WILLIAM DINDA-NUTRITIONIST22/06/2012

"Mothers known to be HIV-infected… should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.” World Health Organization

Martina a 30 year old pregnant lady comes for an ANC visit at 21 weeks gestation and tests HIV positive.

What will you do for her?

Martina reveals that she does not want to disclose her status to her joint family members.

She lives in a thatched house and has no electricityHer source of fuel is wood or occasionally charcoalThey fetch water from the nearby well.

Martina is in good health and is in WHO stage 1.Her CD4 count is 425 and hb 12.7g/dl

What medications will you put her on?

What are Martinas feeding options?

In many countries, both health services and individual mothers have not been able to adequately support and provide safe replacement feeding.

HIV-positive mothers have faced the dilemma of either giving their babies all the benefits of breastfeeding but exposing them to the risk of HIV infection, or avoiding all breastfeeding and increasing the risk of death from diarrhoea and malnutrition

At AIDS 2010, WHO released new guidelines on PMTCT and infant feeding practices.

Kenya has adapted these guidelinesIf widely implemented, these guidelines will provide

the basis for more effective PMTCT interventions in resource-limited settings, and will virtually eliminate the number of new paediatric HIV infections.

For the first time, the elimination of mother-to child transmission of HIV (MTCT) is considered a realistic public health goal.

1. Earlier antiretroviral therapy (ART) for a larger group of HIV-positive pregnant women to benefit both the health of the mother and prevent HIV transmission to her child during pregnancy and breastfeeding.

2.Longer provision of antiretroviral (ARV) prophylaxis for HIV-positive pregnant women with relatively strong immune systems who do not need ART for their own health. This would reduce the risk of HIV transmission from mother to child.

3.Provision of ARV prophylaxis to the mother or child to reduce the risk of HIV transmission during the breastfeeding period. For the first time, there is enough evidence for WHO to recommend ARVs while breastfeeding.

Lifelong ART for HIV-infected women in need of treatment for their own health, which is also safe and effective in reducing mother to child transmission of HIV (MTCT).

Short-term ARV prophylaxis to prevent MTCT during pregnancy, delivery and breastfeeding for HIV-infected women not in need of treatment.

Mother takes ARVs from 28th week of pregnancy until 1 week after labour, or for an indefinite amount of time if the mother is taking ARVs for their own health.

Short ARV regimen during breastfeeding period for either mother and/or infant

Exclusive breastfeeding for 6 months

Rapidly wean from breastmilk No mixed feeding Not recommended to breastfeed

after 6 months

Mother takes ARVs from 14th week of pregnancy until 1 week after labour, or for an indefinite amount of time if the mother is taking ARVs for their own health.

Long ARV regimen during breastfeeding period for either mother and/or infant

Exclusive breastfeeding for 6 months

Gradually wean from breastmilk Mixed (complementary) feed after 6

months Recommended to breastfeed and

mix feed in conjunction with ARVs

2010 WHO Infant Feeding Guidelines

A mother may decide to breastfeed exclusively, but may start giving her infant additional fluids because she does not believe she has enough breastmilk.

"The family will tell her that breast milk is not enough for the baby, she must also mix it with formula feeding, and she can’t deny that because she hasn’t told them why she chose to exclusively breastfeed her baby so she will just mix feed.” South African health worker

It is the only 100 percent effective way to prevent mother-to-child transmission of HIV after birth, but the risk of infant mortality from other illnesses such as diarrhoea must be taken into account.

The World Health Organization recommends that replacement feeding for women in low and middle-income countries should only be implemented if the following circumstances are achieved or appropriate, which can be summarised as AFASS:

A ---ACCEPTABLEF ---FEASIBLEA ---AFFORDABLES ---SUSTAINABLES --- SAFE

Breastfeeding is the norm in most cultures, and is generally encouraged by health workers. By choosing not to breastfeed, a mother risks revealing that she is HIV positive, and becoming a target for stigma and discrimination.

She must be able to cope with this problem and resist pressure from friends and relatives to breastfeed.

A mother 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.

Boiling water over a charcoal stove, for instance, can take up to fifteen minutes per feed. Unless refrigerated, prepared formula becomes unsafe after just two hours.

It is better to feed with a cup rather than a bottle because cups are easier to clean, and because cup feeding promotes greater interaction between the mother and her baby

FUELWATERAND THE

REPLACEMENT FEED

Feeding an infant for the first six months of life requires around 20 kg of formula and regular access to water.

Replacement food should be nutritionally sound and free from germs. The water 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.

PREPARING feedsGIVING feedsNEED for sterile equipment AND hygieneTAUGHT correct dilutionADVISED on dangers of keeping prepared formula for

long periods at room temperature.

WHAT WOULD YOU ADVISE MARTINA?

The 2010 guidelines have great potential to improve the mother’s own health and to reduce mother-to-child HIV transmission risk to 5% or lower in a breastfeeding population, from a background transmission risk of 35% (in the absence of any interventions and with continued breastfeeding).