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Positively Breastfeeding
1. POSITIVELY
BREASTFEEDING:of HIV
A descriptive study of the MTCT
following the implementation of WHO
2010 breastfeeding guidelines in Haiti
Jordan Dozier, MD
Keisha Bonhomme, MD
2. Objectives
To describe the possible risk of HIV
transmission in pediatric patients
breastfed by HIV-infected mothers from
2008-2012
To discuss how the implementation of the
WHO 2010 breastfeeding guidelines have
been received in other resource limited
countries.
3. BACKGROUND
Breastfeeding involves considerable risk of HIV
transmission
Risk of MTCT without breastfeeding is 15-25% in mothers not
on ARV prophylaxis
Risk increases 5-20% to a total of 20-45%
Cumulative effect
However, not breastfeeding in resource-limited settings
present considerable risk to infant survival
According to the MASHI study conducted by Lockman et al.
breastfeeding in comparison to breast-milk substitutes reduces
infant morbidity and mortality associated with infectious
diseases, i.e. diarrhea
4. BACKGROUND
WHO breastfeeding guidelines over the years:
2001- when replacement feeding is AFASS HIV-infected mothers
should avoid breastfeeding; otherwise exclusive breastfeeding
for the first few months of life is recommended.
2006- guidelines updated to more strongly communicate need
for implementation of exclusive breastfeeding
2009- guidelines updated to incorporate recent evidence of ARV
role in decreasing MTCT
2010- guidelines updated to include recommendations whose
objective is to balance HIV prevention with protection from
other causes of child mortality
5. BACKGROUND
Theory into Action!
A study conducted between 2003 – 2007 by
Homsy et al in rural Uganda looked at the effect
HAART had on MTCT in the context of EBF.
Out of 118 infants born, 114 of which had at least
one PCR test conducted and 93% of which were
exclusively breastfeeding, there were ZERO cases
of MTCT transmission.
There was however a 19% mortality rate in this
cohort. (>65% due to gastroenteritis)
Important to note however was that there was a SIX
FOLD increase risk of death associated with early
weaning (< 6 months)
6. METHODS
Criteria:
Four sites were chosen from a national database
solely consisting of pediatric patients. Only sites with
greater than 150 patients were included.
Patients who received two or more PCR tests with
documented results were further assessed. Amongst
those patients the following data were observed:
Conversion vs Non-conversion
Delay in days between each test (Mean, Range)
7. METHODS
Database of 794 GHESKIO HIV-exposed pediatric
patients and 911 tests from 2008-2012
Database of HIV-exposed pediatric patients from
2010-2012
St. Damien (244 pts / 294 tests)
Cayes (218 pts / 237 tests)
Cap Haitien (159 pts / 177 tests)
Patient demographics did not include information on
infant age, breastfeeding compliance or maternal ART
compliance
8. RESULTS
Site # pts with ≥ 2 tests Mean delay between
tests (range)
GHESKIO 113 130.8 (1 to 549 days...)
St Damien 49 115.5 (11 to 362 days)
Cayes 18 147 (21 to 250 days)
Cap Haitien - Justinien 18 173 (21 to 407 days)
9. RESULTS
In total, there were two patients who had a change in
HIV status from Negative to Positive:
One from GHESKIO (delay: 529 days)
One from St. Damien (delay: 144 days)
There were no conversions noted from Positive
Negative, reflecting the sensitivity of PCR testing
There were 11 patients who had tests repeated but
results were not available at the time of this analysis
10. CONCLUSIONS
All conclusions are made under the presumption
that HIV+ mothers have been compliant with
both their ART treatment as well as have
exclusively breastfed their children.
Given the observed occurrence of two conversions
out of 1415 patients, the risk of transmission
may be minimal in ARV compliant mothers who
breastfeed.
However, further assessment of the benefits
involved with breastfeeding is needed to
conclusively determine if the national
recommendation has had a positive effect on the
morbidity and mortality of infants in Haiti.
11. DISCUSSION
Possible Confounders
GHESKIO culture vs. General practice throughout Haiti
Maternal ART compliance
Breastfeeding compliance within the context of cultural
change
How to improve compliance?
Decrease availability of free formula (nationally) in
hopes of reducing the common practice of mixed
feeding
Prospective, controlled study needed to draw
definitive conclusion
12. DISCUSSION cont’d
Home Visits?
Study in Uganda showed that home-based peer
counseling improved levels of exclusive breastfeeding
Mothers appreciated non-dogmatic, non-didactic
approach of peer-counselors (71%) vs health-care
worker (16%)
Women felt empowered by lessons learned and
justified in decision to refuse old formula feeding
practices
13. DISCUSSION cont’d
Standardized counseling sessions?
Weakness in success of PMTCT programs is the
continuous change of policy framework
In a study conducted by Doherty et al in South Africa,
poor quality of counseling, unclear counselor
messages and availability of free formula provided
incentive to choose formula
Partner involvement; in a study conducted by Moland
et al modifications to infant feeding were shown to be
highly dependent upon male support in some settings
14. References
Becquet R, Bland R, Ekouevi D. Universal antiretroviral therapy among pregnant and
postpartum HIV-infected women would improve maternal health and decrease
epostnatal HIV transmission. AIDS. 2010; 24:8.
Doherty T, Sanders D, Goga A, Jackson D. Implications of the new WHO guidelines
on HIV and infant feeding for child survival in South Africa. Policy and Practice. 2011;
89:62-67.
Homsy J, Moore D, Barasa A, et al. Breastfeeding, Mother-to-Child HIV
Transmission, and Mortality Among Infants Born to HIV-Infected Women on Highly
Active Antiretroviral Therapy in Rural Uganda. J Acquir Immune Defic Syndr.
2010;53:1
Lutter C, Daelmans B, Onis M, et al. Undernutrition, Poor Feeding Practices, and Low
Coverage of Key Nutrition Interventions. PEDIATRICS. 2011; 128;e1418
Moland k, Paoli M, Sellen D, et al. Breastfeeding and HIV: experiences from a
decade of prevention of postnatal HIV transmission in sub-Saharan Africa.
Internaional Breastfeeding Journal. 2010; 5:10
Nankunda J, Tumwine J, Nankabirwa V, Tylleskar T. “She would sit with me":
mothers’ experiences of individual peer support for exclusive breastfeeding in
Uganda. International Breastfeeding Journal. 2010; 5:16
Parela D, Blanda R, Hoosen C, et al. Breastfeeding, HIV status and weights in South
African children: a comparison of HIV-exposed and unexposed children. AIDS 2010,
24:437–445
Saloojee H, Gray G, McIntyre J A. OPINION: HIV and infant feeding – one step
forward, two steps back. The Southern African Journal of HIV Medicine. Dec. 2011.