Care of Women with HIV Living in Limited-Resource SettingsHIV and Breastfeeding Jean R. Anderson, MDDirector Johns Hopkins HIV Women’s Health Program
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
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
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
Estimated Timing and Risk of MTCT of HIV (Absolute Rates) Source: DeCock et al 2000.
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.
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.
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.
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
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
HIV Transmission Through Breastfeeding Source: Miotti 1999.
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.
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.
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.
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.
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.
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.
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.
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
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
Newborn Mortality Per 100 Live Birthsby Maternal HIV Status Source: World Bank 1999.
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
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.
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
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
Cumulative MTCT Rates in Selected Breastfeeding Populations Receiving Short Course Antiretrovirals
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
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
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