Mother To Child Transmission (MTCT)/ Infant and Young Child Feeding
At the end of this section you will be provided with
references older than
2004.
NEW! AED, Linkages, USAID, REDSO/ESA.
Nutrition Job Aids: Regions with High HIV Prevalence. Academy for Educational
Development, The Linkages Project, The United States Agency for International
Development, Regional Economic Development Support Office for East and Southern
Africa. April 2005.
Click here for the document.
AED/ WHO. HIV and infant feeding counseling tools. The Academy for
Educational Development, Washington, DC, and World Health Organization, Geneva,
2005.
This document is an educational tool that arose from the meeting that took
place in Geneva in November 2004 in which the participant were invited by WHO
for an informal meeting. This course has been created to help health workers
trained in infant feeding counseling to support HIV-positive mothers.
Click here for the Pubmed Summary.
Becquet R, Leroy V, Ekouevi DK et al.
Complementary feeding adequacy in relation to nutritional status among early
weaned breastfed children who are born to HIV-infected mothers: ANRS 1201/1202
Ditrame Plus, Abidjan, Cote d’Ivoire. Pediatrics, 2006, 117(4): 701-710.
In resource-limited settings the prevention of vertical transmission of HIV
through breastmilk consists, according to actual guidelines, in exclusive
breastfeeding with early cessation. However in such settings where HIV
prevalence is high, this practice is currently questioned because it has
potential adverse effects and remain particularly complex as it exposes
children to risks of infections, wasting and stunting. In areas where
breastfeeding is widely practiced and usually prolonged until one year, the
risk for HIV-transmission through breastmilk is estimated to be 8.9 new cases
per 100 child-years of breastfeeding. There is some evidence that the benefits
associated with this practice have to be balanced with the potential risk for
HIV/AIDS in the infant. On the other hand, the appropriateness of
complementary feeding is often random and its nutrition adequacy and safety
cannot always be guaranteed. Therefore the purpose of this study was to
describe the nature and the ages of introduction of complementary feeding
among early weaned breastfed infants up to their first birthday. The authors
also wanted to assess nutritional adequacy of these complementary foods by
creating a child feeding index and to investigate its association with child
nutritional status. The authors conducted a prospective cohort study in
Abidjan, Côte d’Ivoire, among HIV-infected pregnant women who wanted to
breastfeed and had received a perinatal antiretroviral prophylaxis. To reduce
vertical transmission, mothers were advised to breastfeed exclusively and
initiate early cessation of breastfeeding. An index, ranging form 0 (poor) to
12 (adequate), was created to synthesize nutritional adequacy of infant
feeding practices. Among the 262 infants included, median duration of
breastfeeding was 4 months and complete cessation of breastfeeding occurred
for 77% of children at one year of age. Infant food and formula were
introduced at 4 months, and complementary foods were introduced within the
seventh months of life. Concerning the feeding index, the score showed a low
dietary diversity at 6 months, but was improved in the next months. Inadequate
complementary feeding at 6 months was associated with growth failure during
the next 12 months, with 37% increased probability of stunting. This study
provides useful knowledge on the issue concerning feeding practices around the
weaning period. This time frame seems crucial for achievement of optimal child
growth. Therefore the authors propose that HIV-infected women in resource
limited settings should turn to early cessation of breastfeeding only when
they are counselled about complementary feeding. The index used here could
help detecting children at risk of malnutrition and whose mothers need to
receive appropriate counseling.
Click here for Pubmed summary.
Bentley M, Corneli AL, Piwoz E et al.
Perceptions of the role of maternal nutrition in the HIV-positive breastfeeding
women in Malawi. The Journal of Nutrition. 2005, 135: 945-949.
This article addresses a neglected issue concerning how HIV-positive women
perceive their own bodies and thus how this perception influence their infant
feeding practices and their perceived ability to breastfeed exclusively
through 6 months. The authors conducted formative research to better
understand breastfeeding practices and perceptions. 22 HIV-infected women
living in semi rural areas were recruited. The authors used an adaptation of
the body silhouette methodology to assess women’s view of their preferred body
shape at present and during previous years, and the shape which they perceived
as healthy. They also explored the perception of participants' view to decide
whether 2 fictional women, with different body silhouettes, are able to
breastfeed. In this test, large body shapes were perceived as healthy and many
recognized the role of nutrition in achieving a preferred body shape. Some
women believed their nutritional status was declining while being ill. The
women believed that breastfeeding promoted HIV progression. This suggests that
current guidelines should focus on both mothers' and infants' health and
well-being.
Click here for Pubmed summary.
NEW! Chatterjee A, Bosch RJ, Hunter DJ et al.
Maternal disease stage and child undernutrition in relation to mortality among
children born to HIV-infected women in Tanzania. AIDS, 2007, 46(5): 599-606.
Click here for Pubmed summary.
Coovadia HM, Rollins NC, Bland RM et al.
Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding
in the first 6 months of life: an intervention cohort study. Lancet, 2007, 369:
1107–1116.
Exclusive breastfeeding is uncommon even if there is evidence that it is
better than other forms of infant feeding and is associated with improved
child survival. This non-randomised intervention cohort study aimed to assess
HIV transmission risks and survival associated with exclusive breastfeeding
and other type of infant feeding. 2722 HIV-infected and uninfected pregnant
women attending antenatal clinics in KwaZulu Natal in South Africa were
included in the study. All HIV-positive women received single dose of
neviparine after 28 weeks of gestation and all women were counselled
antenatally about infant feeding options. Feeding practice was recorded
weekly, and blood samples from infants were taken monthly to establish HIV
status. Transmission risks at 6 and 22 weeks of age was determined. 83% of
HIV-infected women initiated exclusive breastfeeding from birth. Median
duration of cumulative exclusive breastfeeding was 159 days. 14,1% (95% CI,
12,0-16,4) of exclusive breastfed infants were infected with HIV by 6 weeks of
age and 19,5% (95% CI, 17,0-22,4) at 6 months. The risk of transmission was
associated with maternal CD4-cell counts below 200 cells/μL (Hazard Ratio
(HR): 3,79; 2,35-6,12) and birthweight less than 2,5 kg (HR: 1,81; 1,07-3,06).
Breastfed infants who also got solids were significantly more likely to
acquire infection than were exclusively breastfed children (HR: 10,87;
1,51-78,00, p=.018) as were infants who at 12 weeks received both breastmilk
and formula milk (HR: 1,82; 0,98-3,36, p=.057). Cumulative mortality at 3
months in exclusively breastfed infants was 6,1% (4,74-7,92) compared to 15,1%
(7,63-28,73) in infants given replacement feeds (HR: 2,06;1,00-4,27, p=.051).
The results from this well designed study support a revision of the present
UNICEF, WHO and UNAIDS infant feeding guidelines.
Click here for the Pubmed summary.
Coutsoudis A. Infant Feeding Dilemmas
Created by HIV: South African Experiences. Journal of Nutrition, 2005,
135:956–959.
This article highlights the dilemma caused by the HIV/AIDS pandemic on infant
feeding options in resource limited settings. It also reports the experience of
an operational research study during the initial period of implementation of the
Safer Breastfeeding Programme in South Africa. The Programme aimed to enhance
the prevention of mother-to-child transmission of HIV/AIDS. It consists in
advising mothers to safer breastfeeding practice, and is build around some
principles like exclusive breastfeeding during a maximum period of six months,
good lactation management, use of condom during lacting period, prompt treatment
of infant oral thrush. Among the 188 breastfeed infants incorporated into the
programme, 4 (2.6%) became infected by 9 months of life. The author reported a
risk of transmission of 0.35%, about half reported in a meta analysis (0.74%)
published in 2004.
Click here for Pubmed summary.
Fawzi WW, Msamanga GI, Kupka R et al.
Multivitamin supplementation improves hematologic status in HIV-infected women
and their children in Tanzania. American Journal of Clinical Nutrition, 2007,
85(5): 1335-1343.
Anemia is a frequent complication among HIV-infected persons and is
associated with various adverse outcomes. Iron supplementation has been shown
to raise hemoglobin concentrations, and treatment and prevention of infections
are other important intervention to control anemia. Despite the widespread
implementation of these interventions, anemia remains a major problem.
According to the authors no study have yet assessed the efficacy of
multivitamins alone in African settings where HIV infection, malaria and other
infectious diseases are prevalent. This study aims to examine the efficacy of
maternal supplementation during pregnancy and after delivery on hemoglobin
concentrations and the risk of anemia among the women and their children.1078
HIV-infected pregnant women from Dar es Salaam in Tanzania were enrolled in a
double-blind placebo-controlled trial. Participants were not receiving
antiretroviral treatment and received daily either vitamin A alone,
multivitamins (b-complex, vitamin C and E but excluding vitamin A),
multivitamin plus vitamin A or placebo. All women received iron and folate
supplement only during pregnancy according to local standard of care.
Hemoglobin measurement and investigation and treatment for parasites occurred
every 6 months. 906 women had at least 2 measurement and therefore were
included in the analysis. Median follow-up time for hemoglobin measurement for
mothers was 57,3 months (28,6-66,8) and for children it was 28 months
(5,3-41,7). The different arms of the trial were not significantly different
according to mean age and gestational age at enrollment. Other baseline
characteristics were also similar. Compared with placebo, multivitamin
supplementation resulted among women in a hemoglobin increase of 0,59 g/dL
during the first 2 years after enrollment (p=.0002). Compared to placebo
group, the children born to mothers who received multivitamins had a 63%
reduced risk of anemia (RR=0,37, 95% CI: 0,18, 0,79, p=.01). Multivitamin
supplementation provided during pregnancy and in the postpartum period
resulted in significant improvements in hemoglobin status among HIV-infected
women and their children.
Click here for the Pubmed summary.
Fawzi WW, Msamanga G. Micronutrients and
adverse pregnancy outcomes in the context of HIV infection. Nutrition Reviews,
2004, 62(7):269-275.
According to relevant literature, micronutrient (vitamins and trace elements)
status may affect the risk of vertical transmission. This article reviews
studies that explored the relationship between individual or multiple
micronutrients supply and pregnancy outcomes in an HIV context in developing
countries. Observational studies and randomized trials are scrutinized. First
the authors present the outcomes of observational and randomized studies on
vitamin A, B complex, C, E, selenium, and zinc supply, and then propose a
critical analysis of the studies themselves. In conclusion, the authors
underline the positive evidence of the use of multivitamins supply including
vitamin B complex, C, and E as a means to reduce low birth weight, prematurity,
and fetal death. The vitamin A supply in prenatal settings does not seem to be
efficient. Finally the authors calls for more research in the field of zinc and
selenium supply in randomized trials.
Click here for Pubmed summary.
Iliff PJ et al. Early exclusive
breastfeeding reduces the risk of postnatal HIV-1 transmission and increases
HIV-free survival. AIDS, 2005, 19(7): 699-708.
The authors provide counseling and education about feeding practices in an
HIV context. The data collected for this study was part of a vitamin A
supplementation trial that took place in a cohort of 14'110 mother-newborn pairs
in Zimbabwe. The authors prospectively collected information about feeding
practice and measured the related child infection and death. At 6 weeks and 3
months after delivery, mothers were asked if they were still breastfeeding.
Breastfeeding practices were classified in 3 categories: exclusive, predominant
or mixed breastfeeding. In seems that exclusive breastfeeding significantly
reduces breastfeeding-related HIV transmission.
Click here for Pubmed summary.
Jimenez MS, Martin L, Ross J. Infant feeding options in the context of
HIV. Washington, DC, LINKAGES, 2004.
This publication stresses some uncertainty about factors that influence HIV
transmission rates and the risk associated with different feeding practices.
The recommendations are based on scientific evidence, current research
findings, and program experience. The objective is to prevent mother-to-child
transmission of HIV and maximize HIV-free survival, while continuing to
protect, promote, and support breastfeeding for women who do not know their
HIV status or are HIV-negative. This document identifies the specific
behaviors required of a mother or caregiver to act upon these recommendations.
Click here for the entire report.
Kapoor A et al. Prevention of mother to child transmission of HIV. Indian
Journal of Pediatrics, 2004, 71(3):247-251.
Perinatal transmission is the most common cause of HIV infection in
pediatric population below the age of 15 years and affects approximately
500,000 infants per year all over the world, mostly in developing countries.
This article focus on prevention of mother-to-child transmission of HIV in an
Indian context. Much progress has been made to decrease the risk of
transmission other than just offering the option of medical termination of
pregnancy to the mother. The authors call for research to develop the simple
preventive programme, and also to make it more cost effective, acceptable and
accessible to everyone. This review focuses on the factors affecting the
transmission of HIV, strategies for the prevention of mother-to-child
transmission using nevirapine and breastfeeding practices in HIV positive
mother. The article also discusses the role of counseling and voluntary
testing.
Click here for the entire report.
Kuhn L, Kasonde P, Sinkala M, et al.
Prolonged breast-feeding and mortality up to two years postpartum among
HIV-positive women in Zambia. AIDS, 2005, 19: 1677–1681.
The association between prolonged lactation and maternal mortality has
raised concern about the detrimental effect of breastfeeding among
HIV-positive women. Therefore this randomized trial aimed to investigate
whether mortality among HIV-positive women is increased with prolonged
breastfeeding. HIV-infected women were randomly encouraged for an abrupt
cessation of breastfeeding at 4 months or encouraged to breastfeed until 6
months with gradual introduction of weaning food thereafter. The authors
explored whether mortality up to 2 years increased with the type of
breastfeeding. Complete data from 653 women were collected (326 for short
breastfeeding with abrupt cessation and 327 for prolonged breastfeeding with
gradual weaning). Both groups were not significantly different and were not
under antiretroviral treatment. There was no difference in mortality rates
among both groups at 4, 12 and 24 months.
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Leroy V, Sakarovitch C, Viho I et al.
Acceptability of formula-feeding to prevent HIV postnatal transmission, Abidjan,
Cote d’Ivoire- ANRS 1201/1202 Ditrame Plus study. Journal of Acquired Immune
Deficiency Syndrome, 2007, 44(1):77-86.
This article intends to investigate the long term efficacy of infant
feeding interventions aimed at reducing breast milk HIV transmission in
Abidjan, Côte d’Ivoire. Long term efficacy was defined as prevalence of
adverse health outcome (diarrhea, acute respiratory infections or
malnutrition), and as the prevalence of severe events (hospitalization or
death). 557 pregnant women supplied with peripartum antiretroviral prophylaxis
were included. They were proposed antenatally with infant feeding choice:
either exclusive breastfeeding with early cessation at 4 months of age or
artificial feeding. Care and nutritional counseling were provided for 2 years
and formula feeding was proposed for free. Breastfeeding was taken as
reference for hazard ratio and cofounders were corrected for analysis. 262
(47%) women decided to breastfeed for a median of 4 months and 295 decided to
use formula feeding exclusively. Over the 2 years of follow-up there was no
difference in the occurrence of adverse health outcome between the 2 groups,
and no difference concerning the probability of presenting a severe event. 96%
probability of survival at 18 months was evaluated among both groups. Compared
to long term breastfeeding without specific infant feeding intervention in a
similar cohort at the same sites, the 18 months mortality rate was similar.
These results provide evidence concerning the safety of alternatives to
prolonged breastfeeding in the prevention of Mother-to-child transmission of
HIV in urban African settings.
Click here for Pubmed summary.
Magoni M et al. Mode of infant feeding
and HIV infection in children in a programme for prevention of mother-to-child
transmission in Uganda. AIDS, 2005, 19(4):433-437.
Click here for Pubmed summary.
Obimbo EM, Mbori-Ngacha DA, Ochieng JO
et al. Predictors of early mortality in a cohort of human immunodeficiency virus
type 1-infected African children. The Pediatric Infectious Disease Journal,
2004, 23(6): 536-543.
This prospective observational study aimed to investigate the predictor of
mortality among HIV-infected African infants during the first two years of
life. Infant from a perinatal cohort were selected and followed monthly until
1 year and quarterly until two years or death. Among 62 HIV-infected infants
included, infection occured by the age of 1 month in 56 (90%) infants, and 32
(52%) died at median age of 6.2 months. All infant death were caused by
infectious diseases, pneumonia and diarrhea. Among other univariate predictors
of infant mortality maternal anemia and formula-feeding are evaluated (hazard
ratio (HR)=3,7; p=.005 and HR=4,0; p=.001). In multivariate analysis, maternal
CD4 count cells <200 (HR=2,7; p=.03) and delivery complications (HR=3,4;
p=.005) were independently associated with infant mortality. Data presented
here may be useful for an early identification and treatment of high risk
infants.
Click here for Pubmed summary.
Otieno PA, Brown ER, Mbori-Ngacha DA et
al. HIV-1 disease progression in breastfeeding and formula-feeding mothers: a
prospective 2-year comparison of T cell subsets, HIV-1 RNA levels, and
mortality. Journal of Infectious Diseases, 2007, 195: 220-229.
The current policies on infant feeding option in HIV setting is based on
infant factors. As maternal health is also an important independent outcome
some authors concurrently considered the impact of the mode of infant feeding
on maternal health. Maternal health is known to improve child survival and
development. To date conflicting evidence remain on the effect of
breastfeeding on maternal health in HIV settings. This prospective study aims
to compare immunological and viral markers of HIV disease progression, as well
as the risk of mortality between breastfeeding and formula feeding
HIV-positive women in Nairobi, Kenya. 296 HIV-positive women were enrolled
during pregnancy. Written informed consent was obtained, and women were
counselled on safe infant-feeding options and were given at least 2 weeks to
decide on how they planned to feed their infants. All women received antenatal
care and a short course of zidovudine. Viral load and CD4 cell counts were
determined at baseline and at different time after delivery and were compared
between breastfeeding and formula feeding mothers. 98 mothers decided to
provide formula feeding to their infant and 198 decided to breastfeed. At
baseline formula-feeding women had higher education level and prevalence of
HIV related illness. Both groups were similar concerning viral load and CD4
cell counts at baseline. During follow up the rate of CD4 cell count decline
was significantly higher in the breastfeeding arm than in the formula-feeding
group (7,2 vs 4,0 cells/μL/month, p=.01). Similarly BMI decreased more rapidly
in the breastfeeding group than in the formula feeding group (p=.04), whereas
there was no differences in mortality and viral load. These results suggest a
limited adverse impact of breastfeeding in mothers receiving extended care for
HIV-infection.
Click here for Pubmed summary. See also
editorial comment in the same issue of the journal on pages 165-167.
NEW! Palombi L, Marazzi MC, Voetberg A et al.
Treatment acceleration program and the experience of the DREAM (The Drug
Resource Enhancement against AIDS and Malnutrition) program in prevention of
mother-to-child transmission of HIV. AIDS, 2007, 21 (S4): 65-71.
Click here for Pubmed summary.
Papathakis PC, Rollins NC. Are WHO/UNAIDS/UNICEF-recommended replacement
milks for infants of HIV-infected mothers appropriate in the South African
context? Bulletin of World Health Organization, 2004, 82(3):164-171.
The objective of this study was to explore suitability of the 2001 feeding
recommendations for infants of HIV-infected mothers for a rural region in
South Africa. With a focus on micronutrients and essential fatty acids, cost,
and preparation times of replacement milks. It occurs that no home-prepared
replacement milks in South Africa meet all micro- and macronutrient
requirements of infants aged <6 months. Commercial infant formula is the only
replacement milk that meets all requirements. A revisions of WHO/UNAIDS/UNICEF
HIV and infant feeding course replacement milk options are needed. If
replacement milks are to provide total nutrition, preparations should include
vegetable oils, additional vitamins and minerals.
Click
here for the entire report.
Papathakis P, Rollins NC. HIV and nutrition: pregnant and lactating women.
Consultation on nutrition and HIV/AIDS in Africa: Evidence, lesson and
recommendations for action. Durban, South Africa, 10-13 April 2005. Geneva,
World Health Organization, 2005.
This document is the report of WHO consultation that took part in Durban,
South Africa about HIV pregnant and lactating women. It reviews general
nutrients needs during pregnancy and lactation and the effect of HIV on
nutritional status, and it discusses reports on nutritional status of
HIV-positive women during pregnancy and lactation. It proposes then some
evidence concerning programmatic considerations and obstacles that might be
encountered, and proposes directions of future research. Finally a valuable
list of research gaps is provided.
Click here for the entire article.
Piwoz E. Nutrition counseling, care and
support for HIV-infected women: guidelines on HIV-related care, treatment and
support for HIV-infected women and their children in resource-constrained
settings. Geneva, World Health Organization, 2004.
This document is part of a series of modules being developed by WHO and its
partners on the care, treatment and support of HIV-infected women and their
children in resource-limited settings. It complements revised guidelines for
antiretroviral treatment (http://www.who.int/3by5/publications/briefs/arv_guidelines/en/).
The document explores the effects HIV/AIDS has on the nutritional status and
provides recommendations on different topics such as malnutrition, vitamins
deficiencies, anaemia and iron supplementation, micronutrients and
mother-to-child transmission, and the nutritional considerations for persons on
antiretroviral treatment.
Click here
for the entire article.
Piwoz EG and Bentley ME. Women’s voices,
women’s choices: the challenge of nutrition and HIV/AIDS. The Journal of
Nutrition. 2005, 135: 933-937.
This document introduces and summarizes the rational for the symposium on
Women and the challenge of nutrition and HIV/AIDS in Asia and Africa that took
place in 2004. The symposium aimed at highlighting the challenge facing
HIV-infected women living in resource limited settings of Asia and Africa in
connection to the everyday decisions which they are forced to make about their
own and their children's health and nutrition. The focus is on women because
they have to support much of the burden of HIV infection in terms of their
numbers and their responsibilities for providing food and care for children,
orphans and HIV-affected family members.
Click here for Pubmed summary.
Ramharter M et al. Shared breastfeeding
in central Africa. AIDS, 2004, 18(13):1847-1849.
This research letter presents results of a prospective cross sectional study
conducted in Gabon that included 139 women. In the area where the study took
place, shared-breastfeeding is current. 40% of mothers breastfeed up to 4
additional infant, and 40% of the infants were breastfeed by up to 3 lactating
women other than the biological mother. The authors reported that
shared-breastfeeding may serve as an epidemiologically relevant multiplier of
vertical transmission of HIV. They call for further research on the influence of
shared breastfeeding on vertical transmission and epidemiology of HIV. They also
propose to include their findings in international breastfeeding recommendation.
Click here for Pubmed summary.
Read JS et al. Late Postnatal
Transmission of HIV-1 in Breast-Fed Children: An Individual Patient Data
Meta-Analysis. The Journal of Infectious Diseases, 2004, 189:2154–2166.
This meta-analysis intends to estimate the contribution of late postnatal (>4
weeks) transmission of HIV to the overall risk of mother-to-child transmission
of HIV and to characterize the timing and determinants of late postnatal
transmission. It brings evidence in areas of the world where total avoidance of
breastfeeding is not feasible. To inform the development of appropriate
interventions to prevent transmission through breast-feeding. The authors
conducted an individual patient data meta-analysis of transmission of HIV
through breastfeeding, including nine studies and 4085 women. The authors
conclude that late postnatal transmission contributes substantially to overall
mother-to-child transmission of HIV. Through breastfeeding the risk of late
postnatal transmission is generally constant, and late postnatal transmission is
associated with a lower maternal CD4+ cell count and the baby being male. They
conclude by a call for urgent interventions to decrease HIV transmission through
breastfeeding.
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Rollins N et al. Preventing postnatal transmission of HIV-1 through
breast-feeding: modifying infant feeding practices. Journal of Acquired Immune
Deficiency Syndromes, 2004, 35(2):188-195.
This article reviews experience from trials and studies on ways to prevent
mother to child transmission of HIV through breastfeeding. So far the success
and availability of antiretroviral drugs have effectively reduced in utero and
intrapartum transmission of HIV. Approaches to reducing or preventing the risk
of transmission of HIV through breastfeeding consist in the avoidance of all
breastfeeding and the use of exclusive replacement feeds. An alternative
approach is exclusive breastfeeding for a limited duration with early and
rapid cessation around 4-6 months of age. The efficacy and safety of this last
approach has not been recognized, but is currently being study. Thus,
inactivation of HIV in breast milk would allow breastfeeding to continue while
reducing the risk of postnatal transmission of HIV and may be usefully applied
in certain circumstances, such as for premature infants or while a mother
recovers from mastitis.
Click here for the Pubmed summary.
Rongkavilit C, Asmar BI. Advances in prevention of mother-to-child HIV
transmission. The Indian Journal of Pediatrics, 2004, 71:69-79.
Advances have been made in the understanding of the pathogenesis of
mother-to-child transmission of HIV. Most transmission occurs during delivery
and after birth through breastfeeding. For this reason, efforts to interrupt
transmission have focused on peripartum period and infant feeding. This
includes the use of antiretroviral therapy, elective cesarean section and
avoidance of breastfeeding. This review summarizes recent major studies and
new development on the prevention of mother-to-child HIV transmission. The
application and the impact of such interventions in developing world is
discussed. Prevention of mother-to-child transmission of HIV should now be
integrated as part of basic maternal and child health services in developing
countries.
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Ross JS, Labbok MH. Modeling the effects of different infant feeding
strategies on infant survival and mother-to child transmission of HIV. American
Journal of Public Health, 2004, 94(7):1174-1180.
The authors of this study investigated how, under various conditions, the
risk of mother-to-child transmission of HIV through breastfeeding compares
with the risk of death from artificial feeding. A spreadsheet simulation model
to predict HIV-free survival during 7 age intervals from 0 to 24 months for 5
different infant feeding scenarios in resource-poor settings was developed. It
occurred that compared with artificial feeding, breastfeeding during the first
6 months by HIV-positive mothers increased significantly survival. After 6
months, as the age-specific mortality rate and risk of death caused by
replacement feeding both decline, replacement feeding appears to be safer. The
article conclude that under conditions common in countries with high HIV
prevalence, replacement feeding by HIV-infected mothers should not be
generally encouraged until after the infant is approximately 6 months old.
Click here for the Pubmed summary.
Saadeh RJ et al. Infant feeding
and HIV transmission. Consultation on Nutrition and HIV/AIDS in Africa:
Evidence, lessons and recommendations for action. Durban, South Africa, 10-13
April 2005. Geneva, World Health Organization, 2005.
This document presents, in the context of The Global Strategy for Infant
and Young Child Feeding, available evidence on infant feeding and HIV
transmission, and is the complete evidence-based document introduced in the
executive summary of a scientific review presented in the “HIV/AIDS Pandemic
(Global Reports)” section of the SCN Nutrition and HIV/AIDS webpages. This
document is the updated version of “HIV transmission through breastfeeding” by
Professor ML Newell, and is a revised edition of “A review of HIV transmission
through breastfeeding”. This review presents the issues that are relevant to
programme and policy actions in resource-limited settings and covers current
knowledge in some aspects of the complex relation between nutrition and
HIV/AIDS. First, it starts with evidence-based knowledge of the risks and
mechanisms of breastfeeding, and presents the factors associated with vertical
transmission. It outlines the infant-feeding options for the prevention of
transmission, the current and prospective roles of antiretroviral drugs in
prevention and therapy, and the current research priorities. The document ends
with propositions of specific research issues.
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Shankar AV et al. Making the choice: the
translation of global HIV and infant feeding policy to local practice among
mothers in Pune, India. Journal of Nutrition, 2005, 135 (4):960-965.
In 2003, there were over 5.1 million infected persons living with HIV/AIDS in
India. Between 1999 and 2003, there was a dramatic increase in the number of
perinatal infections. WHO/UNAIDS/UNICEF recommend the avoidance of breastfeeding
when the use of replacement feeding is safe, feasible, affordable, acceptable,
and sustainable. Despite large advances in reducing in utero and interpartum
transmission with the use of antiretrovirals, there is a critical need to make
infant feeding safer. Therefore, the authors analyzed how the recommendation has
been actualized in the context of an urban government hospital in India. They
highlight a lack of sensibility and sensitivity for the recommendation, and the
difficulty to propose an informed and healthy choice under suboptimal
conditions. Thus, they propose the development of a decision-making algorithm
that includes factors affecting mother-to-infant transmission, including
site-specific data on health risks to the mother and the child. It would allow a
recognition of the healthiest feeding practice depending on the current and
specific situation. It would also avoid the promotion of homogeneous practices
lacking site-specific evidence-based evaluation.
Click here for Pubmed summary.
Taha TE, Kumwenda NI, Hoover DR et al.
The impact of breastfeeding on the health of HIV-positive mothers and their
children in sub-Saharan Africa. Bulletin of the World Health Organization, 2006,
84(7): 546-554.
In Sub-Saharan Africa breastfeeding remains the major way to feed infants.
Breastfeeding protects the child against a range of infectious and
noninfectious disease and has psychological and cognitive benefits. It is also
advantageous to the mother, her family and the society - in terms of health,
economy and ecology However it remains the major way of postnatal HIV
transmission. WHO and UNICEF have developped guidelines to help women in
making an informed decision about whether or not to breastfeed. The effects of
breastfeeding on the health of women infected with HIV however, are not yet
well documented. Therefore this study aims to evaluate the impact of
breastfeeding by HIV infected women on their morbidity and risk of mortality
and on the mortality of their children. The authors analysed data from 2
previous studies in Malawi. Data were collected at birth and at follow-up
visits until 24 months, including maternal morbidity and mortality, mortality
among the children, and patterns of breastfeeding (exclusive, mixed or no
breastfeeding). Descriptive and multivariate analyses were performed to
determine the association between breastfeeding and maternal and infant
outcomes. Of the 2000 infant-mother pairs who were included 2,2% of mothers
and 15,5% children died within the first 24 months. Median duration of
breasfeeding was 18 months, exclusive breasfeeding 2 months and mixed feeding
12 months. It appears that breastfeeding patterns were not significantly
associated with maternal mortality or morbidity after adjustment for maternal
viral load and other covariates Overall breastfeeding seems to reduce
mortality among infants and children (0.44, 95% confidence interval
0.28-0.70), mixed feeding 0.45 (95% confidence interval 0.28-0.71) and
exclusive breastfeeding 0.40 (95% confidence interval 0.22-0.72). These
effects were seen both in HIV infected infants and those who were not.
Click here for Pubmed summary.
Thior I, Lockman S, Smeaton LM, et al.
Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding
plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in
Botswana: a randomized trial: the Mashi Study. JAMA, 2006, 296: 794–805.
This randomized clinical trial aims to compare the efficacy and safety of 2
different infant feeding strategies for the prevention of postnatal mother to
child transmission (MTCT) of HIV. In 4 district hospital in Botswana 1200
HIV-positive pregnant women were randomly selected. All mothers were provided
with 300 mg of zidovudine twice a day from 34 weeks gestation and during
labor. Periodic assessment of the infant was provided until the age of 18
months. Mothers and infants were randomized to receive single dose of
neviparine or placebo. Infants were then randomized to 6 months of
breastfeeding plus zidovudine or formula feeding plus zidovudine. Data from
1179 infants were evaluated. The infection rate after 7 months was higher in
the breastfeeding than in the formula feeding arm (9,0% vs 5,6%, p=.04), but
cumulative infant mortality at 7 months was significantly higher for the
formula feeding group than for the breastfeeding group (9,3% vs 4,9%, p=.03).
Concerning the cumulative mortality or HIV infection rates at 18 months, the
difference between both groups were not significant (13,9% formula feed vs
15,1% breastfeeding, p=.06). According to these results, the trial highlights
the risk of fomula feeding (high mortality and morbidity rates) to infants
receiving extended antiretroviral prophylaxis in sub-Saharan Africa.
Click here for Pubmed summary.
NEW! USAID, AED, Linkages. Training of
Trainers Module Women's Nutrition throughout the Life Cycle and in the Context
of HIV and AIDS. The United States Agency for International Development, Academy
for Educational Development, The Linkages Project. March 2005.
Click here for the entire article.
Villamor A, Aboud S, Koulinska IN et al.
Zinc supplementation to HIV-1-infected pregnant women: effects on maternal
anthropometry, viral load, and early mother-to-child transmission. European
Journal of Clinical Nutrition, 2006, 60(7): 862-869.
This double blind placebo controlled randomized clinical trial aims to
investigate the effect of zinc supplementation among HIV-infected pregnant
women. The outcomes of interest are viral load, early mother-to-child
transmission of HIV (MTCT) and wasting. 400 Tanzanian HIV-infected pregnant
women were randomly assigned to receive daily doses of 25 mg zinc or placebo
from the day of the first prenatal visit until 6 weeks after delivery.
Anthropometric measures were performed monthly and HIV status of babies was
assessed at birth and 6 weeks postpartum. Viral load was controlled in a
random sample of 100 women at baseline and at the end of the research. The
supply had no effects on maternal viral load or early MTCT. Zinc supplement
was associated with an increased risk of wasting (RR=2,7, 95% CI=1.1, 6.4,
p=.03) and to a 4 mm decline in mid upper arm circumference during the second
trimester (p=.02). These findings suggest that zinc supplementation does not
provide any benefits on viral load or MTCT and the clinical relevance of its
impact on mid upper arm circumference needs to be ascertain. Therefore these
data do not support addition of zinc supplements to the standard care of
prenatal care among HIV-infected pregnant women.
Click here for Pubmed summary.
Villamor E et al. Wasting during
pregnancy increases the risk of mother-to-child HIV-1 transmission. Journal of
Acquired Immune Deficiency Syndrome. 2005, 38(5):622-626.
This cohort study was the first to examine the potential impact of wasting,
measured as weight loss and low weight gain, among pregnant women on the risk of
mother-to-child transmission of HIV. The study enrolled 957 HIV positive women
in Dar es Salaam, Tanzania. The authors performed, among other, anthropometric
measurements for the follow-up (mid-upper arm circumference, weight gain). It
occurs that weight loss is related to an increased risk of intrauterine
transmission of HIV, particularly during the second trimester. The authors also
found the rate of weight gain in the third trimester is inversely related to the
risk of intrapartum or early breast feeding HIV transmission. Therefore, there
is a potential benefit of protein energy supplementation among HIV infected
pregnant women on perinatal outcomes and disease progression. Research exploring
body composition changes amongst women who experience HIV wasting during
pregnancy and its predictive value on HIV transmission through breastfeeding is
needed.
Click here for Pubmed summary.
Visco-Comandini U et al. Possible
Child-to-Mother Transmission of HIV by Breastfeeding. Journal of the American
Medical Association, 2005, 294(18): 2301-2302.
In this case control study, the authors point to the potential existence of
child-to-mother transmission of HIV through breastfeeding. The conclusions are
limited to association rather than causation and the validity is limited by a
small sample size. Anyhow, these findings are relevant in the context of a
widespread wet nursing prevalence in countries with limited resources and as
an alternative to formula feeding when the mother is HIV infected.
No summary is available.
NEW! Volmink J, Siegfried NL, van der Merwe L
et al. Antiretrovirals for reducing the risk of mother-to-child transmission of
HIV infection. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD003510.
Click here for Pubmed summary.
WHO. Guiding principles for feeding
non-breastfeed children 6-24 months of age. Geneva, World Health Organization,
2005.
It has been argued and shown by longitudinal studies that good nutrition is
fundamental to the development of each child. The period between birth and two
years of age appears to be the most critical for the promotion of growth,
health and behavioural development. Growth retardation, micronutrients
deficiencies and diverses illnesses are particularly prevalent during this
period, and it appears that after this period it is very difficult to reverse
stunting that has occurred earlier. Therefore, it is essential to ensure that
caregivers are provided with adequate guidance concerning optimal feeding of
young children. In the context of HIV/AIDS and to minimize the risk of
vertical transmission, it is recommended to avoid breastfeeding from birth
when replacement feeding is acceptable, feasible, affordable, sustainable and
safe. Otherwise, exclusive breastfeeding is recommended and the transition to
exclusive replacement feeding must be done as soon as alternative feeding
options become feasible. As guidance for replacement feeding for the first six
months of life in the context of HIV are already available elsewhere, this
guide provides guidance for nonbreastfeed children after six months of life.
The document is intended to guide policy and programmatic action at global,
national, and community levels. It provides information about the amount of
food needed, food consistency, meal frequency and energy density, and the use
of vitamin-mineral supplements or fortified products.
Click here for the entire article.
WHO. HIV and infant feeding counseling. From Research to Practice. WHO,
Geneva, 15-16 November 2004.
In November 2004, WHO convened an informal meeting in Geneva to share the
latest findings from research related to HIV and infant feeding counseling and
information from implementation experience. The intention of this meeting was
to provide targets for an integrated infant feeding counseling course. This
report aims to share and provide a brief explanation of the recommendations
formulated during the meeting. The report starts by presenting some key
research findings, programmatic experience and on-going efforts in the
development of materials for skills buildings. A summary of the implications
for on-going and future efforts to increase the effectiveness of infant
feeding counseling is provided. It finishes with specific recommendations and
steps related to further the development of an HIV component of the integrated
infant feeding counseling course.
Click here for the entire article.
NEW! WHO. HIV and Infant Feeding Technical
Consultation Held on behalf of the Inter-agency Task Team (IATT) on Prevention
of HIV Infections in Pregnant Women, Mothers and their Infants: Consensus
Statement. World Health Organization, Geneva, October 25-27, 2006.
Click here for the entire article.
WHO. Nutrition and HIV/AIDS. Geneva,
World Health Organization, 2005.
The Health Assembly, in resolution WHA57.14, called for integration of
nutrition into a comprehensive response to HIV/AIDS. This document is the
statement of the WHO consultation on nutrition and HIV/AIDS in Africa that took
place in Durban in April 2005. It proposes guidance for different nutrition
topics such as: macronutrients, micronutrients, pregnancy and lactation, infant
and young child feeding, interaction between nutrition and antiretroviral
therapy. It ends with recommendations for action, and stresses on nutrition as
an integral part of the response to HIV/AIDS in Africa.
Click
here for the entire article.
The goal of the consultation is available here.
WHO/ UNICEF/ UNAIDS/ UNFPA. HIV
transmission through breastfeeding: A review of available evidence. Geneva,
World Health Organization, 2004.
This document presents a summary of the evidence on the HIV transmission
through breastfeeding. It briefly describes the benefits of breastfeeding for
both mothers and infants, and summarizes evidence on the relative risk of
mother-to-child transmission of HIV during pregnancy, delivery, and
breastfeeding. The document then focuses on HIV-transmission through
breastfeeding: rates, mechanisms, timing, risk factors and approaches for its
prevention are reviewed.
Click here for the entire article.
In this section you will find documents older than 2004:
Dreyfuss ML, Fawzi WW. Micronutrients and vertical transmission of HIV-1.
American Journal of Clinical Nutrition, 2002, 75(6):959-970.
This complete article summarizes the effects of vitamins and trace elements
status and supplementation on vertical transmission of HIV. Vertical
transmission can occur during pregnancy, at the time of delivery, or post-natally
through breast-feeding and is a major factor in the continuing spread of HIV
infection. The document explains the potential mechanisms of action for
micronutrients in vertical transmission of HIV. Inadequate nutritional status
may increase the risk of vertical HIV transmission by influencing maternal and
child factors for transmission. The authors propose a summary of evidence of
the relation between micronutrients and HIV disease progression by comparing
the endpoint of numerous trials. The ability of prenatal and postpartum
micronutrient supplements to reduce transmission during the breastfeeding
period is still unknown.
Click here for the
entire article.
Jaspan HB, Garry RF. Preventing neonatal HIV: a review. Current HIV
Research, 2003, 1(3):321-327.
Click here for the Pubmed summary.
Read JS. Human milk, breastfeeding, and transmission of human
immunodeficiency virus type 1 in the United States. American Academy of
Pediatrics Committee on Pediatric AIDS. Pediatrics, 2003, 112(5):1196-1205.
Transmission of HIV through breastfeeding is now recognized. This technical
report summarizes the information available regarding breastfeeding
transmission of HIV. The risks of such transmission are now well known and
presented here. In developped countries, where access to clean water and with
widespread cultural acceptance of formula feeding as an alternative to
breastfeeding, avoidance of breastfeeding by HIV infected women is possible.
In countries where breastfeeding is the norm, affordable, feasible, and
culturally acceptable interventions to decrease the risk of breastfeeding
transmission of HIV are urgently needed. Complete avoidance of breastfeeding
by HIV infected women remains the only way that transmission can be avoided.
The authors finally call for additional research to characterize more
completely the mechanisms of human milk transmission of HIV.
Click here for the entire report.
WHO/ UNICEF. Global strategy on infant and young child feeding. Geneva,
World Health Organization, 2003.
WHO, UNICEF jointly developed this document to revitalized the world
attention to the impact that feeding practices have on nutritional status,
growth and development, health, and thus the survival of infants and young
children.
Click
here for the entire report. This publication can be ordered at:
bookorders@who.int
WHO/ UNICEF/ UNFPA/ UNAIDS. HIV and infant feeding: guidelines for
decision-makers. Geneva, World Health Organization, 2003.
The aim of this publication is to provide guidance to decision-makers on
issues that need to be considered in relation to infant and young child
feeding in the context of HIV, and to highlight areas of special concern on
which policy decision need to be made locally.
Click here for the entire report. This publication can be ordered at:
bookorders@who.int
WHO/ UNICEF/ UNFPA/ UNAIDS/ World Bank/ UNHCR/ WFP/ FAO/ IAEA. HIV and
infant feeding: framework for priority action. Geneva, World Health
Organization, 2003.
The objective of this document is to recommend to governments key actions,
related to infant and young child feeding in HIV/AIDS context. The aim is to
create and sustain an environment that encourages suitable feeding practices
for all infant and young child, while scaling-up interventions to reduce HIV
transmission.
Click here for the entire report. This publication can be ordered at:
bookorders@who.int
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