WHERE WE WERE, WHERE WE WANT TO BE INFANT FEEDING IN THE CONTEXT OF HIV
AND ARVS
Nigel Rollins
Maternal, Newborn, Child and Adolescent Health
WHO recommendations on HIV and infant feeding
2000
• When replacement feeding is acceptable, feasible, affordable, sustainable and
safe, avoidance of all breastfeeding by HIV-infected mothers is recommended
• Otherwise, exclusive breastfeeding is recommended during the first months of life
2006
• The most appropriate infant feeding option for an HIV-infected mother should
continue to depend on her individual circumstances, including her health status
and the local situation, but should take greater consideration of the health
services available and the counselling and support she is likely to receive.
• 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
•
HIV-infected women should be given ‘specific guidance in selecting the option
most likely to be suitable for their situation’ i.e. promote informed and free
choice of infant feeding methods for HIV-infected mothers
Assumes accuracy of information and that women can enforce their
‘choice’
Does a recommendation
endorsing breastfeeding
to an HIV-infected
mother in Africa,
represent duplicity in
ethical standards?
December 5th 2000
Wyeth, Nestle Offer Free Tins to Stem Spread of AIDS
"After years of being hated by advocates of breast-feeding, Nestlé
and the rest of the baby food industry must have wept with delight at
articles in the Wall Street Journal last December (2000).
The Wall Street Journal …… painted the baby food manufacturers
as heroes poised to save African children from certain death."
"HIV – will it be the death of breastfeeding?"
23,998 cases of infant diarrhoea
and 486 deaths.
Mainly amongst infants in
PMTCT programmes
Creek T, 2006
Mortality in FF vs. BF infants
(excl. infants weaned before 12m)
HR 6.3 (95%CI = 1.4-28.0,
p=0.02)
In the absence of ARVs
interventions, HIV free
survival of uninfected infants
who were BF or FF @12 m was
equivalent.
Number of respondents
Myth: 100% of infants born to HIV-infected mothers who breastfeed
will become infected
160
140
120
100
80
Response to question: If 100 HIV-infected
women breastfeed until their children are
two years old how many children will be
infected at 2 years of age? (mother and child
do not receive any antiretroviral medicines)
60
40
20
0
0 - 20
20 - 40
40 - 60
60 - 80
80 - 100
Don't Know
Number of infants infected
Chopra and Rollins, Arch. Dis. Child. 2008
Feeding at some PMTCT sites
100
90
80
70
60
50
40
30
20
10
0
BF
FF
Rietvlei ZeerustShongwe COSH
Rural Rural Rural Rural
Durban Pmb
Urban Urban
The quality of infant feeding
counselling translated into
HIV free survival of infants
Woldenbeset. IAS 2009
Then …
Breastfeeding, Antiretroviral and Nutrition
(BAN) study (Chasela, IAS 2009)
3 Arms: Control
Mothers receive lopinavir/ritonavir for 28 wks throughout BF period
Breastfeeding infants received daily NVP for 6 months
Infant HIV transmission and
mortality rates %
10.0
9.0
Control
8.0
7.0
6.0
5.0
7.6%
6.4%
p=0.003
4.0
3.0
2.0
1.0
0.0
Maternal LPV/r
for 6 mo
Inf NVP for 6
mo
4.7%
3%
2.9%
1.8%
p=0.001
Transmission at 6 mo
Death at 6 mo
•NVP to infants
for 14 wks
0.20
0.15
0.00
•NVP and AZT to
infants for 14wks
Control
Extended NVP
Extended NVP+ZDV
0.10
•Control
0.05
3 arms:
Probability of HIV-1 Infection
0.25
0.30
Probability of HIV-1 Infection in Infants
Uninfected at Birth by Treatment Arm: PEPI-Malawi
1wk
9wk
6mo
9mo
12mo
15mo
18mo
24mo
Infant Age
Age
1
wk
6
wks
9
wks
14
wks
6
mos
9
mos
10.6
5.2
6.4
12
mos
15
mos
18
mos
24
mos
Estimates (%)
Control
0.3
5.1
7.4
8.4
10.1
Extended NVP
0.1
1.7
2.6
2.8
4.0
Extended NVP+ZDV
0.2
1.6
2.4
2.8
5.2
11.5
12.4
13.9
14.5
7.0
7.8
10.1
11.2
8.1
8.7
10.2
12.3
Mma bana study
(Shapiro, IAS 2009)
Infant HIV transmission %
2 randomised arms and one observational
Mothers not eligible for ART received either: lopinavir/ritonavir and combivir } for 6m
or abacavir/AZT/3TC
} while BF
Mothers eligible for ART – outcomes observed
10
9
8
7
6
5
4
3
2
1
0
Viral suppression >92%
all groups
LPV/r + combivir
Abacavir/AZT/3TC
Observational
Mothers not eligible for
ART
Observational
Infant HIV-free survival rates to 12 months of age.RCT, by study stratum
2 arms - AZT + 3TC + LPV/r until
•Delivery only (Short) then nil Or
0.95
0.90
Short
Triple
0.75
•End of BF ~6mths (Triple)
0.85
RCT in Kenya, Burk. Faso and SA
0.80
Proportion alive and not infected
1.00
Kesho Bora:
All infants:
HIV-free survival
Log rank test p = 0.022
(stratified on centre and intention to BF)
0
1
2
3
4
5
6
7
8
9
10
Age (in months)
Triple
Short
Events
(cum) /
at risk
Rate
(95% CI)
Events
(cum) /
at risk
Rate
(95% CI)
Reduc
-tion
Birth
11/400
2.7 (1.5, 4.9)
11/403
2.7 (1.5, 4.9)
0%
6 weeks
19/377
4.8 (3.1, 7.4)
24/376
6.0 (4.1, 8.8)
20 %
6 months
33/347
8.3 (6.0, 11.5)
50/334
12.6 (9.7, 16.3)
34 %
12 months
40/278
10.4 (7.7, 13.9)
62/252
16.3 (12.9, 20.5)
36 %
11
12
WHO guidelines
http://www.who.int/hiv/en/
Setting national recommendations for
infant feeding in the context of HIV
National (or sub-national) health authorities should decide
whether health services will principally counsel and support
mothers known to be HIV-infected to:
- breastfeed and receive ARV interventions, or,
- avoid all breastfeeding,
as the strategy that will most likely give infants the greatest
chance of HIV-free survival.
This decision should be based on international recommendations and consideration of
the socio-economic and cultural contexts of the populations served by Maternal and
Child Health services, the availability and quality of health services, the local
epidemiology including HIV prevalence among pregnant women and main causes of
infant and child mortality and maternal and child under-nutrition
22 UNAIDS priority countries (2012)
• The vast majority have adopted Breastfeeding with ARVs
as policy
• Still low/uncertain coverage of ARVs among BF mothers
• Poor quality data
Local adaptation and implications
Individualizing the WHO HIV and infant feeding guidelines: optimal
breastfeeding duration to maximize infant HIV-free survival.
CiarenelloAL. AIDS 2014. Jul 28. Suppl 3:S287-99
• An individualized approach leads to moderate gains in
HFS, but only when mortality risks from replacement
feeding are very low or very high, or antiretroviral drug
availability is limited. The WHO public health approach is
beneficial in most resource-limited settings.
Malawi – option B+
Breastfeed – 24 months
? Botswana – IMR 41
CMR 53
2012
Int J Health Plann Manage. 2013 Jul-Sep;28(3):257-68
'Findings suggest that WHO Guidelines on preventing
vertical transmission of HIV through exclusive
breastfeeding in resource-limited settings are not being
translated into action by governments and front-line
workers because of a variety of structural and
ideological barriers.'
Mma bana study
2 randomised arms and one observational
Mothers not eligible for ART received either:
lopinavir/ritonavir and combivir } for 6m
or abacavir/AZT/3TC
} while BF
Mothers eligible for ART – outcomes observed
Infant HIV
transmission %
10
9
8
7
6
5
4
3
2
1
0
Mothers not eligible for Observational
ART
1248 pregnant women referred
to study sites. After counselling
about study interventions, 110
(8.8%) declined enrolment as
preferred to give formula
feeds.
Where we want to be
• Where HIV-infected mothers do not need to think about their
status when they feed their infants.
• Zero risk of HIV transmission
• HIV-infected mothers have confidence in the benefits of BF
• Health workers have confidence to promote and support BF
• Breastfeeding does not have any negative connotation
• Where HIV investment to promote and support breastfeeding among
HIV-infected mothers, can also support breastfeeding among the
general population and vice versa
• Where HIV-infected mothers and their infants can benefit from all
social and health aspects of breastfeeding
• Where HIV-free survival and development is the metric of
success
Research questions
• Approaches for reducing the residual risk of HIV
transmission
• Confirm minimal risk of low dose ARVs to BF infants
• Implementation research questions
• How to track ARV coverage among HIV-infected mothers who are
breastfeeding – for surveillance and improving programmes
• How to optimally support HIV-infected mother while BF
- Health workers issues / community issues
Revision process of WHO guidelines on
HIV and Infant Feeding
• Last recommendations 2010
• Planning for guideline review mid-2015
• To review experiences and new evidence since last guidelines
• What have been the experiences regarding implementation of
the 2010 guidelines on HIV and IF
• Areas where there is new research
• What are the main issues/challenges related to
implementation of guidelines e.g. 'How long to BF'
• Aspects that need to be examined or need better articulation
• Issues related to specific regions or population
Acknowledgements
• Tin Tin Sint. UNICEF
• Carmen Casanovas. WHO
______________________________________________
• Design and implementation challenges for PMTCT
implementation research. The INSPIRE Initiative:
A South-South collaboration
• Tuesday 22 July. 18.30-20.30
• Plenary 3