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Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding PowerPoint PPT Presentation

Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding Jean R. Anderson, MD Director Johns Hopkins HIV Women’s Health Program Benefits of Breastfeeding to Newborn Provides complete nutrition for first 4 – 6 months of life

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Care of Women with HIV Living in Limited-Resource Settings HIV and Breastfeeding

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Care of women with hiv living in limited resource settings hiv and breastfeeding l.jpg

Care of Women with HIV Living in Limited-Resource SettingsHIV and Breastfeeding

Jean R. Anderson, MDDirector

Johns Hopkins HIV Women’s Health Program


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Benefits of Breastfeeding to Newborn

  • Provides complete nutrition for first 4–6 months of life

  • Provides significant protection from infectious morbidity and mortality

    • Gastrointestinal infections

    • Lower respiratory infections

    • Otitis media

    • Meningitis

  • Lack of breastfeeding is associated with 3–5 fold increase in newborn mortality

  • Reduces exposure to waterborne pathogens in areas with unsafe water supply


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Benefits of Breastfeeding to Mother

  • Delays return of fertility

    • Promotes child spacing

    • Allows maternal recovery from blood loss

  • Promotes mother-newborn bonding

  • Is low in cost


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Objectives

  • Discuss evidence linking breastfeeding to mother-to-child transmission (MTCT) of HIV

  • Explain possible effects of breastfeeding on health of HIV-positive mothers

  • Describe interventions to reduce risk of transmission through breastfeeding


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Estimated Timing and Risk of MTCT of HIV (Absolute Rates)

Source: DeCock et al 2000.


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Cumulative MTCT Rates in Selected Breastfeeding Populations in Africa


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Risk of Transmission

  • International pooled analysis of four African and four European/American breastfeeding studies (n=902)

    • Rate of transmission 3.2 per 100 child-years of breastfeeding

    • Underestimates breastfeeding transmission in first 2.5 months of life

    • Most transmissions occurred after 6 months of breastfeeding

Source: Leroy 1998.


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Risk of Transmission continued

  • Prospective cohort breastfeeding study in Malawi (n=672)

    • Rate of transmission 6.9 per 100 child-years of breastfeeding

    • Underestimates breastfeeding transmission in first month of life

    • Risk highest in first months of breastfeeding but continued throughout entire breastfeeding period

Source: Miotti 1999.


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HIV Transmission During Breastfeeding in Women with Acute HIV Infection

  • Higher plasma HIV levels during acute infection

  • Transmission rate approximately 29% with acute infection

  • Implications

    • Importance of prevention counseling after negative HIV test early in pregnancy

    • Need to reinforce use of male or female condoms during pregnancy and breastfeeding

Source: Dunn 1992.


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Variables Associated with Breastmilk Transmission

  • Maternal factors

    • New HIV infection

    • Advanced HIV infection

    • Plasma viral load, CD4 count

    • Breastmilk viral load

    • Inflammatory breast conditions

      • Mastitis

      • Breast abscess

    • Cracked nipples

    • Vitamin A deficiency


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Variables Associated with Breastmilk Transmission continued

  • Newborn factors

    • Oral thrush

    • Other mucosal lesions due to trauma or other infection

    • Preterm birth or low birth weight

    • Nutritional deficiencies

  • Breastfeeding characteristics

    • Colostrum versus mature milk

    • Timing

      • Highest in first months

      • Increases with longer duration of breastfeeding

    • Pattern of breastfeeding

      • Exclusive breastfeeding versus mixed or replacement feeding


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HIV Transmission Through Breastfeeding

Source: Miotti 1999.


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Breastfeeding versus Formula Feeding

  • Setting

    • Nairobi, Kenya

  • Study participants

    • Mother-newborn pairs randomized to breastfeeding (n=197) versus formula feeding (n=204)

  • Results

    • Compliance with assigned feeding group

      • Breastfeeding – 96%

      • Formula – 70% (p<.001)

    • Cumulative risk of HIV infection (24 months)

      • Breastfeeding – 36.7%

      • Formula – 20.5% (p=.001)

Source: Nduati 2000.


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Breastfeeding versus Formula Feeding

  • Results continued

    • 44% of HIV infection in breastfeeding group due to breastmilk

    • 75% of infection difference between two groups occurred by 6 months

    • Mortality rate at 2 years similar in breastfed (24.4%) and formula newborns (20.0%) (p=.30)

    • HIV-uninfected survival rate at 2 years significantly higher with formula feeding (70%) versus breastfeeding (58%) (p=.02)

Source: Nduati 2000.


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Exclusive Breastfeeding Versus Mixed Feeding

  • Mixed feeding means feeding newborns with mixture of breastmilk and other foods or liquids

    • Water or glucose-water solution

    • Weak tea

    • Formula

    • Cereal or porridge

    • Fruits and vegetables

  • Exclusive breastfeeding is associated with reduced incidence of diarrhea, respiratory illness, allergy, and neonatal mortality

Source: Perera 1999 Cesar 1999 Oddy 1999 Leach 1999.


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Exclusive Breastfeeding versus Mixed Feeding: Risk of HIV Transmission

  • Setting

    • Durban, South Africa

  • Objective

    • To determine risk of HIV transmission by newborn feeding practice

  • Study participants

    • 551 HIV-positive pregnant women and their newborns

  • Comparisons

    • Never breastfed newborns (n=157)

    • Newborns exclusively breastfed x 3 months or more (n=118)

    • All other breastfed newborns (n=276)

Source: Coutsoudis et al 2001.


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Exclusive Breastfeeding versus Mixed Feeding: Risk of HIV Transmission continued

  • Results

    • Newborns exclusively breastfeeding had no excess risk of MTCT of HIV over 6 months as compared to never-breastfed newborns (cumulative risk of infection 19.4% in both groups)

    • Newborns fed with mixture of breastmilk and other foods and liquids at greatest risk for MTCT (cumulative risk of infection 26.1% at 6 months, 35.9% at 15 months)

    • After exclusive breastfeeding ended, new infections began to occur in newborns still breastfeeding (cumulative risk of infection 24.7% at 15 months)

Source: Coutsoudis et al 2001.


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Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women

  • HIV-positive women participating in randomized clinical trial of breastfeeding versus formula feeding in Kenya (197 breastfeeding, 200 formula feeding)

  • Assignment to breastfeeding group associated with over 3-fold increased mortality rate during 2 years of followup

  • After controlling for HIV status in newborn, newborns of mothers who died had 8-fold increase in likelihood of subsequent death

Source: Nduati et al 2001.


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Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued

  • HIV-positive women enrolled in randomized Vitamin A supplementation study in Durban, South Africa

  • Data analyzed by chosen method of newborn feeding, average followup of 11 months

  • No evidence of increased mortality or morbidity in ever- versus never-breastfed group

Source: Coutsoudis et al 2001.


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Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued

  • What is the role of nutritional status?

    • Higher prevalence of anemia in Kenya study than in South African study

    • Women in breastfeeding group had greater weight loss than formula group; significant relationship between weight loss during followup and mortality (Kenya)

    • Combined metabolic demands of HIV and breastfeeding (energy, nutrient stores) may result in increased nutritional impairment, especially in women already malnourished


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Effect of Breastfeeding on Maternal Mortality in HIV-Positive Women continued

  • What is the role of immune status?

    • Maternal deaths associated with lower CD4 counts and higher viral load at enrollment (Kenya)

    • Mortality was related to HIV status

    • Baseline immune status better in South African study subjects


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Newborn Mortality Per 100 Live Birthsby Maternal HIV Status

Source: World Bank 1999.


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Interventions to Prevent HIV Transmission by Breastfeeding

  • Primary prevention of HIV in childbearing women

    • Safer sexual and drug-using practices during pregnancy and lactation

  • Identification of HIV in women who are pregnant or considering pregnancy

    • Voluntary counseling and testing


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Recommendations for Feeding

  • HIV-negative women and women of unknown status

    • Exclusive breastfeeding for 6 months

  • HIV-positive women

    • Avoid all breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe

      • Provide guidance and support to HIV-positive mothers who choose not to breastfeed to ensure adequate nutrition

    • If breastfeeding chosen, encourage exclusive breastfeeding up to 6 months of infant’s life

      • Teach proper attachment of newborn to nipples and frequent breast emptying

      • Teach prevention and recognition and encourage prompt treatment of mastitis, breast abscess, cracked nipples and oral thrush or other oral lesions in newborns

Source: WHO 2001.


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Recommendations for Feeding continued

  • Promote hygiene and food safety for maternal health and safety of replacement feeding

  • Improve the nutritional status of pregnant and lactating mothers

    • Vitamin E supplements reduced mastitis risk in Tanzanian study

    • Maternal iron status


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Recommendations for Feeding continued

  • Keep period of transition from breastfeeding to full replacement feeding (weaning) as short as possible

    • Provide guidance after stopping breastfeeding to ensure adequate newborn nutrition

    • Counsel and give support to maintain breast health and decrease psychological consequences of rapid weaning


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Cumulative MTCT Rates in Selected Breastfeeding Populations Receiving Short Course Antiretrovirals


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Stigma of Not Breastfeeding

  • Women who do not breastfeed may face social stigma

  • Not breastfeeding may arouse suspicion or even violence

  • Strong cultural pressures to breastfeed along with desire to protect newborn by not breastfeeding may increase practice of mixed feeding by HIV-positive mothers


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Further Directions for Research

  • Role of antiretroviral therapy for newborn and/or mother in prevention of MTCT through breastfeeding

  • Feasibility and safety of heat treating breastmilk expressed at home to inactivate HIV

  • Role of immune-based interventions

    • Passive immune therapy

    • Vaccines


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Summary

  • All HIV-positive mothers should receive counseling

    • Information about risks and benefits of newborn feeding options

    • Specific guidance in selecting option most suitable for individual situation

    • Support for maternal choice

  • Local assessments should be conducted to identify range of newborn feeding options that are acceptable, feasible, affordable, sustainable and safe in different locations

  • Information and education on transmission of HIV through breastfeeding should be directed to the general public, communities and families to reduce stigma of not breastfeeding


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