Session-16-HIV-and-Replacement-Feeding-revised-2012.ppt

HIV and
Replacement Feeding
Adapted from :
WHO Infant and Young Child Feeding Counseling:
An Integrated Course

At the end of the session the participants
will be able to:
1. Discuss the importance of counseling HIV
positive women on infant feeding options;
2. Discuss the benefits of BF to newborns and to
mother
3. Enumerate the different factors associated
with HIV transmission through BF
4. Identify the recommended feeding options for
different scenarios
5. Discuss how to stop BF
6. Determine the feeding options after cessation
of BF

Global
summary
of the
HIV/AIDS
epidemic
Western Europe
520,000 – 680,000
North Africa & Middle
East
470,000 – 730,000
Sub-Saharan Africa
27.0 – 29.2 million
Eastern Europe
& Central Asia
1.2 – 1.8 million
South &
South-East Asia
5.6 – 9.2 million
Australia
& New Zealand
12,000 – 18,000
North America
790,000 – 1.2 million
Caribbean
350,000 – 590,000
Latin America
1.3 – 1.9 million
East Asia & Pacific
800,000 – 1.3 million
Adults and children estimated to be living with HIV and AIDS
as of end of 2011 Total: 33 (32.6 – 38.1) million
HIV & AIDS Situationer
Office of the WHO Representative in the Philippines

Is HIV Problem in the Philippines Real?
The Current HIV
Situation

63 countries reported.
The Philippines is
one of only 7countries
with increasing HIV cases

HIV Situation in the
Philippines
Estimated number of People
living with HIV 2011 (15-49 yr
old): 19,022
7,884 cumulative cases reported
(1984 – 2011)
By 2015, estimated HIV
population: 35,941

5yrs ago: 210 new cases/yr
This year: 1500 new cases
In 5yrs: 9,800 new cases/yr
Total: 35,000 PLHIV

DEMOGRAPHIC FIGURES 1984-2012
Demographic Data January 2012 Cumulative Data: 1984- 2012
Total Reported Cases 212 8,576
Asymptomatic Cases 208 7,601
AIDS Cases 4 975
Males 203 7,093
Females 9 1,472
Youth 15-24yo 57 1,974
Children < 15yo 1 59
Reported Deaths due to
AIDS
1 342

Sentinel
Sites
Baguio City
Angeles City
Quezon City
Pasay City
Iloilo City
Cebu City
Cagayan de Oro City
Davao City
Gen. Santos City
Zamboanga City
In 2007…
National adult HIV
prevalence = 0.0168%
Estimated Number of
PLHIV: 7,490
in 2009…
10x increase!

Treatment Hubs 13 (+ 3)
Gov. Celestino Gallares
Mem Hosp (VII)
Jose B. Lingad
Memorial Medical
Center (III)
Cagayan Valley
Medical Center (II)
Makati Med Cntr
The Medical City

Results
• HIV epidemic in the Philippines
expanding
• 10x increase in the number of HIV +
cases
• Evidence of rapid growth rate in some
geosites, among specific most-at-risk
groups (MSM and PWID)
• NO Most-at-risk group is off the hook
• 50% of infection transmitted in the past 5
months (BED Assay)

2009: TWO new cases a day!
Average Number of Cases per Month
2007: One new case a day
2000: One new case every
3 days
N A T I O N A L E P I D E M I O L O G Y C E N T E R
2011 : 5-6 new cases a day!

HIV Transmission
• Exchange of HIV-infected body fluid such as
semen, vaginal fluid or blood during unprotected
sexual intercourse
• HIV-infected blood transfusions
• Percutaneous (contaminated needles or other
sharp instruments) or mucous membrane exposure
to contaminated blood and other body fluids
• Mother to Child Transmission (MTCT) during
pregnancy, labor and delivery Breastfeeding

TRANSMISSION
Transmission Risk:
 Unprotected vaginal intercourse M to F 0.1%
 Unprotected vaginal intercourse F to M 0.05%
 Unprotected anal intercourse 0.56%
 Needle share/ IV drug use 67%
 Needle stick 0.3%
 Mother to child transmission 13-48%
 Blood products 90%
MMWRJanuary 21, 2005 / 54(RR02);1-20adapted

TREATMENT: Drugs to treat HIV
 Antiretroviral drugs or ARVs
 use to reduce the amount of HIV in the body
 given at the end of pregnancy and at the time of
delivery
 Combination antiretroviral therapy has been
shown to be more effective than monotherapy (3
drugs given whenever possible)
 Drugs
 azidothymidine (AZT)
 zidovudine (ZDV)
 nevirapine

Philippine HIV/AIDS Registry
January 1984-Nov 2011 (N= 8,096)
Reported modes of Transmission cases
Sexual Transmission/Contact 7,408
Blood/Blood products 20
Injecting drug use 235
Needle prick injuries 3
Mother-to-Child 55
No Data Available 375

Mother-To-Child Transmission
(MTCT) of HIV
Young children who get HIV are usually
infected through their mother
- during pregnancy across the placenta
- at the time of labour and birth through
blood and secretions
- through breastfeeding
17/3

Estimated risk and timing of MCTC
transmission of HIV in the absence of interventions
Timing of MTCT of HIV Transmission Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
_____________________________________________________________________
Overall without breastfeeding 15-25%
Overall with breastfeeding to 6 months 20-35%
Overall with breastfeeding to 18–24 months 30-45%
17/4

Assume prevalence of
HIV infection among
women in the area is
20 %
Q. How many of these
women are likely to be
HIV-positive ?
100 mothers and babies

Of the 100 mothers and babies
(Only 20 mothers may have HIV)
17/6
++ + + +
+ + +
++ + +
+ + + + +
+ + +
If the prevalence of HIV infection is 20%, 20% of 100 = 20

The MCTC during
pregnancy is 15-25%
(Using 25%) ,
how many of these
infants were infected
before or during
delivery ?
20 mothers are likely to be HIV positive
________________________________________________
++ + + +
+ + +
+++ +
+ + + + +
+ + +

Of the 20 mothers who may have the HIV...
ONLY 5 infants are likely to be infected during pregnancy and
delivery
17/6
+
+ + + +
+ + +
++ + +
+ + + + +
+ + +
25% of 20 = 5

The transmission rate
during breastfeeding is
5-20% …
(using 15%) , assuming
all babies are breastfed
how many will be
infected ?
20 mothers who are likely to be HIV positive
________________________________________________
++ + + +
+ + +
+++ +
+ + + + +
+ + +

100 mothers and babies
Only 20 mothers may have HIV
(About 3 of the infants of HIV positive mothers are likely to be infected by
breastfeeding)
17/6
++ + + +
+ + +
++ + +
+ + + + +
+ + +
15% of 20 = 3

Factors which affect
mother-to-child transmission of HIV
Recent infection with HIV
Severity of disease
Sexually transmitted infections
Obstetric procedures
Duration of breastfeeding
Exclusive breastfeeding or mixed feeding
Condition of the breasts
Condition of the baby’s mouth
17/13

Recent infection with HIV
Woman infected with HIV during
pregnancy or while breastfeeding
 higher levels of virus in her blood
 infant is more likely to be infected
Unprotected extramarital sex exposes
men to infection with HIV

Severity of HIV infection
Mother is ill with HIV-related disease or
AIDS
Mother not treated with drugs
More virus in the body
= Transmission to the baby is more likely

Duration of breastfeeding
Virus can be transmitted any time
during breastfeeding
The longer the duration of
breastfeeding, the greater the risk of
transmission

Exclusive breastfeeding or mixed feeding
Risk of transmission is greater if
infant given any other foods or drinks
Risk is less if exclusive breastfeeding
Other foods may cause diarrhea and
damage the gut

Condition of the breasts
Nipple fissure, mastitis or breast
abscess may increase risk of HIV
transmission
Good breastfeeding technique helps
• prevent these conditions
• reduce transmission of HIV
Condition of the baby’s mouth
• Mouth sores or thrush may enter the
damaged skin

1. Mothers known to be HIV-infected and whose
infants are HIV uninfected or of unknown HIV status.
• This infant feeding option can be observed in the following
situations:
• The mother was started on ARV treatment.
• The mother received zidovudine (AZT) as prophylaxis
during pregnancy and that the baby will be given daily
dose of nevirapine up to 1 week after all exposure to
breastmilk has ended.
• (Dose of Nevirapine (once daily): Birth-6weeks if
<2,500gm – 10mg , if > 2,500 gm – 15 mg ; > 6
weeks-6 months – 20mg; >6-9months – 30mg ;
>9months to end of breastfeeding – 40mg)

2. Mothers known to be HIV infected with an
HIV positive child
• Since the child is already known to be (+),
preventing transmission is no longer a
concern in determining the appropriate
feeding option.
• For this scenario, the best feeding option is
exclusive BF for 6 months and continue BF
up to 12 months of age

Counselling for infant feeding
in relation to HIV
Pregnant or recently-delivered woman
in contact with the health services
Unknown
HIV status
Tested
negative
Tested
positive
Encourage
testing
Counsel and
encourage
breastfeeding
Counsel on
infant feeding
Discuss all
options
available
18/2

• a. safe water and sanitation are assured
at the household level and in the
community
• b. the mother, or other caregiver can
reliably provide sufficient infant formula
milk to support normal growth and
development of the infant
CONDITIONS when to give
Replacement Feeding to infant with
HIV:

c the mother or caregiver can prepare it
cleanly and frequently enough so that it
is safe and carries a low risk of diarrhoea
and malnutrition.
d. the mother or caregiver can, in the
first six months, exclusively give infant
formula milk

• d. the mother or caregiver can, in the
first six months, exclusively give infant
formula milk
• e. the family is supportive of this
practice
• f. the mother or caregiver can access
health care that offers comprehensive
child health services.

• These descriptions are intended to
give simpler and more explicit
options and meaning to the concept
of AFASS (acceptable, feasible,
affordable, sustainable, safe)

Infant feeding options from
0-6 months
for HIV-positive women
Infant feeding options from 0-6 months
Replacement feeding
when requirements
are fulfilled
• Commercial infant
formula
• Home modified
animal milk with a
micronutrient
supplement
Exclusive
breastfeeding
Other breast-milk
options:
• Expression and heat-
treatment
• [Milk banks]
Early cessation
when RF
requirements
are fulfilled
18/3

ADVANTAGES of Exclusive
breastfeeding for an HIV-infected mother
Breast milk is the perfect food for babies
- complete nutrition including water
- no need for any liquid or food
Breast milk gives protection against
common childhood infections, especially
diarrhea and pneumonia
Breast milk is free, always available and
does not need any special preparation

Advantages of exclusive breastfeeding for
an HIV-infected mother
Exclusive breastfeeding reduces
the risk of HIV transmission,
compared to mixed feeding
Exclusive breastfeeding helps
mothers recover from childbirth
and protects them from getting
pregnant too soon

DISADVANTAGES of exclusive
breastfeeding for an HIV-infected mother
As long as the mother breastfeeds, her
baby is exposed to HIV
People may pressure mother to mix feed
which increases the risk of HIV and other
infections
Mother will need support to exclusively
breastfeed until it is possible for her to
use another feeding option

Early cessation of breastfeeding
Reduces the risk of HIV transmission
- by reducing the length of time the
infant is exposed to the virus in breast
milk
- for HIV+ = 12 months is maximum
length of time to breastfed; whereas for
healthy babies continue up to 2 years

Early cessation of breastfeeding
Mothers may consider other breast milk
substitute such as expressing and heat-
treating breast milk from six months
onwards

How to stop breastfeeding
• HIV infected mothers who decided to stop BF
at any time should discontinue it gradually
within a month.
• Infants who are receiving prophylaxis (daily
Nevirapine) should continue taking the drugs
up to one week after the cessation of
breastmilk exposure.
• For HIV infected mothers who decided to stop
BF, the health provider must counsel them on
other infant feeding alternatives.

Breastfeeding by another
woman who is HIV-negative
Wet nursing – a woman breastfeeding
a baby to whom she did not give
birth
Donor breast milk – milk expressed by
another woman for another baby

Pointers about wet-nursing
A woman breastfeeding another infant
need to have sufficient rest, food and
water
Baby’s own mother should provide as
much care as possible to the child by
cuddling, changing, washing, massaging,
and giving other foods

Pointers about wet-nursing
To protect the baby from HIV, wet-nurse
must be HIV-negative
Wet-nurse should protect self from HIV
infection the entire time she is breastfeeding
• Not having sex or using condom
• Have sex with only one partner who is
also faithful to her
• Not sharing razors, needles or other
piercing objects

Heat-treated expressed milk
Heat-treated breast milk is another option to
consider if
• Mother wishes to give her baby her own
milk
• Alternative milks are too expensive
• Sick or low-birth-weight infants are more
at risk from artificial feeding

Heat-treated expressed milk
Heat-treatment destroys HIV in breast milk
Heat-treatment reduces the level of some
anti-infective components of breast milk
Heat-treated milk remains superior to
breast-milk substitute

HOW to heat-treat and store breast milk
Before heating gather the following
Clean containers with wide necks and
covers, enough to store the milk
A small pot to heat the milk
A large container of cool water
A small cup for feeding the baby
Fuel to heat the milk
Soap and clean water to wash the
equipment

How to heat-treat and store breast milk
Follow these steps
- Wash all the pots, cups and containers with soap
and water
- Only heat enough expressed milk for one feed
- Place container with breastmilk inside a wider
pot with boiling water . When the breastmilk is
rolling boil, remove and
- Place the pot in a container of cold water so
that it cools quickly or let the milk stand until it
cools
- Store the boiled milk in clean, covered container

1. ADVANTAGES
 Giving only formula carries no risk of
transmitting HIV to the baby
 Most of the nutrients a baby needs have
already been added to the formula.
 Other responsible family members can
help feed the baby.
ADVANTAGES AND DISADVANTAGES OF
COMMERCIAL INFANT FORMULA

II. DISADVANTAGES of artificial formula
Formula does not contain antibodies that
protect a baby from infections.
A formula-fed baby is more likely to get
seriously sick from diarrhoea, chest
infections and malnutrition, especially if the
formula is not prepared correctly.
A mother should stop breastfeeding
completely or the risk of transmitting HIV
will continue.

People may wonder why a mother is
using formula instead of breastfeeding,
and this could cause them to suspect
she is HIV- positive.
Mother needs fuel, clean water, utensils,
soap etc.
Time consuming
Expensive
Have to teach baby to drink from cup
Mom may get pregnant soon
DISADVANTAGES OF COMMERCIAL FORMULA

Summary
If a mother who is HIV-positive decides to
breastfeed as the best option, she should
be supported to establish and maintain it
If a mother breastfeeds, she should make
sure that her infant is well-attached to the
breast, to prevent nipple fissure and
mastitis, which may increase the risk of
transmission of HIV

Summary
A mother who is HIV-positive should
breastfeed exclusively, no other foods or
fluids
Other breast milk options include :
exclusive breastfeeding and stopping early,
expression, and heat-treatment of breast
milk

“HIV-infected mothers should receive
counselling which includes provision of
general information about the risks and
benefits of various infant feeding
options, and specific guidance in
selecting the option most likely to be
suitable for their situation. Whatever a
mother decides, she should be
supported in her choice”
WHO 2010 Guideline on HIV and Infant Feeding

CASE STUDY NO. 1
• Marian, 28 year old HIV positive
woman, has delivered a baby boy.
During her pregnancy, she was given
AZT as early as 28 weeks of pregnancy.
• As part of post-delivery counseling,
what advice will you give to Marian on
infant feeding?

• During post-delivery counseling, the health provider should
encourage Marian to BF her baby exclusively provided that the
baby will be given daily dose of nevirapine.
• The health provider can explain to Marian that there is risk of
transmission of the HIV virus through BF. However, this risk can
be reduced by providing ARV prophylaxis to her baby since she
has already taken AZT during pregnancy.
• The health provider should also advise her that in case she
would stop BF for whatever cause, daily dose of nevirapine
taken by the baby can only be discontinued one week after the
cessation of BF

CASE STUDY NO. 2
• Helen, 32 year old positive woman that is on
zidovudine, lamivudine and nevirapine, came
to your clinic as part of her antenatal check
up. She is pregnant at 37 weeks age of
gestation. She asked you as her attending
physician if she can breastfeed her baby right
after delivery. Helen said that she has
browsed the internet and found out that HIV
can be transmitted through breast milk.
• What advice will you give to Helen regarding
her concerns?

• The health provider can explain to Helen that
there is risk of transmission of HIV to the
baby because the HIV virus in CD4 cells is
present in breast milk.
• However, antiretroviral drugs can reduce
the risk of transmission.
• The health provider can assure Helen that
she can breastfeed her baby after delivery as
long as she will continue taking her
antiretroviral drugs.

CASE STUDY NO. 3
• Micah, 26 year old woman, is breastfeeding her
4 month old baby when she found out that she
is HIV positive. She submitted herself and her
3 month old baby to HIV testing after the result
of the HIV test of her husband turned out to be
positive. Her baby also turned out to be
positive. During post HIV test counseling,
Micah asked if she can still continue
breastfeeding her baby.
• How will you advise Micah regarding her
concerns.

• Since both Micah and her baby are known to be HIV
positive, risk of transmission is no longer a major
concern.
• In this case, the health provider can advise Micah to
continue breastfeeding exclusively up to 6 months
and at six months, introduce complementary foods.
• Breastfeeding can be continued like the
recommendation for the general population which is
up to 2 years of age.

Session-16-HIV-and-Replacement-Feeding-revised-2012.ppt

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