[pronut-hiv] Fwd: Breastfeeding into the second year for HIV-exposed babies

["Ted Greiner" <tedgreiner@yahoo.com>]

Thank you Rachel for her interest and concern about whether HIV-exposed babies should continue breastfeeding into the second year of life. In the World AIDS Day Statement, WABA relied on data included in the recently published 2007 WHO Final Report from the 2006 HIV and Infant Feeding Technical Consultation.  We set out below several excerpts from that Report, which we hope will clarify Rachel's question:

Excerpts from WHO 2007, HIV and infant feeding : new evidence and programmatic experience : report of a technical consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants, Geneva,
Switzerland, 25-27 October 2006 

Weighed against the low (<1% per month) but ongoing risk of transmission through breast milk [17], breastfeeding substantially reduces the risk of infant mortality from other infectious diseases and malnutritionon average by 4?6 fold in the first six months and close to twofold in the second six months of life [18].
 
Since the 2000 Consultation, further research findings on both timing and risk factors for transmission during breastfeeding as well as infant outcomes with various feeding options have become available from clinical trials and MTCT-prevention programmes. The 2006 meeting discussed this new information, including morbidity and mortality among HIV-exposed but uninfected infants whose mothers stopped breastfeeding by six months, as well as infant 18-month HIV-free survival dependent on type of feeding.
 
Early cessation of breastfeeding (before six months) was associated with an increased risk of infant morbidity (especially diarrhoea) and mortality in
HIV-exposed children in completed (Malawi) and ongoing studies (Kenya, Malawi, Uganda and Zambia).
 
Abrupt early breastfeeding cessation at four months was associated with reduced HIV transmission but also with increased child mortality from 4 to
24 months in preliminary data presented from an ongoing randomized trial in Zambia. 

Breastfeeding of HIV-infected infants beyond six months was associated with improved survival compared to stopping breastfeeding in preliminary data
presented from Botswana and Zambia.
 
The sharp increase in deaths from diarrhoea and malnutrition in non-breastfed infants and young children during a recent diarrhoeal outbreak in one country
emphasizes the vulnerability of replacement-fed infants and young children, and the need for adequate follow-up for all infants.
 
Based on the new evidence and experience, the group agreed on the following recommendations for policy-makers and programme managers. These are intended to supplement, clarify and update existing United Nations guidance and do not replace it. An update of the relevant United Nations guidance incorporating these additional recommendations is available.

The most appropriate infant feeding option for an HIV-infected mother should continue to depend  on her individual circumstances, including her health
status and the local situation, but should take greater consideration of the health services available and the counselling and support she is likely to
receive.

At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, continuation of breastfeeding with additional
complementary foods is recommended, while the mother and baby continue to be regularly assessed. All breastfeeding should stop once a nutritionally
adequate and safe diet without breast milk can be provided.

Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding.

Governments and other stakeholders should revitalize breastfeeding protection, promotion and support in the general population.
 
Governments should ensure that the package of interventions referenced above, as well as the conditions described in current guidance [21], are available
before any distribution of free commercial infant formula is considered. 

The risks associated with early breastfeeding cessation are much clearer now than in 2000, given new information on HIV-free survival from ZEBS [25] and
MASHI [28] as well as data from ongoing trials in Uganda, Malawi, and Kenya. This new information needs to be incorporated into future counselling tools and messages.

For HIV-infected women the message should be exclusive breastfeeding for six months if AFASS criteria are not met; followed by introduction of 
complementary foods and continued breastfeeding until such time as full replacement feeding is feasible.... Those health care systems capable of providing free or subsidized formula must also have adequate health care infrastructure to provide satisfactory monitoring and care for infants who are formula fed to ensure that infant morbidity/mortality is not increased. 

Refs to the above excerpts: 
17) The BHITS Group. Late Postnatal Transmission of HIV-1 in breast-fed children: An individual patient data meta-analyses. Journal of Infectious
Diseases 2004, 189:2154?2166.
18) WHO Collaborative Study Team on the role of breastfeeding on the prevention of infant mortality, effect of breastfeeding on infant and child
mortality due to infectious diseases in less developed countries: a pooled analyses. Lancet, 2000, 355:451?455.
21) WHO, UNICEF, UNFPA, UNAIDS. HIV and Infant Feeding: Guidelines for Decision-makers. Available at: 
http://www.who.int/child-adolescenthealth/NUTRITION/HIV_infant.htm , accessed 1 September 2007.
25) Sinkala M et al for the Zambia Exclusive Breastfeeding Study (ZEBS) Team. No benefit of early cessation of breastfeeding at 4 months on HIVfree
survival of infants born to HIV-infected mothers in Zambia: the Zambia Exclusive Breastfeeding Study. XIV Conference on Retroviruses and
Opportunistic Infections, Feb 25-27, 2007, Los Angeles, Session 24, Abstract 74.
28) Thior I 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. Journal of the American Medical Association, 2006, 296:794?
805.
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We hope this helps, and would welcome further discussion.

Warm regards

Pamela

Pamela Morrison IBCLC
Co-coordinator WABA Breastfeeding and HIV Task Force
Rustington, England
pamelamorrisonibclc@gmail.com
 
**********************************************************************************************************
The World Alliance for Breastfeeding Action (WABA) is a global network of individuals and organisations concerned with the protection,  promotion and support of breastfeeding worldwide based on the Innocenti Declaration, the Ten Links for Nurturing the Future and the WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Its core partners are International Baby Food Action Network (IBFAN), La Leche League International (LLLI), International Lactation Consultant Association (ILCA), Wellstart International and Academy of Breastfeeding Medicine (ABM). WABA is in consultative status with UNICEF and an NGO in Special Consultative Status with the Economic and Social Council of the United Nations (ECOSOC). 
 
WABA, PO Box 1200, 10850 Penang, Malaysia
Tel: 604-658 4816 Fax: 604-657 2655
Email: waba@streamyx.com
Website:www.waba.org.my
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---"Rachel Stern"wrote: 


I've read the WABA statement. Maybe someone
connected to WABA could clarify. 

Are they advocating that breastfeeding by
HIV-positive mothers be continued into the second year
or the infant's life?

Thanks.

Rachel Stern
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