SATISH TIWARI, KETAN BHARADVA, BALRAJ YADAV, SUSHMA MALIK, PRASHANT GANGAL, CR BANAPURMATH, ZEEBA ZAKA-UR-RAB, URMILA DESHMUKH, VISHESHKUMAR AND RK AGRAWAL, FOR THE IYCF CHAPTER OF IAP Correspondence to: Dr Satish Tiwari, Yashodanagar No. 2, Amravati 444 606, Maharashtra, India. email@example.com
INDIAN PEDIATRICS VOLUME 53__AUGUST 15, 2016
The best time to counsel HIV-positive mothers is during antenatal period. They should be informed about infant feeding options, viz. exclusive breastfeeding or exclusive replacement feeding that is recommended by the national authority so to improve HIV free survival of exposed infants. Exclusive breastfeeding is superior to exclusive replacement feeding in developing countries because it maximizes the chances of survival of the infant.
Prevention of parent-to-child transmission (PPTCT) interventions should begin early in the pregnancy for all HIV infected pregnant women
In resource-limited settings, HIV-infected mothers of HIV-uninfected infants often have difficulty in deciding about feeding options, breastfeeding risks transmission of HIV to their infants and formula feeding is not always a feasible option due to high cost, lack of clean water or stigma associated with not breastfeeding. Recent clinical studies have proven that the risk of transmission through breastfeeding is minimal provided mother and the infant receive appropriate antiretroviral prophylaxis.
The global target is “elimination of new HIV infections among children” by 2015 and government of India is actively working towards it. Following the new guidelines from WHO (June 2013), National AIDS control organization (NACO) has decided to provide life-long ART (triple drug regimen) to all pregnant and breastfeeding women living with HIV. With this step, all pregnant women living with HIV should receive a triple drug ART regimen regardless of CD4 count or WHO clinical stage. This would also help in increasing the coverage for those needing treatment to keep them alive and for their own health, avoiding stopping and starting drugs with repeat pregnancies, provide early protection against mother-to-child transmission in future pregnancies and avoiding drug resistance. These recommendations can potentially reduce the risk of mother-to-child-transmission to less than 5% in breastfeeding populations. These guidelines have been implemented across India from January, 2014
Providing an optimized, fixed-dose combination once daily first-line ARV regimen of Tenofovir (TDF), Lamivudine (3TC) (or Emtricitabine [FTC]) and Efavirenz (EFZ) to all pregnant and breastfeeding women HIV has important programmatic and clinical benefits. Where access to CD4 testing is limited, WHO prefers that all pregnant and breastfeeding HIV- infected women, regardless of CD4 cell count, should continue antiretroviral treatment for life (sometimes called “Option B+”)
Exclusive breastfeeding is the recommended infant feeding choice in the first 6 months, irrespective of the fact that mother is on ART early or infant is provided with anti-retroviral prophylaxis for 6 weeks.
No Mixed Feeding is to be done during the first 6 months.
Mothers known to be infected with HIV and whose infants are HIV uninfected or of unknown HIV status should exclusively breastfeed their infants. Complementary foods should be appropriately introduced thereafter, and breastfeeding should be continued for the first 12 months of life. Initiate maternal ART and give Nevirapine (NVP) for 6 weeks.
Mothers known to be infected with HIV and whose infants are HIV infected should exclusively breastfeed for the first 6 months of life, complementary foods should be appropriately introduced thereafter, and breastfeeding should be continued for 24 months of life. Initiate maternal ART and give NVP for 6 weeks.
Mothers who are diagnosed with HIV during labor or in the immediate postpartum period and are planning to breastfeed, such mothers should be initiated on ART and their infants should receive extended NVP prophylaxis for 12 weeks.
Mothers who are diagnosed with HIV during labor or in the immediate postpartum period and are planning exclusive replacement feeding (ERF) should be referred for evaluation and treatment of HIV. Infants of these mothers should be given NVP prophylaxis for 6 weeks.
Mothers who are HIV-infected and insist on not breastfeedingand opt for exclusive replacement feeding (ERF)should be explained that they are doing so at their own risk and this is contrary to the WHO/ NACO’s guidelines of giving exclusive breastfeeds.
When taking choice for exclusive replacement feeding, they should fulfill the AFASS (A – Affordable F – Feasible A – Acceptable S – Sustainable S – Safe) criteria. Explain the advantages of ERF as (i)No risk of HIV transmission; and (ii) ERF milk can be given by other persons. Also enumerate the disadvantages like (i) Animal milk is not a complete food for baby; (ii) Formula milk may be complete but is expensive; (iii) Baby has more risk of infections- diarrhea, respiratory and ear infection and malnutrition; and (iv) Careful and hygienic preparation required each time to sterilize feeding cups, using boiled water and fresh preparation of all feeds 12-15 times in the first 4 months of baby’s life.
Mother who is receiving ART but interrupts ART regimen while breastfeeding (due to toxicity, stock- outs or refusal to continue etc); determine an alternative ART regimen or solution for mother and counsel her regarding continuing ART without interruption. NVP should be given to infant until 6 weeks after maternal ART is restarted or until 1 week after breastfeeding has ended.
The preferred feeding option for HIV-exposed infants <6 months of age is exclusive breastfeeding. However, in certain situations like maternal death and severe maternal illness breastfeeding may not be possible, in such cases ERF should be done only when AFASS criteria is fulfilled.
Breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided. Breastfeeding should not be stopped abruptly. Gradually wean from breast milk over a one month period.
Mothers known to be HIV infected may consider expressing and heat-treating breast milk as an interim feeding strategy in special circumstances such as:
When the infant is born with low birth weight or is otherwise ill in the neonatal period and unable to breastfeed; or
When the mother is unwell and temporarily unable to breastfeed or has a temporary breast health problem such as mastitis; or if antiretroviral drugs are temporarily not available.
Nevirapine should be given as prophylaxis for six weeks daily to infants of HIV-infected mothers who are receiving ART and are breastfeeding. Those infants who are receiving replacement feeding should be given four to six weeks of infant prophylaxis with daily NVP (or twice-daily Zidovudine [AZT]). Infant prophylaxis should begin at birth or when HIV exposure is recognized postpartum.
Infants who are identified as HIV–exposed after birth (through infant testing [at 6 weeks or after] or maternal HIV antibody testing) and are breastfeeding, in such cases maternal ART should be initiated and the infant should receive NVP prophylaxis. Perform infant DNA/PCR test if child is 6 weeks or older, immediately initiate 6 weeks or longer of NVP and strongly consider extending this to 12 weeks.
Infant identified as HIV- exposed after birth(through infant or maternal HIV antibody testing) and are not breastfeeding. Refer mother to ART Centre after CD4 tests and baseline test and treatment should be started. No NVP needs to be given to infants. Do HIV DNA/ PCR test in accordance with national recommendations on early infant diagnosis and initiate treatment if the infant is infected.
For breastfeeding infants who have been diagnosed HIV positive, pediatric ART should be started and breastfeeding to be continued ideally until the baby is 2 years old
For breastfeeding infants, diagnosed HIV-negative, breastfeeding should be continued until 12 months of age ensuring the mother is on ART as soon as possible. The Early Infant diagnosis (EID) is repeated for the 3rd time (when previous 2 EIDs have been negative) after 6 weeks of stopping breast feeds. If rapid test is positive, then do Dried Blood Spot (DBS). If DBS is positive, then do, Whole Blood Sample (WBS) test. If WBS test is positive, Pediatric ART should be initiated.
However, confirmation test for HIV has to be done at 18 months using 3 rapid antibody tests for all babies irrespective of the earlier EID status or the fact that Pediatric ART has already been initiated.