1. Meeting the Challenge of Infant Feeding in the Context of HIV Dr. JP Dadhich MD Coordinator, BPNI Taskforce on Research and Interventions Co-coordinator, IBFAN Asia Pacific WG on HIV & Infant Feeding New Delhi, India 10 th IWHM, September 2005, New Delhi

2. Outline Magnitude of HIV/AIDS Global response Risk factors for transmission from parents to child Challenges in HIV and IF Partnership

3. Magnitude of HIV/AIDS Pandemic By the end of 2003, an estimated 38 million people were infected with HIV Over 95 % were in developing countries Approximately 17 million people with HIV are women 2.1 million are children under 15

4. Known Routes of HIV transmission India NACO, 2002

5. Situation of PTCT in India 27 million pregnancies per year 108,000 infected pregnancies Annual Cohort of 32,000 infected newborns 0.4% prevalence 30% transmission

6. Overview of HIV Transmission to Children

7. Timing of Parent-to-child Transmission Early Antenatal (<36 wks) Late Antenatal (36 wks to labor) Late Postpartum (6-24 months) Early Postpartum (0-6 months) Adapted from N Shaffer, CDC 5-10% 10-20% Labor and DeliveryBreastfeeding Pregnancy

8. PTCT in 100 HIV+ Mothers by Timing of Transmission Uninfected: 63 Breastfeeding: 15 Delivery: 15 Pregnancy: 7

9. Risk Factors For PTCT Feeding method Immune/health status of mother Plasma viral load Breast inflammation (mastitis, abscess, bleeding nipples)

10. Early Mixed Breastfeeding Coutsoudis et al, 1999; 2001 Cumulative HIV transmission Durban, SA

11. Exclusive Breastfeeding Falls Rapidly From First Month Onwards (NFHS-II-1999)

12. Maternal Virus Load and Perinatal Transmission Viral LoadTransmission Rate (%) < 1000 copies/ml0 1000 –1000016.6 10,001-50,000-21.3 50,001-100,00030.9 > 100,00040.6 Garcia BM. NEJM, 1999

13. Maternal Immune Status Leroy et al 2003

14. Breast Pathology Prevalence of breast pathologies on clinical exam.In HIV+ women in Africa Mastitis: 7-11% Nipple lesions: 11-13% Breast abscesses:12% (Embree et al; John et al; Semba et al)

15. Technical and Programmatic Guidance Global strategy on infant and young child feeding (2002) HIV & infant feeding: framework for priority action (who/UNICEF/UNFPA/UNAIDS/world bank/UNHCR/WFP/FAO/IAEA) HIV & infant feeding: guidelines for decision-makers (WHO/UNICEF/UNFPA/UNAIDS) HIV & infant feeding: A guide for health care managers and supervisors (WHO/UNICEF/UNFPA/UNAIDS) WABA/UNICEF colloquium at Arusha 2002 IBFAN/BPNI/UNICEF colloquium at new Delhi 2003

16. Unique Global Consensus 9 UN agencies ratified in 2003 5 priority actions, first being development of policy and plans for IYCF including HIV, promotion of exclusive breastfeeding for ALL babies

17. WHO/UNAIDS/UNICEF Guidelines on HIV&IF (1997-2005) HIV- or status unknown Exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for 2 years HIV+ When replacement feeding is acceptable, feasible, affordable, safe and sustainable, avoidance of all breastfeeding is recommended.Otherwise EBF is recommended for the first months of life

18. Feeding Options for First 6 Months Replacement feeding: –Commercial infant formula –Home-modified animal milk Breastfeeding: –Exclusive with early cessation Breast-milk feeding options: –Expressed and heat-treated BM –Wet-nursing –BM banks

19. Summary of Background Major public health problem with socio- economic dimensions Global guidelines are available Fair knowledge about the mode and various risk factors for PTCT

20. Challenges in HIV and IF

21. Challenges…. Implementation of UN tools and inclusion of PTCT in national programs is not a priority

22. HIV IF – Status at National Level 5 Country Assessment IBFAN-AP, WABA; 2005 IssueCountry A’stanB’deshIndonesiaMalaysiaNepal National program on HIV/AIDS NoYes No Nodal agency on HIV NoYes No Policy on PPTCTNoYesDraft ready YesNo National policy on HIV IF No Yes AF Yes AF No Capacity building in IF Counseling absent Lack of training program Needs strengthe ning Absent

24. Challenges…. Information to parents and community is negligible, inadequate and improper Training of health workers and counselors is lacking or inadequate

25. Where HIV+ Women Receive Counseling and Free Infant Formula, Its Use Is Not Optimal

26. Bacterial Contamination and Improper Preparation of Commercial Infant Formula in a PMTCT Program (Durban, South Africa) Contamination of milk samples  64% E Coli  26% Enterococci Over dilution of milk samples  22% for infants <= 12 months  78% for children > 12 months Bergström, 2003

27. Assessment of PPTCT Counselors BPNI, NACO -2004 Inadequate, Biased Knowledge Inappropriate Practices Insufficient Skill Transfer

28. Challenges…. Keeping mothers healthy is not a priority action

29. Focus on Maternal Health & Nutrition Keeping HIV+ mothers well may be among the most important things we can do to prevent P/N transmission and maternal survival BF transmission was ~2% between 6 w-24 months in women with CD4 >500 (Leroy et al, 2003) No programmatic intervention to ensure maternal health

30. Expanding Use of ARVs Legitimate demand for a single standard of care regardless of socioeconomic conditions  currently HAART for mother, peri-natal ARV therapy Lower prices, wider variety of available regimens, easier logistics,  expanding postnatal use and availability of ARVs

31. Challenges…. Infant feeding is linked with child survival, but ignored in context to HIV Paucity of research directed towards HIV free survival Available research is not being disseminated

32. Proportion of All < 5 Yrs Deaths That Could Be Prevented With Infant Feeding Interventions Jones et al, 2003, Lancet * *Estimate would be 15% without effects of HIV

33. Risks of artificial feeding (in developing countries risks are elevated above these levels) Increased levels of accute illness: Respiratory infections Middle ear infection: 3-4x risk Gastroenteritis: 3-4x risk (developing countries 17- 25x) Bacterial infection requiring hospitalization: 10x risk Meningitis: 4x risk Higher mortality from sudden infant death syndrom (SIDS)

34. HIV/Infant feeding is about Assessing the risks

35. Ross J et al. 2004, AJPH Model for Per 1000 HIV-Positive Mothers (IMR 96) Ross and Labbok, AJPH, 2004

36. Feeding Mode and Survival Multi-centric trial from Ghana, India, Peru Published in bulletin of WHO Non-breastfed infants had a higher risk of dying V/V breastfed infants Bahl et al. 2005

37. Challenges…. Making feeding safer is not seen as an option to prevent PTCT

38. Strengthen Approaches for Making Breastfeeding Safer for ALL Women Provide adequate lactation counseling and support, involving families/communities –Increase adherence to exclusive breastfeeding –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 Safe sex/condom use for prevention of fresh inf

39. Make Breastfeeding Safer for HIV+ Women Avoid mixed feeding,ensure exclusive breastfeeding Prevent breast problems Minimize maternal viral load Improve maternal immunity Provide ARVs to mother and child

40. Make Replacement Feeding Safer for HIV+ Women Provide safe water & environmental conditions Adequate sustained supply Ensure hygiene Family support, community understanding – take care of stigma

41. Challenges…. Policy makers, planners, health care providers and counselors are not sensitized on gender issues

42. Gender Issues in HIV and Infant Feeding The terminology used “mother to child transmission” (MTCT) puts the blame on the mother, the woman – who is already often a victim of the HIV epidemic Stigma and discrimination against the women is much stronger Often seen as a vector, blamed for spread Risks violence, abandonment, neglect, destitution

43. Gender Issues in HIV and Infant Feeding Information from health system almost always directed at mothers/women Women/mothers are tested, women are made responsible for feeding, caring etc Men are not targeted as equally responsible

44. Issues for Partnership Gender sensitization of policy makers, planners, health care providers, media and counselors Universalizing preventive services like VCT, skilled counseling on feeding options Empowering parents to choose interventions which ensures improved HIV free survival Publicizing available research and knowledge

45. Thanks !!!! Thanks !!!