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Feeding HIV-exposed babies after 6 months of exclusive breastfeeding: issues, challenges,

Feeding HIV-exposed babies after 6 months of exclusive breastfeeding: issues, challenges, and unanswered questions. Jean Humphrey, DSc Associate Professor, Johns Hopkins Bloomberg School of Public Health Director and Principal Investigator, ZVITAMBO.

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Feeding HIV-exposed babies after 6 months of exclusive breastfeeding: issues, challenges,

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  1. Feeding HIV-exposed babies after 6 months of exclusive breastfeeding: issues, challenges, and unanswered questions. Jean Humphrey, DSc Associate Professor, Johns Hopkins Bloomberg School of Public Health Director and Principal Investigator, ZVITAMBO

  2. Why consider breastfeeding cessation at 6 months for HIV+ mothers?

  3. 2/3rds of all breastfeeding-associated HIV transmission occurs after 6 monthsRisk of death due to not breastfeeding declines substantially with infant age

  4. For the 6-9 month baby • Breast milk normally provides: • 60-80% energy needs • 60-80% protein needs • 50-90% of micronutrient needs • Majority of fluid requirements • Replacing breast milk is hard to do • NOT breastfeeding 6-9 month babies in rural Africa is experimental: there are few precedents

  5. Diets of 7 HIV-exposed, PCR-negative rural babies Mealie meal (7) Sugar (5) Tomato (4) Peanut butter (4) Pumpkin (3) Pumpkin leaves (3) Oil (3) Meat (2) Fish (2) Formula (2) Cucumber, banana, cow milk, mhewya (1)

  6. Median nutrient intakes (% requirement)

  7. How could these diets be made adequate?

  8. Conclusions: • most diets were grossly inadequate in energy and most micronutrients. • AFASS replacement feeding without a generous sustainable source of milk or specialized food is virtually impossible.

  9. Observations elsewhere in Africa • Mozambique – 10% of mothers reported inclusion of Fe-rich, animal-sourced food • Malawi: HIV-exposed babies weaned at 6 months had very high rates of gastroenteritis, frank malnutrition. • Uganda : High mortality among babies of BF women on HAART associated with shorter duration of BF. (“…revised infant feeding guidelines may be warranted.”) • Botswana: recent diarrhea epidemic (35,000 cases, 532 deaths). Not breastfeeding was associated with 50-fold higher risk of diarrhea and 8-fold higher risk of dying from the diarrhea illness.

  10. Suggested criteria for assessing AFASS: • Baby is uninfected • PCR, IMCI algorithm, parallel rapid tests • Baby is growing well and not acutely ill • Mother has disclosed her status • Specific feeding plan for providing safe and adequate fluid and nutrients • Nearly impossible without milk source or “special food” • Specific follow-up plan since the non-BF baby will get sick more often and is more likely to progress from mild to severe illness

  11. Potential alternative • Enhanced maternal care: • Current analysis: In the ZVITAMBO trial 253 women transmitted during BF. Assuming BF-associated transmission by HAART-treated women is nil, how much would could have been averted if mothers had been treated as soon as they had become HAART-eligible? • Measure the effect of early BF cessation on infection-free survival in a context of enhanced maternal care

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