Session Six:

Infant Feeding and

Prevention of Mother-to-Child
Transmission of HIV
 Purpose

Provide concepts and latest research findings

related to prevention of mother-to-child
transmission of HIV (PMTCT) for application in
the workplace.

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 Learning Objectives
• Describe modes of HIV transmission from
mother to child.
• Understand mother-to-child transmission
(MTCT) risk analysis.
• Understand key MTCT research findings.
• Explain infant feeding challenges faced by HIV-
positive mothers.
• Describe PMTCT interventions.
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 Session Outline

• Discussion of MTCT, including associated risk

factors
• Risk analysis of infant feeding choices in the HIV
context
• Overview of a comprehensive PMTCT approach

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 Magnitude of the MTCT Problem

• In 2005, 2.3 million children in the world were

HIV positive; 87% of them were in sub-Saharan
Africa.
• 800,000 children are infected with HIV every
year, mainly through MTCT.
• The number of child deaths is expected to
increase over 100% between 2002 and 2010.

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Timing of MTCT with No Intervention

Early antenatal Early post-partum Late post-partum

(< 36 weeks) (0−6 months) (6−24 months)

Pregnancy Labor and delivery Breastfeeding

Late antenatal
(36 wks to labor)

5−10% 10−20% 5−20%

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Adapted from CDC
 Timing of Mother to Child
Transmission of HIV
100 INFANTS BORN TO HIV
POSITIVE WOMEN WHO 55-80 INFANTS WILL
BREASTFEED, WITHOUT ANY NOT BE HIV INFECTED
INTERVENTION

10-15
5-10 INFANTS 5-20 INFANTS
INFANT INFECTED INFECTED
DURING
S DURING
INFECT LABOUR
DELIVERY
B/FEEDING
ED IN
UTERO

20-45 INFANTS INFECTED IN PREGNANCY,

during Labour & Delivery AND through BREASTFEEDING

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 Transmission Risk Factors
during Pregnancy
• Viral, bacterial, or parasitic placental infection in
the mother during pregnancy
• HIV infection of mother during pregnancy
• HIV viral load
• Severe immune deficiency associated with
advanced AIDS in the mother

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 Transmission Risk Factors
during Labor and Delivery
• Duration of membrane rupture
• Acute infection of the placental membranes
(chorioamnionitis)
• Invasive delivery techniques
• CD4 count of mother
• Severe clinical disease of mother

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 HIV Transmission
during Breastfeeding
• 5−20% risk
• Exact timing of transmission difficult to determine
• Exact mechanism unknown
• HIV in blood appears to pass to breastmilk
− Virus shed intermittently (undetectable 25−35%)
− Levels vary between breasts in samples taken at same
time
• Virus may also come directly from infected cells in
mammary gland, produced locally in mammary
macrophages, lymphocytes, epithelial cells
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 HIV in Breast milk
• HIV-1 in breast milk originate as:
– Blood cell–free virus released into breast milk
– Produced by local replication in macrophages and in ductal and
alveolar mammary epithelial cells
• It is detected in both
– Cellular compartment of breast milk
– Cell-free milk (viral load usually +/- 2 logs lower than plasma)
• Detection is associated with: .
– Lower maternal CD4
– Lower maternal Vit A
– Mastitis
– Infrequent emptying
– Sooner after birth
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 Transmission Risk Factors
during Breastfeeding: Mother
• Maternal immune system status (measured by
CD4 count)
• Maternal plasma viral load
• Breastmilk viral load
• Recent HIV infection
• Breast health
• Maternal nutritional status
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 Transmission Risk Factors
during Breastfeeding: Infant
• Infant age
• Mucosal integrity in the mouth and intestines

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 Transmission Risk Factors
during Breastfeeding: Practices
• Duration of breastfeeding
• Pattern of breastfeeding (exclusive
breastfeeding or mixed feeding)

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Risk Analysis of Infant Feeding Choices
for an HIV-Positive Mother
• Replacement feeding prevents HIV
transmission through breastmilk, but in
resource-limited settings, infants risk dying of
other infections if replacement feeding is not
done properly.
• The benefits of breastfeeding, despite the risk
of HIV transmission, outweigh the risk of
replacement feeding.

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Relative Risk of Mortality from Diarrhea
and ARI by Mode of Feeding
16 14.2
14
12
Relative risk

10
8
6 4.2 3.6
4
1 1 1.6
2
0
Exclusive Breastfeeding + Formula only
breastfeeding formula
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Diarrhea Acute respiratory infections
 Nutrition Contribution of Breastmilk
in Resource-Limited Settings

100
% contribution of BM

80

60

40

20

0
Energy Protein Calcium Vitamin A Vitamin C Folate Zinc

6-8 months 9-11 months 12-23 months

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 Determining Infant Feeding Policy
by Infant Mortality Rate

Infant feeding
Infant mortality rate
recommendation

Replacement feeding by
< 25/1000 live births HIV-positive mothers from
birth

Exclusive breastfeeding to
> 25/1000 live births 6 months followed by early
cessation
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 Informed Choice

“HIV and breastfeeding policy supports

breastfeeding for infants of women without HIV
infection or of unknown status and the right of a
woman infected with HIV who is informed of her
sero-status to choose an infant feeding strategy
based on full information about the risks and
benefits of each alternative.”

UNAIDS, WHO, UNICEF

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Infant Feeding Consensus Statement
• The most appropriate infant feeding option for HIV-infected
mothers depends on their individual circumstances.
• Exclusive breastfeeding is recommended for HIV-infected
women for the first 6 months of life unless replacement
feeding is AFASS.
• When replacement feeding is AFASS, avoiding all
breastfeeding by HIV-infected women is recommended.
• At 6 months, if replacement feeding is still not AFASS,
continuing breastfeeding with additional complementary
foods is recommended.
Source: Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant
Women, Mothers, and Their Infants convened by WHO, October 2006

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21
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 Comprehensive PMTCT Approach

Obstetrical Prevention
care

Government VCT
Maternal and child Organizations
health services
Community
Private sector
Treatment
Counseling
Infant feeding

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Photo: Tony Schwarzwalder
 2000 – Revised UN Agency Infant
Feeding Guidelines
• Avoidance of breastfeeding if AFASS situation exists
• Specific guidance should be given to mothers who
replacement feed
• Not AFASS – exclusive breastfeeding in first months
of life (duration not stipulated)
• In practice – interpreted as breastfeeding, if chosen,
should cease by 6 months
• In practice - feeding policy was not always
accompanied by effective nutritional counseling

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 Feeding practice influence
transmission risk
Exposure Duration Prophylaxis Risk

Exclusive Breast 6 wks – 6 months None 4%

Mixed
6 wks – 6 months None 8%
Breast/Formula

Mixed Breast / solid

6wks – 6 months None UP TO 40%
foods

Children exposed at least once to solids
in first 2 months of life were
2.9-fold (CI 1.1-8.0) time more likely to
be infected postnatally (p=0.04).
VTS Study – Coovadia et al, Lancet 2007
BAN Study – Chasela et al, NEJM 362;24 2010
MASHI study – Thior et all, JAMA Vol 296 No 7 2006
Mma Bana study – Shapiro et al, NEJM 362;24
2010
Becquet R CROI 2008
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 PMTCT Entry Points
Pregnancy Labor & delivery Post-natal
• Prevention • ARVs • ARVs
• Treatment of STIs • Safe delivery • Counseling and
• VCT planning support for infant
• Adequate nutrition • Non-invasive feeding option
• Treatment of malaria procedures • Prevention and
and other infections • Elective C-section treatment of breast-
• ARVs • Vaginal cleansing feeding problems
• Counseling on safe • Minimal infant • Care of infant thrush
sex, infant feeding, exposure to and oral lesions
family planning, self- maternal fluids • Counseling on
care, and preparing complementary
for the future feeding/early weaning
• Infection prevention
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 Conclusions
• HIV can be transmitted from mother to child
during pregnancy, labor and delivery, and
breastfeeding.
• A comprehensive package of services is
needed to prevent transmission.
• HIV-positive mothers must weight the benefits
and risks of breastfeeding before making infant
feeding choices.
• Replacement feeding must be AFASS.

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