hiv and breast feeding. speaker- dr nishant verma

8/14/2019 HIV and Breast feeding. Speaker- Dr Nishant Verma

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HIV

andBreast Feeding


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RISKS

Once an HIV positive mother delivers a

baby the risk of transmission throughbreast-milk is about 15 per cent.


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RISK FACTORS FOR BREASTFEEDING

TRANSMISSION OF HIV-1

Mixed breastfeedingExclusivity of breastfeeding

Higher viral load, Lower concentrations

of antiviral substances (eg, lactoferrin,

lysozyme, SLPI, epidermal growthfactor), Lower concentration of virus-

specific cytotoxic T-lymphocytes,Lower

secretory IgA,Lower IgM

Human milk characteristics

Oral candidiasisInfant characteristics

Younger age, Higher parity ,Lower

CD4+ count, Higher peripheral blood

viral load, Breast abnormalities, Breastabscess, Mastitis ,Nipple lesions

Maternal characteristics

Longer durationDuration of breastfeeding

Risk factorCategory


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WHO recommendations for

breastfeeding and replacement 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 .


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(2000) contd

To minimize HIV transmission risk,

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).


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(2000) contd

When HIV-infected mothers choose not to

breastfeed from birth or stop breastfeeding

later, they should be provided with specific

guidance and support for at least the first

2 years of the childs life to ensure

adequate replacement feeding.

Programmes should strive to improveconditions that will make replacement

feeding safer for HIV-infected mothers and

families.


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POTENTIAL INTERVENTIONS TO PREVENT

BREASTFEEDING TRANSMISSION OF HIV-1 Decreasing Viral Load in Human Milk

Treating Human Milk

Treatment of human milk with chemical agents or heat to

inactivate HIV-1 has been investigated. Boiling expressedhuman milk appeared to decrease HIV-1 infectivity of themilk. Pasteurization of human milk, including using devicesthat can be used in a home setting, can decrease theinfectious titer HIV-1 .Use of any or all of thesemethodologies would not be feasible in many settings andmay not be culturally acceptable. Finally, with any treatmentto inactivate HIV-1, the extent to which the treatmentdiminishes the protective or nutritionalcomponents ofhuman milk must be carefully assessed


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Maternal Antiretroviral Therapy

Several studies in Africa are planned to

evaluate antiretroviraltherapy for HIV-1-infected women during breastfeeding for

theprevention of breastfeeding

transmission of HIV-1.


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POTENTIAL INTERVENTIONS TO PREVENT BREAST

FEEDING TRANSMISSION OF HIV-1 (contd)

Preventing or Treating Maternal Breast

Abnormalities and Infant CandidiasisRecommendation: HIV-infected women who

breastfeed should be assisted to ensure that

they use a good breastfeeding technique to

prevent these conditions

Avoiding Mixed Breastfeeding


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Antiretroviral Prophylaxis to Breast

feeding Infants

Extended-dose nevirapine to 6 weeks of

age for infants to prevent HIV transmission

via breastfeeding in Ethiopia, India, andUganda: an analysis of three randomised

controlled trials

The Lancet2008; 372:300-313


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RESULTS

Although a 6-week regimen of daily

nevirapine might be associated with areduction in the risk of HIV transmission at6 weeks of age, the lack of a significant

reduction in the primary endpointrisk ofHIV transmission at 6 monthssuggeststhat a longer course of daily infantnevirapine to prevent HIV transmission via

breast milk might be more effective whereaccess to affordable and safe replacementfeeding is not yet available and where therisks of replacement feeding are high.


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Antiretroviral Prophylaxis to

Breastfeeding Infants (contd)

A trial, called the Post-Exposure Prophylaxis of Infants

(PEPI) trial, recently concluded in Malawi. Its aim

was to determine whether extended prophylaxis of

infants with nevirapine or with nevirapine pluszidovudine until the age of 14 weeks (when the

infant immunization schedule is completed in

Malawi) would decrease the rate of HIV-1 infection,

as compared with single-dose nevirapine combined

with 1 week of zidovudine (control regimen).


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Results

Among 3016 infants in the study, the controlgroup had consistently higher rates of HIV-1

infection from the age of 6 weeks through 18

months. At 9 months, the estimated rate ofHIV-1 infection (the primary end point) was

10.6% in the control group, as compared

with 5.2% in the extended-nevirapine group

(P


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Results (contd)

There were no significant differences inefficacy between the two extended-prophylaxis groups. However, seriousadverse events (primarily neutropenia)

that were possibly related to a study drugwere more frequent in the extended-dual-prophylaxis group. Whether the two-drugregimen would reduce the risk ofresistance to nevirapine among infantswho become infected with HIV-1 despiteextended prophylaxis is beinginvestigated.


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Conclusions

Extended prophylaxis with nevirapine

or with nevirapine and zidovudine for

the first 14 weeks of life significantly

reduced postnatal HIV-1 infection in 9-

month-old infants.

NEJM Volume 3 JULY 10,2008 59:119-129Number 2


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Cessation of breastfeeding

There are concerns about the possibleincreased risk of HIV transmission with

mixed feeding during the transition period

between exclusive breastfeeding and

complete cessation of breastfeeding.

Indirect evidence on the risk of HIV

transmission through mixed feeding,

suggests that keeping the period oftransition as short as possible may reduce

the risk.


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Cessation of breastfeeding (contd)

Shortening this transition period however may

have negative nutritional consequences for the

infant, psychological consequences for the infant

and the mother, and expose the mother to therisk of breast pathology which may increase the

risk of HIV transmission if cessation of

breastfeeding is not abrupt.

The best duration for this transition is not knownand may vary according to the age of the infant

and/or the environment.


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WHO Recommendation:

HIV-infected mothers who breastfeed

should be provided with specific

guidance and support when theycease breastfeeding to avoid harmful

nutritional and psychological

consequences and to maintain breasthealth.


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Effects of Early, Abrupt Weaning on HIV-free

Survival of Children in Zambia(NEJM Volume 359:130-141JULY 10,2008 Number 2)

A randomized trial was conducted to

evaluate whether abrupt weaning at 4

months as compared with the standard

practice has a net benefit for HIV-free

survival of children.


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Methods- 958 HIV-infected women and their

infants were enrolled. All the women planned to

breast-feed exclusively to 4 months; 481 were

randomly assigned to a counselling program thatencouraged abrupt weaning at 4 months, and

477 to a program that encouraged continued

breast-feeding for as long as the women chose.

The primary outcome was either HIV infection ordeath of the child by 24 months


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Results

In the intervention group, 69.0% of themothers stopped breast-feeding at 5

months or earlier; 68.8% of these women

reported the completion of weaning in lessthan 2 days. In the control group, the

median duration of breast-feeding was 16

months. In the overall cohort, there was no

significant difference between the groups in

the rate of HIV-free survival among the

children.


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Results (contd)

Among infants who were still being breast-fed and were not infected with HIV at 4months, there was no significant

difference between the groups in HIV-freesurvival at 24 months .Children who wereinfected with HIV by 4 months had ahigher mortality by 24 months if they had

been assigned to the intervention groupthan if they had been assigned to thecontrol group.


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Conclusions

Early, abrupt cessation of breast-

feeding by HIV-infected women in a

low-resource setting, such as Lusaka,Zambia, does not improve the rate of

HIV-free survival among children born

to HIV-infected mothers and isharmful to HIV-infected infants.


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Conclusions (contd)

Early cessation of breast-feedinghas

substantial programmatic costs,

including the provision

of breast-milksubstitutes, and carries risks that are

difficultto quantify, including the

disclosure of HIV status,stigmatization andincreased fertility.


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ANTIRETROVIRAL DRUGS FORANTIRETROVIRAL DRUGS FOR

TREATING PREGNANTTREATING PREGNANT

WOMEN ANDWOMEN ANDPREVENTING HIV INFECTIONPREVENTING HIV INFECTION

IN INFANTSIN INFANTSIN RESOURCE-LIMITEDIN RESOURCE-LIMITED

SETTINGSSETTINGS

WHOWHOrecommendations(2006recommendations(2006))


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3 Subdivisions3 Subdivisions

1.1. ARV prophylactic regimens forARV prophylactic regimens for

preventing HIV infection in infantspreventing HIV infection in infants

among women seen duringamong women seen during

pregnancypregnancy2.2. Women living with HIV who are inWomen living with HIV who are in

labour and who have not receivedlabour and who have not received

ARVARV

prophylaxisprophylaxis

3.3. Infants born to women living withInfants born to women living with

HIV who have not received ARVHIV who have not received ARV

drugs duringdrugs during

ARV prophylactic regimens forARV prophylactic regimens for


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ARV prophylactic regimens forARV prophylactic regimens forpreventing HIV infection in infantspreventing HIV infection in infants

amongamong

women seen during pregnancywomen seen during pregnancyRecommendationsRecommendations

Among women who do not have indicationsAmong women who do not have indications

for ART,for ART, prophylactic regimenprophylactic regimenconsists ofconsists of

AZT starting from 28 weeks of pregnancy (orAZT starting from 28 weeks of pregnancy (oras soon as possible thereafter); AZT and 3TCas soon as possible thereafter); AZT and 3TC

+ Sd-NVP intrapartum; and AZT and 3TC+ Sd-NVP intrapartum; and AZT and 3TC

postpartum for seven days for women, andpostpartum for seven days for women, and

for infants Sd-NVP and AZT for one weekfor infants Sd-NVP and AZT for one week(Level A-I recommendation).(Level A-I recommendation).

3-TC - Lamivudine


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RecommendationsRecommendations (contd)(contd)

The NVP dose can be given to an infant upto 72The NVP dose can be given to an infant upto 72

hours after childbirth but should preferably behours after childbirth but should preferably begiven as soon as possible after delivery (Levelgiven as soon as possible after delivery (Level

A-II recommendation)A-II recommendation)

If the mother receives less than four weeks ofIf the mother receives less than four weeks of

AZT before delivery, the AZT dose for the infantAZT before delivery, the AZT dose for the infant

should be extended to four weeks (Level A-Ishould be extended to four weeks (Level A-I

recommendation)recommendation)

When delivery occurs within two hours of aWhen delivery occurs within two hours of a

woman taking Sd-NVP, the infant should receivewoman taking Sd-NVP, the infant should receive-Sd-NVP immediatel after deliver and AZT for


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Women living with HIV who are in labourWomen living with HIV who are in labour

and who have not received ARVand who have not received ARV

prophylaxisprophylaxis

RecommendationsRecommendations Intrapartum Sd-NVP + AZT and 3TC;Intrapartum Sd-NVP + AZT and 3TC;

postpartum AZT and 3TC given to thepostpartum AZT and 3TC given to thewoman for seven days, plus for the infantwoman for seven days, plus for the infant

Sd-NVP immediately after delivery andSd-NVP immediately after delivery andAZT for four weeks (Level A-IAZT for four weeks (Level A-Irecommendation)recommendation)

If delivery is expected imminently, the NVPIf delivery is expected imminently, the NVP

dose for the mother should be omitted,dose for the mother should be omitted,and the same recommendations andand the same recommendations andconsiderations apply as for infants born toconsiderations apply as for infants born towomen living with HIV who do not receivewomen living with HIV who do not receive

antenatal or intrapartum ARV prophylaxis.antenatal or intrapartum ARV prophylaxis.


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Infants born to women living with HIVInfants born to women living with HIV

who have not received ARV drugs duringwho have not received ARV drugs during

pregnancy or labourpregnancy or labour

RecommendationsRecommendations Sd-NVP immediately after delivery and AZT forSd-NVP immediately after delivery and AZT for

four weeks are recommended for infants bornfour weeks are recommended for infants bornto women living with HIV who do not receiveto women living with HIV who do not receive

any ARV prophylaxis,because this regimenany ARV prophylaxis,because this regimenresults in a greater reduction in transmissionresults in a greater reduction in transmissionthan just Sd NVP for the infant. (Level A-IIIthan just Sd NVP for the infant. (Level A-IIIrecommendation).recommendation).

ARV prophylaxis for infants born to womenARV prophylaxis for infants born to womenliving with HIV who had not received antenatalliving with HIV who had not received antenatalor intrapartum ARV prophylaxis should beginor intrapartum ARV prophylaxis should beginimmediately after delivery or within 12 hoursimmediately after delivery or within 12 hours

after delivery, if possible. (Level A-IIIafter delivery, if possible. (Level A-III


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Hope-giving treatment - PPTCT

Programme in India

This new treatment for the prevention of parentto child transmission (PPTCT) is an importantcomponent of the Indian governments AIDScontrol programme. The National AIDS ControlOrganisation (NACO) has already extended thisprogramme to 235 centres located in medicalcolleges and district hospitals across thecountry. It is a simple treatment: a 200 mg pill is

given to the mother during labour and a spoonfulof syrup to the baby(2mg/Kg) within 72 hours ofbirth.


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PPTCT (contd)

UNICEF support begins right at the start ofthe programme, helping train a five-member team at each of the designated

PPTCT centres. The team consists of agynaecologist, a paediatrician, amicrobiologist, a counsellor and a staffnurse. At the end of training, the teams

hold workshops in their respectivehospitals to help initiate the programme.


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Counselling is the key Counsel about HIV testing in pregnancy

Counsel about proper and regular antenatal

treatment

Counsel about feeding options

Counsel about breast feeding technique

Counsel about cessation of breast feeding -duration and rapidity


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hiv and breast feeding. speaker- dr nishant verma

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