number of exceptionally difficult circumstances. 4. Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their infant feeding decisions.

3 5. Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings. A critical component of programmes targetting HIV-positive women, whether through PMTCT, PMTCT-plus or ARV access programmes, should be training on infant feeding of counsellors, who may be doctors, MCH nurses, midwives, peer counsellors, or other health or communitybased staff. WHO and other partners have developed courses, job aids and other tools for this purpose, as well as guidance to assist in policy development and programme planning. Experience in the provision by governments of infant formula for HIV-positive mothers has been mixed, and some studies indicate that young child survival outcomes have not been improved by its use. Commercial infant formula should only be supplied when a comprehensive set of measures to ensure its safe use are in place. In summary (the full list is available in Guidelines for Decision-makers): Formula should be provided free or at a subsidized cost only to those HIV-positive women and their infants for whom replacement feeding is acceptable, feasible, sustainable and safe. The government concerned should ensure that it can afford to supply formula with no interruption, even in the remotest areas, for as long as the child needs it. Governments should ensure implementation of the International Code of Marketing of Breastmilk Substitutes with appropriate mechanisms for monitoring and enforcement. Staff responsible for distributing formula should have guidelines specifying the HIV-positive women who will receive it, under what conditions, how frequently and for how long, where it will be distributed, etc. Before commercial infant formula is made available in health facilities, counsellors trained in relation to breastfeeding, complementary feeding and HIV and infant feeding should be identified. Information on the health and nutritional status (especially growth) of infants fed with breastmilk substitutes should be collected and analysed to permit the monitoring of health outcomes. Countries that consider providing free or subsidized infant formula for HIV-positive women who choose not to breastfeed should also consider providing nutritional or related support to HIVpositive mothers who make other choices. Recommended Indicator on HIV and infant feeding for national PMTCT programmes o Women receiving counselling on infant feeding at first infant follow-up visit Box 3: Key UN recommendations on HIV and infant feeding The most appropriate infant feeding option for an HIV-infected mother depends on her individual circumstances, including her health status and the local situation, but should also take consideration of the health services available and the counselling and support she is likely to receive.

4 Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommended. Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding. Key resources 1. WHO on behalf of IATT. Consensus Statement from HIV and infant feeding technical consultation, October 25-27, Geneva, WHO/UNICEF. Infant and young child feeding counselling: An integrated course. Geneva, in press (to be available on 3. WHO/UNICEF/UNAIDS. HIV and Infant Feeding Counselling: A Training Course. Geneva, 2000 (WHO/FCH/CAH/00.2-4, UNICEF/PD/NUT/(J)00-2, UNAIDS/99.56E) WHO/UNICEF/USAID. HIV and infant feeding counselling tools: Counselling cards. Geneva, ISBN WHO/UNICEF/USAID. HIV and infant feeding counselling tools: Reference Guide. Geneva, ISBN WHO. Guiding principles for feeding non-breastfed children 6-24 months of age. Geneva, WHO/UNICEF/UNFPA/UNAIDS/World Bank/UNHCR/WFP/FAO/IAEA. HIV and infant feeding: Framework for priority action. Geneva, WHO/UNICEF/UNFPA/UNAIDS. HIV transmission through breastfeeding: A review of available evidence. Geneva, 2004 (under revision) WHO/UNICEF/UNFPA/UNAIDS. HIV and infant feeding: Guidelines for decision-makers. Geneva, WHO/UNICEF/UNFPA/UNAIDS. HIV and infant feeding: A guide for health-care managers and supervisors. Geneva, WHO. What are the Options?: Using formative research to adapt global recommendations on HIV and infant feeding to the local context. Geneva, HQ Peggy Henderson, Constanza Vallenas hendersonp@who.int vallenasc@who.int AFRO Charles Sagoe Moses sagoemosesc@who.afr.int AMRO Chessa Lutter lutterch@paho.org EMRO Susan Farhoud farhouds@emro.who.int

5 Kunal Bagchi EURO Francesco Branca SEARO Sudhansh Malhotra WPRO Tommaso Cavalli Sforza Marianna Trias