Session6 - Infant Feeding & PMTCT

SESSION 6.
INFANT FEEDING AND PREVENTION OF MOTHER-TO-CHILD

TRANSMISSION OF HIV/AIDS
Purpose (slide 2)
The purpose of this session is to provide students with the concepts and latest
research findings related to prevention of mother-to-child transmission of HIV (PMTCT)
and lessons for future application to services.
Learning objectives (slide 3)
At the end of this session, students will be able to:
• Describe modes of HIV transmission from mother to child.

• Understand a risk analysis associated with vertical transmission of HIV in
pregnancy, labor, and breastfeeding
• Summarize the key research findings on mother-to-child transmission of HIV
(MTCT).
• Explain infant feeding challenges faced by HIV-infected and -affected mothers
and households, including cultural and social influences on breastfeeding.
• Describe PMTCT interventions.
Prerequisite knowledge
• Basic understanding of reproductive health, including pregnancy, labor, and

delivery
• Knowledge of and experience in labor and delivery techniques
• Understanding of infant and young child and maternal nutrition
• Knowledge and understanding of lactation management
• Basic counseling skills
• Knowledge of prenatal, intranatal, and post-natal care
• Understanding of social and cultural aspects of infant and young child feeding
Estimated time: 180 minutes excluding field work
Nutrition and HIV/AIDS: A Training Manual for Nurses and Midwives 147
ECSA-HC, FANTA, and LINKAGES
Session guide (slide 4)
Estimated
Content Methodology Activities time
(minutes)
HIV epidemic in Presentation Briefly present 5
women, infants, and transmission of HIV from
children in east, an infected mother to her
southern, and central child.
Africa (ECSA)
Small group Have participants form 15
work three groups to
brainstorm the size of the
problem, consequences,
and strategies to prevent
HIV infection in women,
infants, and children.
Risk factors Participatory Present the magnitude of 35
associated with lecture risk of MTCT and risk
mother-to-child factors during pregnancy,
transmission of HIV labor, and delivery.
(MTCT)
Large group Discuss possible 15
discussion mechanisms of MTCT
during breastfeeding,
including risk factors for
mothers and infants.
Risk analysis of infant Large group Present the evidence on 30
feeding options in the discussion risks associated with
context of HIV different infant feeding
options in the context of
HIV and define “informed
choice.”
Ask students to explain 15
“informed choice in their
own words and give
examples.
A comprehensive Participatory Present an overview of a 5
approach to prevention lecture comprehensive approach
of mother-to-child to PMTCT.
transmission of HIV
(PMTCT)
Ask students to discuss 20
where the suggested
entry points for PMTCT
are found in the healthy
system in their country.
Role-play Facilitate a counseling 20
role-play on managing
drug-food interactions
using the case study in
Handout 5.3 and class
discussion.
Conclusions Explore students’ ideas 10
about the need for future
research, as well as
programming and policy
needs in PMTCT and
infant feeding, in their
country.
Conclusions 5
Review 5
Total time 180
Required materials
• Flipchart paper and stand

• Writing pens
• Blackboard and chalk or whiteboard and markers
• Overhead projector or LCD projector
Materials provided
• PowerPoint 6
• Handout 6.1. AFASS Criteria for Replacement Feeding
Preparation
1. Review Lecture Notes and PowerPoint 6.

2. Review the handout to identify questions that can help students master the
concepts.
3. Modify the names and any other aspects (e.g., foods described) of the case
studies as appropriate for the students’ context.
Suggested reading
Coutsoudis, A., et al. 2001. Method of Feeding and Transmission of HIV-1 from
Mothers to Children by 15 Months of Age: Prospective Cohort Study from Durban,
South Africa. AIDS 15:379–87.
Dabis, F., V. Leroy, K. Castelbon, et al. 2000. Preventing MTCT of HIV-1 in Africa in
the Year 2000. AIDS 14:1017–26. Available at:
http://archive.mail-list.com/pkids/msg00127.html.
Guay, L., P. Musoke, T. Fleming, et al. 1999. Intrapartum and Neonatal Single Dose
Nevirapine Compared with Zidovudine for Prevention of MTCT of HIV-1 in Kampala,
Uganda: HIVNET 012 randomized trial. Lancet 354:795–09. Available at
http://pdf.thelancet.com/pdfdownload?uid=llan.354.9181.original_research.3219.1&x=x
.pdf.
LINKAGES Project, 2005. Infant Feeding Options in the HIV Context. Washington, DC:
FHI 360.
Ross, J. 1999. A Spreadsheet Model to Estimate the Effects of Different Infant Feeding
Strategies on Mother-to-Child Transmission of HIV and on Overall Infant Mortality.
Washington, DC: LINKAGES Project, FHI 360.

Available at: http://www.iaen.org/ models/mtctriskmodel2.pdf.
United Nations Children Fund (UNICEF), Joint United Nations Program on HIV/AIDS
(UNAIDS) and World Health Organization (WHO). 1998. HIV and Infant Feeding: A
Review of HIV Transmission through Breastfeeding. Geneva.
______. 1998. HIV and Infant Feeding: A Guide for Health Care Managers and
Supervisors. Geneva
______. 1998. HIV and Infant Feeding: Guidelines for Decisionmakers. Available at:
http://www.unaids.org/publications/documents/mtct/hivmod3.doc.
WHO. 2006. Consensus Statement on 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, Geneva, October 25–27, 2006,
Available at: http://www.who.int/child-adolescent-health/New_Publications
/NUTRITION/consensus_statement.pdf
______. 2005. HIV and Infant Feeding Counseling Tools: Reference Guide. Geneva.
Available at: http://www.who.int/child-adolescent
health/New_Publications/NUTRITION/HIV_IF_CT/ISBN_92_4_159301_6.pdf
______. 2001. New Data on PMTCT of HIV and Their Policy Implications: Conclusions
and Recommendations. Geneva.
Introduction (slide 5)
By the end of 2005 an estimated 2.3 million children worldwide were HIV positive, and
almost 90 percent of them were in sub-Saharan Africa (UNAIDS 2006). Each year
800,000 more children are infected with HIV, mainly through MTCT (Ross 2004).
HIV has also increased infant mortality in the most severely affected countries.
UNICEF and UNAIDS report that approximately 500,000 HIV-infected children die each
year from AIDS-related causes (IRIN 2005). An over 100 percent Increase in child
deaths is projected from 2002 to 2010 in the most heavily affected regions of the world
(UNAIDS 2002).
Timing of mother-to-child transmission of HIV (slide 6)
An HIV-positive mother can transmit HIV to her infant during pregnancy, labor and
delivery, and breastfeeding. In the absence of any PMTCT interventions, between 20
and 50 percent of HIV-infected mothers will transmit HIV to their infants. Without
interventions approximately 5–10 percent of HIV-infected mothers transmit the virus
during pregnancy, 10–20 percent during labor and delivery, and 5–20 post-natally
through breastfeeding up to 24 months. Labor and delivery is the single point of
greatest risk, with as much infection occurring within 24 hours as occurs post-natally
within 24 months of breastfeeding.
This session focuses primarily on infants who are infected by HIV through breastmilk.
Breastfeeding is the basis of most infant nutrition in sub-Saharan Africa, regardless of
the mothers’ HIV status. PMTCT interventions are the subject of the second portion of
the session.
Transmission risk factors during pregnancy (slide 7)
HIV transmission during pregnancy occurs when HIV crosses the placenta to the fetus.
The following factors increase the risk of transmission during pregnancy:
• A viral, bacterial, or parasitic placental infection in the mother during pregnancy

• HIV infection of the mother during pregnancy
• A higher viral load (Shaffer et al 1999)
• Severe immune deficiency associated with advanced AIDS in the mother (WHO
Without treatment, the rate of transmission of HIV during pregnancy ranges from 5–10
percent. A child is considered to have been infected in utero if the HIV-1 genome is
detected within 48 hours of delivery by a polymerase chain reaction test (DNA-PCR) or
viral culture (UNICEF, UNAIDS, and WHO 1998a).
Transmission risk factors during labor and delivery (slide 8)
Labor and delivery is the time point of greatest risk. There is a 10–20 percent risk of
transmission of HIV during this period.
During labor and delivery transmission most often occurs when infants suck, imbibe, or
aspirate maternal blood or cervical secretions containing HIV. Higher risks of HIV
transmission during labor and delivery are associated with duration of membrane
rupture, acute infection of the placental membranes (chorioamnionitis) resulting from
untreated sexually transmitted infections (STIs) or other infections, and invasive
delivery techniques that increase the infant’s contact with the mother’s blood, such as a
caesarean section (WHO 1999). Additionally, research has shown that mothers with
low CD4 counts near the time of delivery and mothers with severe clinical disease are
about three times more likely to transmit HIV to their infants than women who are less
severely affected (Leroy et al 2002; European Collaborative Study 2001).
UNICEF, WHO, and UNAIDS (1998) consider transmission to have occurred

intrapartum if the results of the diagnostic tests were negative during the first 48 hours
after delivery but became positive in subsequent samples taken within 7 to 90 days of
delivery.
HIV transmission during breastfeeding (slide 9)
There is a 5–20 percent risk of transmission of HIV through breastfeeding. It is difficult

to determine precisely when HIV transmission occurs following birth. The presence of
maternal antibodies, combined with a period during which the infection is undetectable,
makes it difficult to determine whether infection occurred during delivery or through
breastfeeding.
How is HIV transmitted during breastfeeding?
The exact mechanisms for HIV transmission during breastfeeding are not yet
completely known or understood. HIV appears to pass from the mother’s circulatory
systems into her breastmilk.
Studies that have examined breastmilk samples from HIV-positive mothers have
shown that 25–35 percent of samples have no detectable virus present. This means
either that the virus is not present or that it is present in levels below the limit of
detection for the tests used. The HIV appears to be shed intermittently over time.
Studies also show that the amount of virus in breastmilk varies between breasts in
samples taken at the same time.
When an infant drinks breastmilk from an HIV-positive mother, the virus can enter or
infect the infant through permeable mucosa, lymphoid tissues, or lesions in the gastro
intestinal tract. This can happen anywhere from the mouth to tonsil area to the
intestine. Transmission is not necessarily a result of the presence of HIV in breastmilk,
but rather a complex interaction between the anti-infective agents—macrophages,
lymphocytes, and immunoglobulin— in breastmilk and HIV.
The most remarkable aspect of HIV transmission during breastfeeding is that although
infants exposed to HIV may consume 300,000 or more virons and 25,000 HIV-infected
cells each per day, most do not become infected (Lewis et al 2001). Immune factors in
breastmilk and infant saliva are believed to play a role in preventing transmission. It
has also been hypothesized that exposure through breastmilk may create a protective
immunity for some infants.
The exact mechanisms of HIV transmission during breastfeeding are not yet known.
Late post-natal transmission (after 3–6 months) can be estimated with the PCR test. A
meta-analysis of five studies concluded that the best available estimate of the risk of
breastmilk transmission is 14 percent (Dunn et al 1992).
Transmission risk factors during breastfeeding
Post-natal transmission of HIV during breastfeeding can be influenced by a number of

risk factors related to the mother’s status, the infants, and breastfeeding practices.
These risk factors are discussed below.
Mothers (slide 10)
Maternal immune system status. Maternal immune status appears to increase the
risk of transmission of HIV. Immune deficiencies in the mother, including a low CD4 or
high CD8 cell count, increase the risk of transmission. The ZVITAMBO study in
Zimbabwe (Iliff et al 2005) found post-natal transmission at 33.7 percent in mothers
who had baseline CD4 cell counts below 200, but only 6.3 percent among mothers with
CD4 counts above 500. A study in Kenya (Richardson et al 2003) found that maternal
immune status, as measured by CD4 cell count, was predictive of breastmilk infectivity.
Increased breastmilk infectivity was also found in mothers with prenatal CD4 cell
counts below the median of the cohort (median = 400).
Maternal plasma viral load. The same study in Kenya (Richardson et al 2003) found
that maternal disease, as measured by HIV-1 RNA plasma level, was also predictive of
breastmilk infectivity. Mothers with prenatal HIV-1 RNA plasma levels above the
median in the cohort (43,120 copies/mL) had fourfold higher breastmilk infectivity.
Breastmilk viral load
Breastmilk viral loads have been found to correlate well with viral load in blood (plasma
viral load) and to be associated with the risk of HIV transmission during breastfeeding
(Rousseau et al 2002).
Data have also shown that the incidence of HIV transmission is significantly higher in
mothers with higher viral loads in their breastmilk over time (Richardson at al 2003).
The Kenya study collected multiple samples of breastmilk. Women who repeatedly had
evidence of HIV in their breastmilk were significantly more likely to transmit HIV to their
infants than those whose milk only sometimes or never had detectable virus levels.
Recent HIV infection. Maternal viral load is higher in mothers with recent HIV
infection. The risk of MTCT during breastfeeding nearly doubles if the mother becomes
infected while breastfeeding. An analysis of four studies in which mothers became
infected post-natally found a 29 percent risk of transmission through breastfeeding, as
compared to the expected 8–20 percent risk seen with most HIV-positive breastfeeding
mothers (Dunn et al 1992). This increased risk provides a strong rationale for voluntary
counseling and testing (VCT) and prevention measures during pregnancy and delivery.
Breast health. Breast health and problems such as mastitis, cracked and bloody
nipples, and other indications of breast inflammation may affect transmission of HIV
(John et al 2001; Semba et al 1999). The risk of transmission is also higher in an infant
with oral lesions such as thrush (Hoffman et al 2003; Ekpini et al 1997; Semba et al
1999). Mastitis may be caused by infectious agents, poor positioning and attachment,
or weak suckling. Deficiencies in the antioxidants vitamin E and selenium also may
increase the risk of mastitis. Mastitis causes junctions in the mammary epithelium to
become “leaky,” allowing blood plasma constituents (HIV) to enter breastmilk.
Cytokines and other immune reactions resulting from mastitis can damage the
intestines of young babies.
Maternal nutritional status. The ZVITAMBO study in Zimbabwe (Iliff et al 2005)

indicates that maternal nutritional status in Zimbabwe was associated independently
with increased risk of post-natal transmission. The assessment of maternal nutritional
status was based on measures of underweight (mid-upper arm circumference, or
MUAC) and anemia (hemoglobin). Severe maternal anemia was a positive predictor of
post-natal transmission of HIV, with the greatest risk in the first 6 months.
Infants (slide 11)
Infant age. While it is difficult to determine how important infant age is for transmission
risk (because of the difficulty of determining precisely the timing of transmission in the
first month of infancy), several studies report higher post-natal HIV transmission in the
first month (4–6 weeks) of life (Moodley et al 2003; Nduati et al 2000; John et a, 2001).
Possible explanations include a higher prevalence of mastitis and breastfeeding
problems at this age, a more immature and permeable infant gut, and/or greater
exposure to HIV because the infant takes in more milk or a higher concentration of
cells.
Mucosal integrity (mouth, intestines). Studies show that disruption of the epithelial
integrity of the mucous membranes of the intestine or mouth of the infant increases the
risk of transmission of HIV (Ekpini et al 1997). Mixed feeding, allergic reactions to
complementary foods, and infectious illness can damage the intestine and increase
risk of transmission (Bobat et al 1997; Ryder et al 1991; Tess et al 1998b). Oral thrush
in an infant may also be associated with MTCT.
Breastfeeding practices (slide 12)
Breastfeeding duration. A meta-analysis of nine studies in Africa (BHITS 2004)

showed that the risk of HIV transmission is cumulative, meaning that the longer
breastfeeding goes on, the greater the risk of transmission (Read et al 2003; Leroy et
al 2002). The risk is about 0.8 percent per month of breastfeeding, or 8.9 infections per
100 child years of breastfeeding.
Pattern or mode of breastfeeding. The pattern or mode of breastfeeding also affects

transmission. Infants who are exclusively breastfed have a lower risk of becoming
infected than those who consume other liquids, milks, or solid foods in addition to
breastmilk during the first months of life (Coutsoudis et al 1999, 2001; Smith and Kuhn
2000). For example, the ZVITAMBO study (Iliff et al 2005) showed that exclusive
breastfeeding was associated with a lower risk of infection than mixed feeding. In this
study, exclusive breastfeeding was associated with 5.1 HIV infections per 100 child-
years of breastfeeding, whereas early mixed feeding was associated with a rate of 10.5
infections per 100 child years of breastfeeding. The twofold increase in the rate of
infection remained statistically significant after adjusting for maternal baseline CD4
count and nutritional status, infant birth weight, and maternal death during the follow-up
period.
Research conducted in South Africa (Coutsoudis et al 1999, 2001) showed that
mothers who exclusively breastfed their infants for 3 months were less likely to transmit
the virus than mothers who introduced other foods or fluids before 3 months. At 3
months, infants who were exclusively breastfed had significantly lower transmission
rates (19.4 percent) than mixed-fed infants (26.1 percent) and the same transmission
rate as formula-fed infants (19.4 percent).
HIV and infant feeding risk analysis (slide 13)
While there is ample evidence of the risks of HIV transmission through breastfeeding,
the overwhelming benefits of breastfeeding and risks associated with replacement
feeding have been known for a long time. Replacement feeding prevents breastmilk
transmission of HIV, but in resource-limited settings and unhygienic conditions, the risk
of death from other infections caused by artificial feeding must be weighed against the
risk of HIV infection.
Mode of feeding and infant mortality as a result of diarrhea and acute respiratory
infection (ARI) (slide 14)
To understand the risks involved in infant feeding choices, it is necessary to examine

the evidence of the importance of breastfeeding in reducing risks of infant mortality
from infectious diseases. One study (Victora 2000) did a pooled analysis of research
on the relative risk of infant mortality by diarrhea and ARI by mode of feeding. The
different modes of feeding examined included exclusive breastfeeding, breastfeeding
and infant formula feeding, and infant formula feeding only. Differences in the relative
risk of infant mortality resulting from the mode of infant feeding were seen most clearly
in cases of diarrhea and ARI. After accounting for confounding variables, the study
found the following:
• Infants who received powdered milk or cow milk in addition to breastmilk had a
4.2 times higher risk of death from diarrhea and 1.6 times the risk of death from
ARI than infants who were exclusively breastfed.
• Infants who did not receive any breastmilk had a 14.2 times higher risk of death
from diarrhea and 3.5 times higher risk of death from ARI than infants who were
exclusively breastfed.
Similar results were obtained when infants who died from diarrhea were compared with
infants who died from diseases that were presumed to be the result of noninfectious
causes. The study also found that each additional daily breastfeed reduced the risk of
diarrhea death by 20 percent.
Nutritional contributions of breastmilk in resource-limited settings (Slide 15)
Breastmilk provides all the nutrient needs of infants younger than 6 months old and
contributes more than 50 percent of the nutrient intake of children 6–11 months old in
developing countries. This nutritional contribution is not easy to replace with other
foods available in these settings. This is an important point because undernutrition is a
major underlying cause of child mortality, and poor infant feeding practices contribute
to undernutrition.
Use of infant mortality rate (IMR) to determine infant feeding policy (slide 16)
Taking all of this information about the risks of infant mortality from HIV transmission
and replacement feeding, Piwoz and Ross (2005) used mathematical simulation
modeling to develop estimates to guide policy decisions about infant feeding in the HIV
context using population-specific infant mortality rates. The estimates led to the
following suggestions:
• In settings where IMR is < 25/1,000 live births, exclusive replacement feeding
from birth by HIV-positive mothers is recommended.
• In settings where IMR is > 25/1,000 live births, exclusive breastfeeding up to 6

months followed by early breastfeeding cessation is recommended.
Informed choice (slide 17)
Given the risks associated with both breastfeeding and replacement feeding, HIV-
positive mothers must be given all the information they need to make an informed
choice, which is defined by UNAIDS, WHO, and UNICEF as follows:
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 serostatus to choose an infant feeding strategy
based on full information about the risks and benefits of each alternative.
WHO recommendations on infant feeding for HIV-positive women (slide 18)
In October 2006 the Inter-agency Task Team (IATT) on Prevention of HIV Infections in
Pregnant Women, Mothers and their Infants convened by WHO released a Consensus
Statement on HIV and Infant Feeding. The following recommendations from the
Consensus Statement are intended for policymakers and program managers and
should supplement, clarify, and update existing UN guidance but not replace it. A full
report of the review of current evidence on HIV and infant feeding and the IATT
recommendations is forthcoming.
• 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 counseling and support she is likely to receive.
• Exclusive breastfeeding is recommended for HIV-infected women for the first 6

months of [infant] life unless replacement feeding is acceptable, feasible,
affordable, sustainable, and safe (AFASS) for them and their infants before that
time.
• When replacement feeding is AFASS, avoidance of all breastfeeding by HIV-

infected women is recommended.
• At 6 months, if replacement feeding is still not AFASS, 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 breastmilk can be
provided.
• Whatever the feeding decision, health services should follow-up all HIV-
exposed infants and continue to offer infant feeding counseling and support,
particularly when feeding decisions may be reconsidered, such as the time of
early infant diagnosis and at 6 months of age.
• Breastfeeding mothers 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. They should also actively
support HIV-infected mothers who choose to exclusively breastfeed and take
measures to make replacement feeding safer for HIV-infected women who
choose that option.
• National programs should provide all HIV-exposed infants and their mothers
with a full package of child survival and reproductive health interventions (WHO
2004, 2005) with effective linkages to HIV prevention, treatment, and care
services. In addition, health services should make special efforts to support
primary prevention for women who test negative in antenatal and delivery
settings, with particular attention to the breastfeeding period.
• Governments should ensure that the package of interventions referenced

above, as well as the conditions described in current guidance, is available
before any distribution of free commercial infant formula is considered.
• Governments and donors should greatly increase their commitment and

resources for implementation of the Global Strategy for Infant and Young Child
Feeding and the UN HIV and Infant Feeding Framework for Priority Action in
order to effectively prevent postnatal HIV infections, improve HIV-free survival,
and achieve relevant UNGASS goals.
Table 6.1. defines AFASS criteria for replacement feeding. This is also given in
Handout 6.1.
Table 6.1. AFASS criteria for replacement feeding
Acceptable The mother perceives no barrier to choosing replacement feeding for
cultural or social reasons, or for fear of stigma and discrimination.
Feasible The mother or family has adequate time, knowledge, skills, resources, and
support to correctly prepare breastmilk substitutes and feed the infant 8–
12 times in 24 hours.
Affordable The mother and family, with available community and/or health system
support, can pay the costs associated with the purchase/production,
preparation, storage, and use of replacement feeds without compromising
the health and nutrition of the family. Costs include
ingredients/commodities, fuel, clean water, and medical expenses that
may result from unsafe preparation and feeding practices.
Sustainable A continuous, uninterrupted supply and a dependable system for
distribution of all ingredients and products needed to safely practice
replacement feeding are available for as long as needed.
Safe Replacement foods are correctly and hygienically stored and prepared and
fed with clean hands using clean cups and utensils, not bottles or teats.
Comprehensive PMTCT approach (slide 19)
A successful approach to PMTCT has to integrate several different programming

areas. These areas include prevention of HIV infection; VCT; treatment; infant feeding;
counseling on nutrition, safe pregnancy, and infant feeding choices; maternal and child
health service delivery; and optimal obstetrical care. A comprehensive approach needs
the support, involvement, and participation of the government, international and local
organizations, the community, and the private sector in order to make all of these
services accessible and affordable.
PMTCT entry points (slide 20)
PMTCT-related interventions can occur during pregnancy, labor and delivery, or the
post-natal period. Each of these stages is an opportunity for nurses and midwives to
support PMTCT, including infant feeding.
Pregnancy
During pregnancy women should be counseled on primary prevention and the risks of
re-infection if they are already HIV positive. They should have access to treatment for
STIs that can make them more vulnerable to HIV infection and have been associated
with a higher risk of HIV transmission during labor and delivery. Women need access
to VCT so that they are aware of their status and can make informed decisions about
treatment, infant feeding, safe sex, and labor and delivery based on their status. While
the benefits of HIV testing in pregnancy are easily recognized in terms of prevention
and care for mother and child, the possible risks of stigmatization, discrimination, and
violence also need to be taken into consideration. All testing must be voluntary and
confidential.
All women should be encouraged to stay well nourished and hydrated during
pregnancy, but this is especially important for HIV-infected pregnant women because
1) they are at increased risk of undernutrition, and 2) as discussed above, maternal
nutritional status has been independently associated with an increased risk of
transmission of the virus to the fetus.
A growing body of research finds a strong link between HIV and malaria. Studies show
that malaria increases viral loads and decreases CD4 counts in pregnant women and
that HIV and AIDS impair immunity to malaria in pregnant women (Grimwade et al,
2004; van Eijk et al, 2003). An analysis of data collected from HIV-positive pregnant
women in Kigali, Rwanda (Ladner et al 2004) also supports an association between
HIV infection and malaria in HIV-positive pregnant women.
Antiretroviral drugs (ARVs) play a key role in PMTCT. ARVs can reduce the risk of
transmitting HIV to the infant and should be available when appropriate. Combination
therapy in the last 8 weeks of pregnancy along with singe-dose Nevirapine during labor
and delivery has been shown to reduce MTCT to less than 6 percent at 6 weeks
(Lallemant et al 2004). During pregnancy, quality counseling should focus on helping
women make decisions regarding treatment, infant feeding, safe sex, labor and
delivery, and family planning.
Labor and delivery
Labor and delivery comprise the single biggest risk point for transmission of HIV, with
more transmission occurring during a 24 hour period than occurs post-natally during 24
months of breastfeeding. Most ARV prophylaxis regimens aim to reduce HIV
transmission during this time.
Women need a safe delivery plan and access to optimal obstetric practices that can
prevent avoidable exposure to HIV at birth. For example, the artificial rupture of
membranes to hasten labor should be avoided, as well as routine episiotomy for all
primagravidas. After delivery the infant should be thoroughly dried, and any remaining
maternal blood and amniotic fluid should be removed. Vigorous suctioning of the
infant’s mouth and pharynx right after delivery should be avoided, and the umbilical
cord should be cut and handled carefully. Elective caesarean sections are used for
PMTCT but may be risky in certain environments.
Post-natal period
ARVs continue to have a role in the reduction of MTCT during the post-natal period,
which is the subject of several ongoing studies. Quality counseling and support for
infant feeding decisions by HIV-positive women becomes increasingly important during
this period. Whether women opt to exclusively breastfeed or use exclusive replacement
feeding in the first months of their infants’ lives, considerable challenges need to be
addressed. Women who opt to breastfeed need to understand the importance of
exclusive breastfeeding and the dangers posed by mixed feeding. They also need
informed counseling on maintaining breast health and preventing problems such as
mastitis and cracked nipples. All women can benefit from good counseling on
complementary feeding.
Women also need to avoid re-infection with HIV for their own health and to reduce the
risks of MTCT during breastfeeding. Practices to avoid-infection include abstinence
from sexual intercourse or the use of condoms.
Conclusions (slide 21)
The future of PMTCT depends on service providers, programmers, policymakers, and

researchers. While successful programs are now being implemented, an even greater
investment is needed to address this problem, with particular emphasis on infant
feeding.
At the policy level many governments have developed national guidelines on PMTCT.
There is a need to share experiences among countries and ensure that guidelines are
based on current research findings and programmatic experience. Finally, further
research is needed on factors affecting PMTCT.
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Lallemant, M., et al. 2001. A Trial of Shortened Zidovudine Regimen to Prevent

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Handout 6.1 AFASS Criteria for Replacement Feeding
Acceptable The mother perceives no barrier to choosing replacement feeding
for cultural or social reasons, or for fear of stigma and
discrimination.
Feasible The mother or family has adequate time, knowledge, skills,
resources, and support to correctly prepare breastmilk substitutes
and feed the infant 8–12 times in 24 hours.
Affordable The mother and family, with available community and/or health
system support, can pay the costs associated with the
purchase/production, preparation, storage, and use of replacement
feeds without compromising the health and nutrition of the family.
Costs include ingredients/commodities, fuel, clean water, and
medical expenses that may result from unsafe preparation and
feeding practices.
Sustainable A continuous, uninterrupted supply and a dependable system for
distribution of all ingredients and products needed to safely practice
replacement feeding are available for as long as needed.
Safe Replacement foods are correctly and hygienically stored and
prepared and fed with clean hands using clean cups and utensils,
not bottles or teats.
Purpose
Session Six:
Provide concepts and latest research findings
Infant Feeding and
related to prevention of mother-to-child
transmission of HIV (PMTCT) for application in
Prevention of Mother-to-Child
the workplace.
Transmission of HIV
Learning Objectives Session Outline

• Describe modes of HIV transmission from
mother to child.
• Discussion of MTCT, including associated risk
factors
• Understand mother-to-child transmission
(MTCT) risk analysis.
• Risk analysis of infant feeding choices in the HIV
context
• Understand key MTCT research findings.
• Overview of a comprehensive PMTCT approach
• Explain infant feeding challenges faced by HIV-
positive mothers.
• Describe PMTCT interventions.
3 4
Magnitude of the MTCT Problem Timing of MTCT with No Intervention

• In 2005, 2.3 million children in the world were
Early antenatal Early post-partum Late post-partum
HIV positive; 87% of them were in sub-Saharan (< 36 weeks) (0−6 months) (6−24 months)
Africa.
• 800,000 children are infected with HIV every
Pregnancy Labor and delivery Breastfeeding
year, mainly through MTCT.
• The number of child deaths is expected to
increase over 100% between 2002 and 2010. Late antenatal
(36 wks to labor)
5−10% 10−20% 5−20%
5 6
Adapted from CDC
166
Transmission Risk Factors Transmission Risk Factors
during Pregnancy during Labor and Delivery
• Viral, bacterial, or parasitic placental infection in • Duration of membrane rupture
the mother during pregnancy
• Acute infection of the placental membranes
• HIV infection of mother during pregnancy (chorioamnionitis)
• HIV viral load • Invasive delivery techniques
• Severe immune deficiency associated with • CD4 count of mother
advanced AIDS in the mother
• Severe clinical disease of mother
7 8
HIV Transmission Transmission Risk Factors

during Breastfeeding during Breastfeeding: Mother
• 5−20% risk
• Maternal immune system status (measured by
• Exact timing of transmission difficult to determine CD4 count)
• Exact mechanism unknown
• Maternal plasma viral load
• HIV in blood appears to pass to breastmilk
• Breastmilk viral load
− Virus shed intermittently (undetectable 25−35%)
− Levels vary between breasts in samples taken at • Recent HIV infection
same time
• Breast health
• Virus may also come directly from infected cells
in mammary gland, produced locally in mammary • Maternal nutritional status
macrophages, lymphocytes, epithelial cells 9 10
Transmission Risk Factors Transmission Risk Factors

during Breastfeeding: Infant during Breastfeeding: Practices
• Infant age
• Duration of breastfeeding
• Mucosal integrity in the mouth and intestines
• Pattern of breastfeeding (exclusive
breastfeeding or mixed feeding)
11 12
167
Risk Analysis of Infant Feeding Choices Relative Risk of Mortality from Diarrhea
for an HIV-Positive Mother and ARI by Mode of Feeding
16 14.2
• Replacement feeding prevents HIV 14
transmission through breastmilk, but in 12
Relative risk
resource-limited settings, infants risk dying of 10
other infections if replacement feeding is not 8
done properly. 6 4.2 3.6
4
• The benefits of breastfeeding, despite the risk
1 1 1.6
2
of HIV transmission, outweigh the risk of
0
replacement feeding.
Exclusive Breastfeeding + Formula only
breastfeeding formula
13 14
Diarrhea Acute respiratory infections
Nutrition Contribution of Breastmilk Determining Infant Feeding Policy

in Resource-Limited Settings by Infant Mortality Rate
100 Infant feeding

Infant mortality rate
recommendation
% contribution of BM
80
60
Replacement feeding by
40 < 25/1000 live births HIV-positive mothers from
birth
20
Exclusive breastfeeding to
0
Energy Protein Calcium Vitamin A Vitamin C Folate Zinc > 25/1000 live births 6 months followed by early
cessation
6-8 months 9-11 months 12-23 months
15 16
Infant Feeding Consensus Statement

Informed Choice • The most appropriate infant feeding option for HIV-
infected mothers depends on their individual
circumstances.
“HIV and breastfeeding policy supports
• Exclusive breastfeeding is recommended for HIV-
breastfeeding for infants of women without HIV infected women for the first 6 months of life unless
infection or of unknown status and the right of a replacement feeding is AFASS.
woman infected with HIV who is informed of her • When replacement feeding is AFASS, avoiding all
sero-status to choose an infant feeding strategy breastfeeding by HIV-infected women is recommended.
based on full information about the risks and • At 6 months, if replacement feeding is still not AFASS,
benefits of each alternative.” continuing breastfeeding with additional complementary
foods is recommended.
Source: Inter-agency Task Team (IATT) on Prevention of HIV Infections in
UNAIDS, WHO, UNICEF Pregnant Women, Mothers, and Their Infants convened by WHO, October
2006
17 18
168
Comprehensive PMTCT Approach PMTCT Entry Points
Pregnancy Labor & delivery Post-natal
• Prevention • ARVs • ARVs
Prevention • Treatment of STIs • Safe delivery • Counseling and
Obstetrical
• VCT planning support for infant
care
• Adequate nutrition • Non-invasive feeding option
Government • Treatment of malaria procedures • Prevention and
VCT and other infections • Elective C-section treatment of breast-
Maternal and child Organizations
health services • ARVs • Vaginal cleansing feeding problems
Community • Counseling on safe • Minimal infant • Care of infant thrush
Private sector sex, infant feeding, exposure to and oral lesions
family planning, self- maternal fluids • Counseling on
Treatment care, and preparing complementary
Counseling
for the future feeding/early weaning
Infant feeding • Infection prevention
Photo: Tony Schwarzwalder
19 20
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.
21
169

Session6 - Infant Feeding & PMTCT

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SESSION 6.

INFANT FEEDING AND PREVENTION OF MOTHER-TO-CHILD

Learning objectives (slide 3)

At the end of this session, students will be able to:

• Describe modes of HIV transmission from mother to child.

• Basic understanding of reproductive health, including pregnancy, labor, and

Estimated time: 180 minutes excluding field work

• Flipchart paper and stand

1. Review Lecture Notes and PowerPoint 6.

Strategies on Mother-to-Child Transmission of HIV and on Overall Infant Mortality.

Washington, DC: LINKAGES Project, FHI 360.

Timing of mother-to-child transmission of HIV (slide 6)

Transmission risk factors during pregnancy (slide 7)

• A viral, bacterial, or parasitic placental infection in the mother during pregnancy

Transmission risk factors during labor and delivery (slide 8)

UNICEF, WHO, and UNAIDS (1998) consider transmission to have occurred

HIV transmission during breastfeeding (slide 9)

There is a 5–20 percent risk of transmission of HIV through breastfeeding. It is difficult

How is HIV transmitted during breastfeeding?

Transmission risk factors during breastfeeding

Post-natal transmission of HIV during breastfeeding can be influenced by a number of

Mothers (slide 10)

Breastmilk viral load

Maternal nutritional status. The ZVITAMBO study in Zimbabwe (Iliff et al 2005)

Infants (slide 11)

Breastfeeding practices (slide 12)

Breastfeeding duration. A meta-analysis of nine studies in Africa (BHITS 2004)

Pattern or mode of breastfeeding. The pattern or mode of breastfeeding also affects

HIV and infant feeding risk analysis (slide 13)

To understand the risks involved in infant feeding choices, it is necessary to examine

Nutritional contributions of breastmilk in resource-limited settings (Slide 15)

• In settings where IMR is > 25/1,000 live births, exclusive breastfeeding up to 6

Informed choice (slide 17)

HIV and breastfeeding policy supports breastfeeding for infants of women

WHO recommendations on infant feeding for HIV-positive women (slide 18)

• Exclusive breastfeeding is recommended for HIV-infected women for the first 6

• When replacement feeding is AFASS, avoidance of all breastfeeding by HIV-

• At 6 months, if replacement feeding is still not AFASS, continuation of

• Breastfeeding mothers who are known to be HIV infected should be strongly

• Governments and other stakeholders should revitalize breastfeeding protection,

• Governments should ensure that the package of interventions referenced

• Governments and donors should greatly increase their commitment and

Comprehensive PMTCT approach (slide 19)

A successful approach to PMTCT has to integrate several different programming

PMTCT entry points (slide 20)

Labor and delivery

Conclusions (slide 21)

The future of PMTCT depends on service providers, programmers, policymakers, and

Bobat, R., D. Moodley, A. Coutsoudis, and H. Coovadia. 1997. Breastfeeding by HIV-

Hoffman, I. F., F. E. A. Martinson, P. W. Stewart, D. A. Chilongozi, S. Y. Leu, P. N.

Integrated Regional Information Network News Service. 2006. UN Agencies Launch

Ladner, J., V. Leroy, A. Simonon, E. Karita, J. Bogaerts, A. de Clercq, P. Van de Perre,

Lallemant, M., et al. 2001. A Trial of Shortened Zidovudine Regimen to Prevent

Leroy, V., et al. 2002. 24 Months Efficacy of a Maternal Short-Course Zidovudine

Moodley D., et al. 2003. A Multicenter Randomized Controlled Trial of Nevirapine

Richardson, B., G. John-Stewart, J. Hughes, R. Nduati, D. Mbori-Ngacha, J.

Strategies on Mother-to-Child Transmission of HIV and on Overall Infant Mortality.

Washington, DC: LINKAGES Project, FHI 360.

Available at: http://www.iaen.org/ models/mtctriskmodel2.pdf.