BREASTFEEDING AND HIV

Reno Ar-razzak Rayendra 030.05.187

DEFINITION

Breastfeeding : the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container Babies have a sucking reflex that enables them to suck and swallow milk Most mothers can breastfeed for six months or more, without the addition of infant formula or solid food The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) Both recommend : exclusive breastfeeding for the first six months of life supplemented breastfeeding for at least one year and up to two years or more

BENEFITS FOR INFANT

Greater immune health Fewer infections Protection from SIDS Higher intelligence Less diabetes Less tendency to develop allergic diseases (atopy) Less necrotizing enterocolitis in premature infants Other long term health effects

BENEFITS FOR MOTHER

Bonding Hormone release Weight loss Natural postpartum infertility Long-term health effects

ORGANIZATIONAL ENDORSEMENTS

World Health Organization Exclusive breastfeeding for the first six months of life, after which infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond American Academy of Pediatrics (AAP) Exclusive breastfeeding for the first six months of life. Furthermore, breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child

BREASTFEEDING DIFFICULTIES

Common Most important HIV infection

HIV

Genus : Lentivirus, Family : Retroviridae Two species of HIV : HIV-1 Initially discovered and termed both LAV & HTLV-III. more virulent, more infective & is the cause of the majority of HIV infections globally HIV-2 The lower infectivity of HIV-2 compared to HIV-1. Because of its relatively poor capacity for transmission, HIV-2 is largely in West Africa

EPIDEMIOLOGY

UNAIDS 33.3 million people were living with HIV at the end of 2009 (up from 26.2 million people in 1999) AIDS-related deaths in 2009 at 1.8 million people (down from a peak of 2.1 million 2004) Number of people in low or middle income countries receiving antiretroviral therapy in 2009 at 5.2 million, up from 4.0 million in 2008 Indonesia 314.000 people (the fastest growing epidemic in Asia)

SIGNS AND SYMPTOMPS

HIV infection has four basic stages : 1. Incubation period Asymptomatic & usually lasts between 2 and 4 weeks 2. Acute infection Lasts an average of 28 days and can include symptoms such as fever, lymphadenopathy, pharyngitis, rash, myalgia, malaise, and mouth and esophageal sores 3. Latency stage Shows few or no symptoms and can last anywhere from 2 weeks to 20 years 4. AIDS The final stage of HIV infection shows as symptoms of various opportunistic infections

TRANSMISSION

Sexual Blood products Mother to child Multiple infection

DIAGNOSIS
1.

2.

3.

Enzyme-linked immunosorbent assay (ELISA) Sensitivity 98.1-100%, Usually positive in 2-3 months after infected, detect antibodies to HIV-1, Western blot/Immunofluorescence assay (IFA) Spesifity 99.6-100% Only specimens that are repeatedly reactive by ELISA and positive by IFA or reactive by Western blot are considered HIV-positive and indicative of HIV infection PCR HIV test for infant

TREATMENT

Highly active antiretroviral therapy (HAART)

PROGNOSIS

Without treatment, the net median survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype, and the median survival rate after diagnosis of AIDS in resource-limited settings where treatment is not available ranges between 6 and 19 months, depending on the study In areas where it is widely available, the development of HAART as effective therapy for HIV infection and AIDS reduced the death rate from this disease by 80%, and raised the life expectancy for a newly diagnosed HIV-infected person to 2050 years As new treatments continue to be developed and because HIV continues to evolve resistance to treatments, estimates of survival time are likely to continue to change. Without antiretroviral therapy, death normally occurs within a year after the individual progresses to AIDS Most patients die from opportunistic infections or malignancies associated with the progressive failure of the immune system. The rate of clinical disease progression varies widely between individuals and has been shown to be affected by many factors such as host susceptibility and immune function health care and co-infections, as well as which particular strain of the virus is involved

RESEARCH

Stem cell transplantation Banlec Virus entry inhibitor VIR-576

BREASTFEEDING & HIV

HIV-POSITIVE MOTHERS IN HIGHINCOME COUNTRIES

Breastfed babies are less likely to become ill than those given replacement foods Replacement feeding means giving a baby commercial infant formula (prepared from powder and boiling water) or homemodified animal milk (boiled with added water, sugar and micronutrients) instead of breast milk While some HIV positive mothers in high income countries may wish to breastfeed their child the advice from national health agencies is straightforward, they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding Replacement (sometimes known as formula) feeding is the only infant feeding method that does not expose an infant to HIV and in regions of the world where clean water and facilities are available, it is usually promoted as the only option

HIV-POSITIVE MOTHERS IN LOW & MIDDLE-INCOME COUNTRIES

Advice on infant feeding differs from high income countries to reflect the fact there are limited resources and infrastructure It is known that where there is little access to clean water, sanitation and health services, that not breastfeeding can greatly increase the risks of disease and even the death of the baby So as most HIV positive women in these countries cannot safely formula feed their infants breastfeeding is the only realistic option available

ANTIRETROVIRAL DRUG REGIMENS FOR PREGNANT WOMAN IN LOW AND MIDDLE INCOME COUNTRIES IN 2008

Author: World Health Organization

WHO INFANT FEEDING GUIDELINES 2006 & 2010

In 2006 WHO recommended that HIV positive mothers exclusively breastfeed their infants for 6 months and then rapidly wean After weaning, mothers were advised to begin giving replacement feeding such as biscuits, soft foods and milk but an emphasis was placed on the dangers of mixed feeding Mixed feeding, or complementary feeding, is defined as breastfeeding and replacement feeding at the same time and was believed to increase HIV transmission. It was also advised that replacement feeding could take place where it was acceptable, feasible, affordable, sustainable and safe.

Breastfeeding, which is essential for child survival has posed an enormous dilemma for mothers living with HIV. Now, WHO says mothers may safely breastfeed provided that they or their infants receive ARV drugs during the breastfeeding period. This has been shown to give infants the best chance to be protected from HIV transmission in settings where breastfeeding is the best option. (World Health Organization)

EXCLUSIVE BREASTFEEDING

If an HIV positive mother is breastfeeding, she will be advised to exclusively breastfeed for 6 months, that is to feed only breast milk and nothing else. Breast milk provides all of the fluids and nutrients that a young baby requires, so exclusive breastfeeding means that even water can and should be avoided and studies have shown this to be successful When neither infant nor mother are taking an extended course for ARVs, they should be made aware of the dangers of mixed feeding. They should also be shown the correct technique for suckling, so as to minimise the likelihood of breast disorders, and should be enabled to seek help should any problems occur, such as mastitis which leads to increased HIV transmission The longer an HIV positive mother breastfeeds, the more likely she is to infect her baby but this risk has to be weighed against the benefits of breastfeeding. Before interventions were introduced it was necessary to rapidly wean so that the baby was not exposed to mixed feeding for too long For this reason the WHO, in their 2006 guidelines, recommended that : breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual womans situation and the risks of replacement feeding (including infections other than HIV and malnutrition)

TIME RECOMMEND TO REPLACE FEEDING

Feasibility : A mother who chooses replacement feeding must have adequate time, knowledge, skills and other resources to prepare the replacement food and feed her baby up to twelve times in 24 hours Affordability : Someone has to pay for the ingredients, fuel, water and other equipment needed for replacement feeding. In some countries, the cost of infant formula alone is similar to the minimum urban wage and, unless heavily subsidised, is well beyond the reach of most families Sustainability : Feeding an infant for the first six months of life requires around 20 kg of formula and regular access to water. Even a brief disruption in supplies may have serious health implications Safety : Replacement food should be nutritionally sound and free from germs. The water it is mixed with should be boiled, and utensils should be cleaned (preferably boiled) before each use. This means the mother must have access to a reliable supply of safe water and fuel.

PREVENTING MOTHER TO CHILD TRANSMISSION OF HIV (PMTCT)

Mother to child transmission (MTCT) is when an HIV-infected woman passes the virus to her baby. This can occur during pregnancy, labour and delivery, or breastfeeding. Without treatment, around 15-30% of babies born to HIV positive women will become infected with HIV during pregnancy and delivery. A further 520% will become infected through breastfeeding Effective prevention of mother to child transmission (PMTCT) requires a three-fold strategy. Preventing HIV infection among prospective parents making HIV testing and other prevention interventions available in services related to sexual health such as antenatal and postpartum care - Avoiding unwanted pregnancies among HIV positive women providing appropriate counseling and support to women living with HIV to enable them to make informed decisions about their reproductive lives - Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labour, delivery and breastfeeding - Integration of HIV care, treatment and support for women found to be positive and their families The last of these can be achieved by the use of antiretroviral drugs, safer infant feeding practices and other interventions

ANTIRETROVIRAL DRUGS

Single dose Nevirapine Combining AZT with single dose nevirapine Triple combinations

INFANT FEEDING ADVICE FOR WOMAN WITH REGULAR ACCESS TO ANTIRETROVIRAL DRUGS

The World Health Organization's (WHO) recommendations are based on whether a women has access to antiretroviral drugs or not. If a woman has support and a regular supply of antiretroviral drugs Then she should exclusively breastfeed for the first 6 months of an infant's life Then introduce mix feeding until the infant is able to have a safe diet without breastmilk. Mixed feeding (breastfeeding mixed with bottle feeding of water or formula, or providing other foods) is only safe in this situation because the mother or infant is taking antiretrovirals

INFANT FEEDING ADVICE FOR WOMAN WHO DO NOT HAVE REGULAR ACCESS TO ANTIRETROVIRAL DRUGS
In situations where health services cannot supply women or infants with a regular supply of antiretroviral drugs, for an extended period of time, women are recommended to : Exclusive breastfeed for the first 6 months of an infant's life Rapidly wean to avoid mixed feeding Mixed feeding is not recommend because studies suggest it carries a higher risk than exclusive breastfeeding. Potentially this is because it damages the lining of the baby's stomach and intestines thus making it easier for HIV in breast milk to infect the baby If a HIV positive mother does not have access to ARVs she is strongly recommended to rapidly wean. Unfortunately, the best duration for this is not yet known and may vary according to the infant's age and/or the environment

MTCT-Plus

The MTCT-Plus Initiative was established in 2002, and is coordinated by the Mailman School of Public Health at Columbia University The Initiative aims to move beyond interventions aimed only at preventing infant HIV infection. It does this by supporting the provision of specialised care to HIV-infected women, their partners and their children who are identified in MTCT programmes. Funding for the initiative is provided by a group of private foundations, including the Gates Foundation, the Kaiser Family Foundation and the Rockefeller Foundation, as well as by PEPFAR via USAID The MTCT-Plus Initiative provides operational funding, medications, training and technical assistance at 13 sites in sub-Saharan Africa and at one site in Thailand Since its inception MTCT-Plus has provided care & treatment to more than 16,000 adults and children

REFERENCES

Breastfeeding. Available at : http://www.wikipedia.com/breastfeeding.html. Accessed January 7, 2011. Human Immunodeficiency Virus. Available at : http://www.wikipedia.com/humanimmunodeficiencyvirus.html. Accessed January 7, 2011. HIV World. Available at : http://www.avert.org/html. Accessed January 2, 2011. Breastfeeding Produces Smarter, Healthier Babies. Available at : http://www.washingtonpost.com/wpdyn/articles/A49325-2002May7.html. Accessed January 2, 2011. Academy of Breastfeeding Medicine. News release: Academy of Breastfeeding Medicine endorses new WHO child growth standards. Available at : http://www.bfmed.org/aceimages/ABMEndorsesWHOChildGrowthStandards.doc Accessed January 4, 2011. American Academy of Pediatrics and American College of Obstetricians and Gynecologist (AAP/ACOG). Guidelines for perinatal care. 5th ed.. Elk Grove Village, IL: American Academy of Pediatrics; 2002. Ministry of Health Uganda, AIDS Control Programme. National Guidelines for the Prevention of Mother to Child HIV Transmission. Revised ed. August 2006.

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