Hiv And Breast Feeding. Speaker- Dr Nishant Verma

HIV and Breast Feeding

RISKS

Once an HIV positive mother delivers a baby the risk of transmission through breast-milk is about 15 per cent.

RISK FACTORS FOR BREASTFEEDING TRANSMISSION OF HIV-1 Category

Risk factor

Duration of breastfeeding

Longer duration

Maternal characteristics

Younger age, Higher parity ,Lower CD4+ count, Higher peripheral blood viral load, Breast abnormalities, Breast abscess, Mastitis ,Nipple lesions

Infant characteristics

Oral candidiasis

Human milk characteristics

Higher viral load, Lower concentrations of antiviral substances (eg, lactoferrin, lysozyme, SLPI, epidermal growth factor), Lower concentration of virusspecific cytotoxic T-lymphocytes,Lower secretory IgA,Lower IgM

Exclusivity of breastfeeding

Mixed breastfeeding

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 .

WHO recommendations for breastfeeding and replacement feeding (2000) contd… • To minimize HIV transmission risk, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV and malnutrition).

WHO recommendations for breastfeeding and replacement feeding (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 child’s life to ensure adequate replacement feeding. Programmes should strive to improve conditions that will make replacement feeding safer for HIV-infected mothers and families.

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 expressed human milk appeared to decrease HIV-1 infectivity of the milk. Pasteurization of human milk, including using devices that can be used in a home setting, can decrease the infectious titer HIV-1 .Use of any or all of these methodologies would not be feasible in many settings and may not be culturally acceptable. Finally, with any treatment to inactivate HIV-1, the extent to which the treatment diminishes the protective or nutritional components of human milk must be carefully assessed

Maternal Antiretroviral Therapy Several studies in Africa are planned to evaluate antiretroviral therapy for HIV-1infected women during breastfeeding for the prevention of breastfeeding transmission of HIV-1.

POTENTIAL INTERVENTIONS TO PREVENT BREAST FEEDING TRANSMISSION OF HIV-1 (contd…)

• Preventing or Treating Maternal Breast Abnormalities and Infant Candidiasis Recommendation: HIV-infected women who breastfeed should be assisted to ensure that they use a good breastfeeding technique to prevent these conditions

• Avoiding Mixed Breastfeeding

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, and Uganda: an analysis of three randomised controlled trials

The Lancet 2008; 372:300-313

• RESULTS

Although a 6-week regimen of daily nevirapine might be associated with a reduction in the risk of HIV transmission at 6 weeks of age, the lack of a significant reduction in the primary endpoint—risk of HIV transmission at 6 months—suggests that a longer course of daily infant nevirapine to prevent HIV transmission via breast milk might be more effective where access to affordable and safe replacement feeding is not yet available and where the risks of replacement feeding are high.

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 plus zidovudine 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).

Results • Among 3016 infants in the study, the control group had consistently higher rates of HIV-1 infection from the age of 6 weeks through 18 months. At 9 months, the estimated rate of HIV-1 infection (the primary end point) was 10.6% in the control group, as compared with 5.2% in the extended-nevirapine group (P<0.001) and 6.4% in the extended-dualprophylaxis group (P=0.002).

Results (contd…) There were no significant differences in efficacy between the two extendedprophylaxis groups. However, serious adverse events (primarily neutropenia) that were possibly related to a study drug were more frequent in the extended-dualprophylaxis group. Whether the two-drug regimen would reduce the risk of resistance to nevirapine among infants who become infected with HIV-1 despite extended prophylaxis is being investigated.

• Conclusions Extended prophylaxis with nevirapine or with nevirapine and zidovudine for the first 14 weeks of life significantly reduced postnatal HIV-1 infection in 9month-old infants.

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

Cessation of breastfeeding • There are concerns about the possible increased 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 of transition as short as possible may reduce the risk.

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 the risk 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 known and may vary according to the age of the infant and/or the environment.

WHO Recommendation: • HIV-infected mothers who breastfeed should be provided with specific guidance and support when they cease breastfeeding to avoid harmful nutritional and psychological consequences and to maintain breast health.

Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia (NEJM Volume 359:130-141 JULY 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.

• 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 that encouraged 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 or death of the child by 24 months

Results • In the intervention group, 69.0% of the mothers stopped breast-feeding at 5 months or earlier; 68.8% of these women reported the completion of weaning in less than 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.

Results (contd…) • Among infants who were still being breastfed and were not infected with HIV at 4 months, there was no significant difference between the groups in HIV-free survival at 24 months .Children who were infected with HIV by 4 months had a higher mortality by 24 months if they had been assigned to the intervention group than if they had been assigned to the control group.

Conclusions • Early, abrupt cessation of breastfeeding 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 is harmful to HIV-infected infants.

Conclusions (contd…) • Early cessation of breast-feeding has substantial programmatic costs, including the provision of breast-milk substitutes, and carries risks that are difficult to quantify, including the disclosure of HIV status, stigmatization and increased fertility.

ANTIRETROVIRAL DRUGS FOR TREATING PREGNANT WOMEN AND PREVENTING HIV INFECTION IN INFANTS IN RESOURCE-LIMITED SETTINGS WHO recommendations(2006)

3 Subdivisions 1.

2.

3.

ARV prophylactic regimens for preventing HIV infection in infants among women seen during pregnancy Women living with HIV who are in labour and who have not received ARV prophylaxis Infants born to women living with HIV who have not received ARV drugs during

ARV prophylactic regimens for preventing HIV infection in infants among women seen during pregnancy Recommendations ► Among women who do not have indications for ART, prophylactic regimen consists of AZT starting from 28 weeks of pregnancy (or as soon as possible thereafter); AZT and 3TC + Sd-NVP intrapartum; and AZT and 3TC postpartum for seven days for women, and for infants Sd-NVP and AZT for one week (Level A-I recommendation). 3-TC - Lamivudine

Recommendations (contd…) ► The

NVP dose can be given to an infant upto 72 hours after childbirth but should preferably be given as soon as possible after delivery (Level A-II recommendation)

► If

the mother receives less than four weeks of AZT before delivery, the AZT dose for the infant should be extended to four weeks (Level A-I recommendation)

► When

delivery occurs within two hours of a woman taking Sd-NVP, the infant should receive Sd-NVP immediately after delivery and AZT for

Women living with HIV who are in labour and who have not received ARV prophylaxis

Recommendations ► Intrapartum

– Sd-NVP + AZT and 3TC; postpartum – AZT and 3TC given to the woman for seven days, plus for the infant Sd-NVP immediately after delivery and AZT for four weeks (Level A-I recommendation) ► If delivery is expected imminently, the NVP dose for the mother should be omitted, and the same recommendations and considerations apply as for infants born to women living with HIV who do not receive antenatal or intrapartum ARV prophylaxis.

Infants born to women living with HIV who have not received ARV drugs during pregnancy or labour Recommendations ► Sd-NVP immediately after delivery and AZT for four weeks are recommended for infants born to women living with HIV who do not receive any ARV prophylaxis,because this regimen results in a greater reduction in transmission than just Sd NVP for the infant. (Level A-III recommendation). ► ARV prophylaxis for infants born to women living with HIV who had not received antenatal or intrapartum ARV prophylaxis should begin immediately after delivery or within 12 hours after delivery, if possible. (Level A-III

Hope-giving treatment - PPTCT Programme in India • This new treatment for the prevention of parent to child transmission (PPTCT) is an important component of the Indian government’s AIDS control programme. The National AIDS Control Organisation (NACO) has already extended this programme to 235 centres located in medical colleges and district hospitals across the country. It is a simple treatment: a 200 mg pill is given to the mother during labour and a spoonful of syrup to the baby(2mg/Kg) within 72 hours of birth.

PPTCT (contd…) • UNICEF support begins right at the start of the programme, helping train a fivemember team at each of the designated PPTCT centres. The team consists of a gynaecologist, a paediatrician, a microbiologist, a counsellor and a staff nurse. At the end of training, the teams hold workshops in their respective hospitals to help initiate the programme.

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