HIV AND INFANT FEEDING

HIV AND INFANT FEEDING
By James Achanyi-Fontem
Cameroon Link
HIV was first detected in breastmilk in the mid-1980s, creating problems as to how to advise HIV-infected mothers on the feeding of their infants. The risk of transmitting HIV through breastfeeding must be balanced against the risks that can result from not breastfeeding.
Breastfeeding is near universal in Cameroon, making it hard to conduct studies on the risks of artificial feeding. The lack of data makes it difficult to balance these risks. As at now, HIV prevalence is high and rising in pregnant women in Cameroon, so it is important that guidance should be developed to help reduce the risk of mother-to-child transmission (MCTC). It must be borne in mind that breastfeeding in Cameroon is recommended usually from birth and may continue in most cases to over 24 months, but also that complementary foods are often introduced within the first 3 months of life.
In the resource poor settings, the many benefits of breastfeeding become especially important and the risks associated with the alternatives to breastfeeding also become greater. In developing countries like Cameroon, the high cost and irregular supply of breast milk substitutes, and the lack of safe water to make up such foods, results in higher levels of morbidity and mortality for infants who are not breastfed.
Studies carried in Cameroon by Cameroon Link have found that babies who are not breastfed in the first month of life are six times more likely to die than breastfed babies. The protective effect of breastfeeding declines with age but remains significant for the first 8 months of infancy, and it is greatest among mothers with limited education.
In the district hospitals in Cameroon today, for an HIV-infected mother, the decision whether to break with tradition and not breastfeed, or to run the risk of transmitting the virus through breastfeeding, imposes a heavy burden. A woman who does not breastfeed may be stigmatised and others will suspect she has HIV, and there could be many adverse social consequences.
A woman may try to hide her HIV status by breastfeeding but also use artificial feeding in an attempt to reduce the risks to the baby. This , however, exposes her baby to both sets of risks. For now , options for replacement of infant feeds to HIV-positive mothers and children for the first six months are discussed by the UN agencies like UNICEF,WHO, and WHA.
On the other hand, there is information on home-prepared foods for children over this age. These guide are generic and should be locally adapted. Through counselling, they should also be tailored to individual circumstances . Local guidelines are being developed in Cameroon, but little is known about their implementation or effectiveness. What is known is that it is difficult to achieve safe replacement feeding in Cameroon for now.
HIV transmission through breastfeeding
The mechanisms of HIV transmission through breastfeeding are not clear but the virus probably infects the infant through breaches in the integrity of the intestinal mucosa. An improved understanding of how HIV transmission through breastfeeding occurs might make it possible to reduce the transmission risk.
Data suggest that 10 – 20 % of babies born to HIV-positive mothers will become infected through breastfeeding when it continues beyond one year. Several factors associated with increased risk of breastfeeding transmission have been identified. Those for which there is strong evidence of increased risk include:
* high maternal HIV load (found in recent infection and in advanced disease)
• clinical symptoms of advanced disease
• immune deficiency (low CD4 and high CD8 counts)
• duration of breastfeeding
•breastfeeding whilst experiencing mastitis, abscesses, or ripple fissures.
Exclusive Breastfeeding
Exclusive breastfeeding defined as breastfeeding without any supplementary food or liquid, is generally recommended for the first 6 months of life. It reduces mortality from diarrhoea and respiratory infections and protects against other diseases. Infants who are breastfed exclusively for at least 3 months have significantly lower HIV transmission at 3 and 6 months compared with infants who received breast milk plus other feeds (“mixed feeding”) within the first 3 months of life.
The rate of transmission in exclusively breastfed infants and infants who were never breastfed were similar , 19,4 % at 6 months. In contrast, 26,1 % of infants who were mixed fed are HIV-positive at this age. At 15 months, 24,7% of babies exclusively breastfed for at least 3 months are HIV-infected , compared with 35,9% of the babies who are mixed fed in the early months of life.
Mastitis
Mastitis is a condition resulting from inadequate or poor drainage of milk from the breast. It may be either infectious or non-infectious in origin. Mastitis affects up to a third of breastfeeding women, usually in the first 3 months after delivery. Some vitamin deficiencies may increase the risk of mastitis.
Mastitis can be treated with low-cost antibiotics. Counselling women about good breastfeeding techniques can help them avoid problems that would cause elevated milk sodium, poor milk drainage and inflammation leading to mastitis, as well as nipple problems which may also increase the risk of HIV transmission.
Antiretroviral drug trials for prevention of MTCT
Short-course , prophylactic Antiretroviral drugs (ARV) are the most effective way to reduce MTCT during pregnancy, labour and delivery, and through breastfeeding during the first days of infant life.
It must also be recognised that ARV protocols require the identification of HIV-positive women through voluntary counselling and testing (VCT) services, which need to be expanded in Cameroon.
Recommendations for making breastfeeding safer in the context of HIV
Mothers have a right to information and support so that they can feed their babies safely. They must know their HIV status and they must understand the consequences of each feeding option.
Most of the options for reducing MTCT discussed in this supplement so far only apply to those women who know their HIV status. In Cameroon, however, the vast majority of HIV-infected mothers are unaware of this.
The UN policy is that breastfeeding should be promotes and supported among women who are HIV-negative and those who do not know their HIV status. The following recommendations are therefore made.
• Breastfeeding should begin within 30 minutes of birth
• Breastfeeding skills (proper position and attachment, how to feed the baby ) comfortably) should be established immediately.
• Infants should be fed frequently, ‘on demand’.
• Breastfeeding should be exclusive ( no other solids or liquids) for about the first six months.
• Age-appropriate complementary foods should be introduced at 6 months;
• Women at risk of HIV should take steps to avoid infection during the breastfeeding period. (Risk of MTCT is greater immediately after infection because of elevated levels of the virus in the blood).
• Mothers should seek immediate treatment for breast inflammation, cracked nipples or infant mouth sores.
• If such problems occur in one breast only, mothers should express and discard milk from that breast.
These “safer” breastfeeding practices are important for public health programs because they may reduce transmission risks when mothers are:
• unaware of their HIV-status
• HIV-negative but at risk of infection
• HIV-positive but have decided to breastfeed.