Current Knowledge and Future Research on Infant Feeding in the Context of HIV: Basic, Clinical, Behavioral, and Programmatic Perspectives

Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94110, USA.
Advances in Nutrition (Impact Factor: 3.2). 05/2011; 2(3):225-43. DOI: 10.3945/an.110.000224
Source: PubMed

ABSTRACT In 2008, between 129,000 and 194,000 of the 430,000 pediatric HIV infections worldwide were attributable to breastfeeding. Yet in many settings, the health, economic, and social consequences of not breastfeeding would have dire consequences for many more children. In the first part of this review we provide an overview of current knowledge about infant feeding in the context of HIV. Namely, we describe the benefits and risks of breastmilk, the evolution of recommended infant feeding modalities in high-income and low-income countries in the last two decades, and contextualize the recently revised guidelines for infant feeding in the context of HIV current knowledge. In the second section, we suggest areas for future research on the postnatal prevention of mother-to-child transmission of HIV (PMTCT) in developing and industrialized countries. We suggest two shifts in perspective. The first is to evaluate PMTCT interventions more holistically, to include the psychosocial and economic consequences as well as the biomedical ones. The second shift in perspective should be one that contextualizes postnatal PMTCT efforts in the cascade of maternal health services. We conclude by discussing basic, clinical, behavioral, and programmatic research questions pertaining to a number of PMTCT efforts, including extended postnatal ARV prophylaxis, exclusive breastfeeding promotion, counseling, breast milk pasteurization, breast milk banking, novel techniques for making breast milk safer, and optimal breastfeeding practices. We believe the research efforts outlined here will maximize the number of healthy, thriving, HIV-free children around the world.

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    ABSTRACT: Objective:Guidelines for prevention of mother-to-child transmission of HIV have developed rapidly, yet little is known about how outcomes of HIV-exposed infants have changed over time. We describe HIV-exposed infant outcomes in Kinshasa, Democratic Republic of Congo, between 2007 and 2013.Design:Cohort study of mother-infant pairs enrolled in family-centered comprehensive HIV care.Methods:Accounting for competing risks, we estimated the cumulative incidences of early infant diagnosis, HIV transmission, death, loss to follow-up, and combination antiretroviral therapy (cART) initiation for infants enrolled in three periods (2007-2008, 2009-2010, and 2011-2012).Results:1707 HIV-exposed infants enrolled at a median age of 2.6 weeks. Among infants whose mothers had recently enrolled into HIV care (N=1411), access to EID by age two months increased from 28% (95% confidence limits [CL]: 24,34%) among infants enrolled in 2007-2008 to 63% (95% CL: 59,68%) among infants enrolled in 2011-2012 (Gray's p-value <0.01). The 18-month cumulative incidence of HIV declined from 16% (95% CL: 11,22%) for infants enrolled in 2007-2008 to 11% (95% CL: 8,16%) for infants enrolled in 2011-2012 (Gray's p-value = 0.19). The 18-month cumulative incidence of death also declined, from 8% (95% CL: 5,12%) to 3% (95% CL: 2,5%) (Gray's p-value = 0.02). LTFU did not improve, with 18-month cumulative incidences of 19% (95% CL: 15,23%) for infants enrolled in 2007-2008 and 22% (95% CL: 18,26%) for infants enrolled in 2011-2012 (Gray's p-value = 0.06). Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43,75%) to 97% (95% CL: 82,100%) (Gray's p-value <0.01); the median age at cART decreased from 17.9 to 9.3 months. Outcomes were better for infants whose mothers enrolled before pregnancy.Conclusions:We observed encouraging improvements, but continued efforts are needed.
    AIDS (London, England) 07/2014; 28 Suppl 3:S301-S311. DOI:10.1097/QAD.0000000000000331 · 6.56 Impact Factor
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    ABSTRACT: Background The prevention of mother-to-child transmission (PMTCT) program in South Africa is now successful in ensuring HIV-free survival for most HIV-exposed children, but gaps in PMTCT coverage remain. The study objective was to identify missed opportunities for prevention of mother-to-child transmission of HIV using the four PMTCT stages outlined in National Guidelines. Methods This descriptive study enrolled HIV-exposed children who were below the age of 7 years and therefore born during the South African PMTCT era. The study site was in Gauteng, South Africa and enrolment was from June 2009 to May 2010. The clinical history was obtained through a structured caregiver interview and review of medical records and included socio-demographic data, medical history, HIV interventions, infant feeding information and HIV results. The study group was divided into the "single dose nevirapine" ("sdNVP") and "dual-therapy" (nevirapine & zidovudine) groups due to PMTCT program change in February 2008, with subsequent comparison between the groups regarding PMTCT steps during the preconception stage, antenatal care, labor and delivery and postpartum care. Results Two-hundred-and-one HIV-exposed children were enrolled: 137 (68%) children were HIV infected and 64 (32%) were HIV uninfected. All children were born between 2002 and 2009, with 78 (39%) in the "sdNVP" and 123 (61%) in the "dual-therapy" groups. The results demonstrate significant improvements in antenatal HIV testing and PMTCT enrolment, known maternal HIV diagnosis at delivery, mother-infant antiretroviral interventions and infant HIV-diagnosis and cotrimoxazole prophylaxis. Missed opportunities without improvement include pre-conceptual HIV-services and family planning, tuberculosis screening, HIV disclosure, psychosocial support and postnatal care. Not receiving consistent infant feeding messaging was the only PMTCT component that worsened over time. Conclusions Multiple missed opportunities for optimal PMTCT were identified, which collectively increase children's risk of HIV acquisition. Although HIV-testing and antiretroviral interventions improved, all PMTCT components need to be optimized to reach the goal of total pediatric HIV elimination.
    BMC Public Health 12/2014; DOI:10.1186/1471-2458-14-1265 · 2.32 Impact Factor
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    ABSTRACT: Aim To present a systematic review that evaluates the contributions of the INDEPTH Network of health and demographic surveillance systems (HDSSs) to research efforts on prevention and treatment of HIV/AIDS in low- and middle-income countries. Methods Publication titles were sent to INDEPTH by member centres. These were uploaded onto the Zotero research tool from different databases (most from PubMed). We searched for publications using the keyword “HIV” and the publication date. The 540 relevant papers were all published in peer-reviewed English language journals between 1999 and 2012. For a paper to be included in this study it must have extensively tackled the issue of HIV (1), prevention (2) and challenges associated with the treatment. After a thorough review, 89 papers were finally selected. Results Consistent condom use has been found to be highly protective against HIV infection. Although women feel at risk of contracting HIV from their partners and many women knew about condoms, they were unable to use them due to the partner's refusal. Infection with STDs is associated with HIV infection, populations with high rates of STDs and high-risk sexual behaviour, interventions to treat STDs can help prevent HIV transmission. The study also found that mother-to-child transmission was 2.7 times higher in infants breastfed for more than six months than in those breastfed for less than six months. The study found that the most promising prevention intervention discovered so far is male circumcision. Conclusion INDEPTH member centres have tracked the course of the HIV/AIDS epidemic in sub-Saharan Africa. They have analysed how the virus is transmitted and how it impacts families, communities and economies. Prevention and treatment policies and technologies have also come under scrutiny, including prevention of mother-to-child transmission of HIV, male circumcision, behaviour change polices, antiretroviral treatment and other key interventions. The robust and extensive data HDSSs have generated provide critical insights to policy-makers as the epidemic moves into its fourth decade.
    07/2014; 14(1). DOI:10.1016/j.hivar.2014.06.004


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Jun 3, 2014