Breast always best?

Tanzania Guideline for managing and counseling HIV Infected

Mothers who are breastfeeding

Rashid, Hazra, Mike

Introduction
20 - 45%

5-10% 10-15% 5-20%

 Breastfeeding Transmission
• ⅕ of all new HIV infections in Tanzania are due to mother-to-child
transmission (MTCT)[1]

• highest infection risk in the first 4 - 6 weeks of life, 0.7% - 1% per week[2]
• >6 weeks: 8.9 infections / 100 child-years of breastfeeding[2]

• Cracked or bleeding niples

• Oral thrush and mouth sores
[1] Tanzania Ministry of Health (2014): 'Global AIDS Response Country Progress Report
[2] Nduati R. et.al. Effect of breastfeeding and formula feeding on transmission of HIV-1, JAMA. 2000
Scope and objective
• The objective of this guideline is to give highlights to clinicians and
nurses on the proper measures that mother should take to prevent
MTCT among infants exposed to HIV through proper feeding practices
in low resource setting such as Tanzania.
Questions covered by guideline
• What is the transmission risk without any intervention?
• What is transmission risk w/ short term EB while on ART?
• For how long should bf, introduce complementary foods in context of
HIV infection?
• What are options in case of breast conditions (mastitis, fissures,
abscess) during bf?
 CDC Guideline PMTCT
• Mother-to-child HIV transmission during pregnancy and labor = low <1%[3]

• Breastfeeding is not recommended

• transmission rates with antiretroviral prophylaxis administered = low
(1% - 5%) but not 0%[4]
• transmission despite undetectable viral load[4]
• ART has different penetration into breast milk
• low infant toxicity, but some anemia and resistance[5]

[3] Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission Washington DC, 2011
[4] Shapiro RL, et al Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010
[5] Dryden-Peterson S,et al Increased risk of severe infant anemia after exposure to maternal HAART, Botswana 2011
 Other Reasons to Breastfeed
• Health benefits[6]
• optimal infant nutrition
• immune-modulating factors
• health benefits mother

• Child bonding
• Stigma[7]

[6] Christine M. Dieterich, et al Breast feeding and Health Outcomes for the Mother-Infant Dyad, 2013
[7] Greene S, et al. "Why aren't you breastfeeding?": How mothers living with HIV talk about infant feeding in a
"Breast Is Best" world. Health Care Women Int. 2015
CDC Guideline Breastfeeding
• demonstrated maternal ART adherence
• viral loads every 1-2 mo during breastfeeding
• plan for slow weaning
• infant 6 wks of ARV profylaxis (nevirapine)
• infant screening of HIV (during and till 6 mo after stop breastfeeding)
• prompt identification and treatment of maternal mastitis and infant thrush

CDC: Guidance for Counseling and Managing Women Living with HIV in the United States Who Desire to Breastfeed, 2018
Breastfeeding Tanzania
• Resources
• formula
• clean water
• Diagnostics
WHO Guideline on HIV and Infant Feeding (2016)

• HIV mothers: breastfeed 12 - 24 mo (or longer)

• fully supported for ART adherence!
• Interventions and support
• Exclusive breastfeeding is recommended, practicing mixed feeding is
not a reason to stop breastfeeding in the presence of ARV drugs.
• <12 mo of breastfeeding is better than never starting
Guideline Breastfeeding in Tanzania
For uninfected and unknown HIV status
• counselling on the benefits of 1st 6 months exclusive breastfeeding
• reducing death risk from malnutrition, diarrhea etc.
• testing of woman with unknown HIV status
• retesting of woman exposed to HIV during pregnancy or while
breastfeeding
Guideline Breastfeeding in Tanzania
for women living with HIV
• woman: lifelong ART
• 1st 6 mo exclusive breastfeeding
• 6-12 mo complementary feeding + breastfeeding
• HIV test child (12mo)
• +: 12-24 mo continue breastfeeding
• -/unknown: stop breastfeeding
• children: ARV prophylaxis (6wks nevirapine)
Breast and Child Mouth Conditions
• mouth sores and thrush = chance of transmission
• stop breastfeeding → express milk and boil
• in case of unilateral mastitis, nipple fissures or abscess
• breastfeed with healthy breast
• in case of bilateral mastitis, nipple fissures or abscess
• stop breastfeeding → express milk and boil

Viral, Nutritional, and Bacterial Safety of Flash-Heated and Pretoria-Pasteurized Breast Milk to Prevent Mother-to-Child
Transmission of HIV in Resource-Poor Countries
Inactivation of HIV by Pretoria Pasteurization
• Heated for 10-15 min
• Temperature range 56-62.5C
• Use small aluminum dish + small glass jar
• Nutritional components not destroyed
• HIV inactivated

J Trop Pediatr. 2001 Dec;47(6):345-9. Determination of the effectiveness of inactivation of human immunodeficiency virus by
Pretoria pasteurization.
 Risk of Transmission Tanzania
• WHO systematic reviews (2011-2016)
• 6 mo: pooled transmission rate of 3.54% (95% CI 1.15% to 5.93%)
• 6wk - 6 mo: pooled transmission rate of 1.08% (95%CI 0.32% to
1.85%)

• 12mo: The pooled estimated HIV-free survival was 89.8% (95% CI

86.5%, 93.2%)

Chikhungu Let al, HIV free survival in breastfed infants of HIV-positive woman on ART: systematic review, 2016
Summary
• Lifelong ART
• 1st 6 mo exclusive breastfeeding
• 6-12 mo complementary feeding + breastfeeding
• >12 continue or stop
• Test Child (12 mo)
• Watch out for transmission risks
 Discussion Guideline
Coverage ;
• only people who seek medical attention during pregnancy.
Escapes
• Women delivering at home. (only 63% deliver in health facilities) => TDHS
2016/17
⇒ testing? => know their status? => attended by skilled midwives? => if +
=>no intervention (transmission rate 20-45%)
⇒ Education
⇒ Local trained midwives
Tanzania demographic health survey 2016-2017
Discussion Guideline
• Pregnant women refusing testing.
⇒ Good pre-test counseling
• Non compliant mothers
=> Post-test counseling + follow up.
Questions?