Book: GUIDELINE UPDATE ON HIV AND INFANT FEEDING: The duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV

WHO & UNICEF, 2016, GUIDELINE UPDATE ON HIV AND INFANT FEEDING: The duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV

Mixed feeding: an infant younger than six months of age is given other liquids and/or foods together with breast milk. is could be water, other types of milk or any type of solid food.

HIV-free survival: an infant or young child born to a mother living with HIV remains both HIV uninfected (con rmed negative HIV status) and also alive over a de ned follow-up period. It is commonly reported at 18 months or 24 months of age.

HIV: the human immunode ciency virus. ere are two types of HIV: HIV-1 and HIV-2. e vast majority of people living with HIV infections globally have HIV-1.

Exclusive breastfeeding: the infant receives only breast milk without any other liquids or solids, not even water, except for oral rehydration solution or drops or syrups of vitamins, minerals or medicines.

Postnatal transmission: transmission of HIV to an infant or child a er birth. Most postnatal transmission is through the breast milk of a woman living with HIV, but this also includes accidental infection, such as through an infected needle or through child abuse.

Prevention of mother-to-child transmission of HIV: previous WHO guidelines have used the terms “options A, B and B+” to refer to di erent approaches to preventing the mother-to-child transmission of HIV. e 2013 WHO consolidated guidelines on the use of ARV drugs recommended one of two approaches: (1) providing ART during pregnancy and breastfeeding to women who are otherwise not eligible for ART (option B); or (2) providing lifelong ART to all pregnant and breastfeeding women living with HIV regardless of CD4 count or clinical stage (option B+).

Background

Breastfeeding is one of the foundations of child health, development and survival, especially where diarrhoea, pneumonia and undernutrition are common causes of mortality among children younger than ve years. For these reasons, exclusive breastfeeding for the rst six months of life is the recommended way of feeding infants, followed by continued breastfeeding with appropriate complementary foods for up to two years or beyond.

In southern and eastern Africa, where child mortality rates are among the highest in the world, HIV infection is common and a leading cause of death. In these settings, use of commercial breast-milk substitutes and other replacement feeds among infants not exposed to HIV is associated with signi cantly increased morbidity and mortality. Moreover, the evidence for the long-term bene ts of longer duration of breastfeeding for both maternal and child health outcomes, including child development and prevention of noncommunicable diseases, highlights the relevance of supporting breastfeeding in high- and low-income settings alike.

In 2010, WHO for the rst time recommended antiretroviral (ARV) drug interventions to prevent postnatal transmission of HIV through breastfeeding. In the same year, WHO revised its guidelines on HIV and infant feeding to recommend a public health approach that advised national authorities to promote and support one feeding practice to all women living with HIV accessing care in public health facilities. Since then, countries have largely implemented the recommendations in the 2010 WHO guidelines on HIV and infant feeding. However, these guidelines had not been updated since then, since little new evidence emerged on either the uptake or impact of the recommendations.

WHO consolidated guidelines on the use of ARV drugs for treating and preventing HIV infection were updated in 2013 and again in 2016. WHO now recommends lifelong antiretroviral therapy (ART) for everyone from the time when any adult (including pregnant and breastfeeding women) or child is rst diagnosed with HIV infection. ese revisions to the ARV drug guidelines, recent evidence and programmatic experience and demand for clarification on specific issues created a need to review the HIV and infant feeding guidelines. (pp 1)

Purpose of this guideline

The objective of this guideline is to improve the HIV-free survival of HIV-exposed infants by providing guidance on appropriate infant feeding practices and use of ARV drugs for mothers living with HIV and by updating WHO-related tools and training materials.

The guideline is intended mainly for countries with high HIV prevalence and settings in which diarrhoea, pneumonia and undernutrition are common causes of infant and child mortality. However, it may also be relevant to settings with a low prevalence of HIV depending on the background rates and causes of infant and child mortality.

This guideline aims to help Member States and their partners in their e orts to make informed decisions on the appropriate nutrition actions to achieve the Sustainable Development Goals, the global targets set in the comprehensive implementation plan on maternal, infant and young child nutrition, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and the Global Health Sector Strategy on Sexually Transmitted Infections 2016–2021.

The target audience for this guideline includes: (1) national policy-makers in health ministries; (2) programme managers working in child health, essential drugs and health worker training; (3) health-care providers, researchers and clinicians providing services to pregnant women and mothers living with HIV at various levels of health care; and (4) development partners providing nancial and/or technical support for child health programmes, including those in con ict and emergency settings.

Guideline development methods

WHO developed the present evidence-informed recommendations using the WHO procedures outlined in the WHO handbook for guideline development. The steps in this process included: (i) identification of priority questions and outcomes; (ii) retrieval of the evidence; (iii) assessment and synthesis of the evidence; (iv) formulation of recommendations, including research priorities; and planning for (v) dissemination; (vi) implementation, equity and ethical considerations; and (vii) impact evaluation and updating of the guideline. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was followed, to prepare evidence pro les related to preselected topics, based on up-to-date systematic reviews.

In November 2014, a WHO Guideline Development Group reviewed the former guidelines on HIV and infant feeding and identi ed speci c questions that should be updated. ese questions and clari cations related mainly to one recommendation (number 2) from the 2010 WHO guidelines. All other recommendations and principles in those guidelines remain valid (see summary table below). Four areas were given priority for review:

•    The duration of breastfeeding by mothers living with HIV; 


•    Interventions to support infant feeding practices by mothers living with HIV; 


•    What to advise when mothers living with HIV do not exclusively breastfeed (if a mother living with HIV does not exclusively breastfeed, is mixed feeding with ART better than no breastfeeding at all?); and 


•    What to advise when mothers living with HIV do not plan to breastfeed for 12 months (if a mother living with HIV plans to return to work or school, is a shorter duration of planned breastfeeding with ART better than no breastfeeding at all?). 
e Guideline Development Group also suggested examining the implications of recommendations in two programmatic areas: 


•    What guidance on infant feeding should be provided to mothers living with HIV and to health authorities in con ict or emergency settings? 


•    What are the implications of the updated recommendations for monitoring and evaluation? 


To develop these recommendations, a WHO Steering Committee and a Guideline Development Group of 21 experts was convened. Based on the evidence reviews, the WHO Steering Committee developed an initial set of dra recommendations. Members of the Guideline Development Group then reviewed and evaluated the quality of the evidence identi ed through the systematic reviews using the GRADE method and revised and nalized the guideline recommendations and guiding practice statements. Tables 1 and 2 present the nal recommendations and guiding practice statements, which were submitted for approval to the WHO Guideline Review Committee. 
(pp 2)

RECOMMENDATIONS

The 2016 WHO Recommendations on HIV and infant feeding

1.     The duration of breastfeeding by mothers living with HIVa

Breastfeeding for at least 12 months and may continue for up to 24 months with support of ART adherence (strong recommendation): Quality of the evidence 12 months (low) & 24 months (very low)

For how long should a mother living with HIV breastfeed if she is receiving ART and there is no evidence of clinical, immune or viral failure?

Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding
for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence (see the WHO consolidated guidelines on ARV drugs for interventions to optimize adherence).b

The Guideline Development Group agreed that recommendation 1 should be framed by the following statement.

In settings where health services provide and support lifelong ART, including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted.

“Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the rst six months of life, introducing appropriate complementary foods thereafter and continue breastfeeding.”

“Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.

2.     Interventions to support infant feeding practices by mothers living with HIV

Can facility- and community-based interventions improve the quality of infant feeding practices among mothers living with HIV?

National and local health authorities should actively coordinate and implement services in health facilities and activities in workplaces, communities and homes to protect, promote and support breastfeeding among women living with HIV.

2016 Guiding practice’s Statement

1.     When mothers living with HIV do not exclusively breastfeed

If a mother living with HIV does not exclusively breastfeed, is mixed feeding with ART better than no breastfeeding at all?

Mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practising mixed feeding is not a reason to stop breastfeeding in the presence of ARV drugs

2.     When mothers living with HIV do not plan to breastfeed for 12 months

If a mother living with HIV plans to return work or school, is a shorter duration of planned breastfeeding with ART better than no breastfeeding at all?

Mothers living with HIV and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.

The 2010 WHO Principles and Recommendations on HIV and infant feeding: valid and updated

Balancing HIV prevention with protection from other causes of child mortality

Integrating HIV interventions into maternal and child health services

National authorities should aim to integrate HIV testing, care and treatment interventions for all women into maternal and child health services. Such interventions should include access to CD4 count testing and appropriate ART or prophylaxis for the woman’s health and to prevent the mother-to-child transmission of HIV.

Setting national or subnational recommendations for infant feeding in the context of HIV

National or subnational health authorities should decide whether health services will mainly counsel and support mothers known to be living with HIV to either (1) breastfeed and receive ARV drug interventions or (2) avoid all breastfeeding as the strategy that will most likely give infants the greatest chance of HIV-free survival.

(pp 6)

This decision should be based on international recommendations and consideration of:

•    the socioeconomic and cultural contexts of the populations served by maternal and child health services; 


•    the availability and quality of health services; 


•    the local epidemiology, including the HIV prevalence among pregnant women; and 


•    the main causes of maternal and child undernutrition and infant and child mortality. 


When ARV drugs are not (immediately) available, breastfeeding may still provide infants born to mothers living with HIV a greater chance of HIV-free survival

Every effort should be made to accelerate access to ARV drugs for both maternal health and preventing HIV transmission to infants.

While ARV drug interventions are being scaled up, national authorities should not be deterred from recommending that mothers living with HIV breastfeed as the most appropriate infant feeding practice in their setting.

(pp 6)

Informing mothers known to be living with HIV about infant feeding alternatives

Pregnant women and mothers known to be living with HIV should be informed of the infant feeding practice recommended by the national or subnational authority to improve the HIV-free survival of HIV-exposed infants and the health of mothers living with HIV and informed that there are alternatives that mothers might want to adopt.

Avoiding harming infant feeding practices in the general population

Counselling and support to mothers known to be living with HIV and health messaging to the general population should be carefully delivered to avoid undermining optimal breastfeeding practices among the general population

Advising mothers who are HIV uninfected or whose HIV status is unknown

Mothers who are known to be HIV uninfected or whose HIV status is unknown should be counselled to exclusively breastfeed their infants for the rst six months of life and then to introduce complementary foods while continuing breastfeeding for 24 months or beyond.

Mothers whose status is unknown should be offered HIV testing.

Mothers who are HIV uninfected should be counselled about ways to prevent HIV infection and about the services that are available, such as family planning, to help them to remain uninfected

Investing in improving infant feeding practices in the context of HIV

Governments, other stakeholders and donors should greatly increase their commitment to
and resources for implementing the Global Strategy for Infant and Young Child Feeding, the United Nations HIV and infant feeding framework for priority action and the global scale-up
of the prevention of the mother-to-child transmission of HIV to effectively prevent infants from becoming infected with HIV postnatally, improve HIV-free survival and achieve relevant goals of the United Nations General Assembly Special Session on HIV/AIDS.

(pp 7)

Recommendation for 2010

What to feed infants when mothers stop breasteeding

When mothers known to be living with HIV decide to stop breastfeeding at any time, infants should be provided with safe and adequate replacement feeds to enable normal growth and development.

•    For infants younger than six months of age: 
Alternatives to breastfeeding include:

                                —  commercial infant formula milk if the home conditions outlined in recommendation 5 are ful lled; or 


                                —  expressed, heat-treated breast milk (see recommendation 6 below). 
Home-modi ed animal milk is not recommended as a replacement food in the rst six months of life. 


•    For children older than six months of age: 
Alternatives to breastfeeding include:

                                —  commercial infant formula milk if the home conditions outlined in recommendation 5 are ful lled; or 


                                —  animal milk (boiled for infants under 12 months), as part of a diet providing adequate micronutrient intake; meals, including milk-only feeds, other foods and combination of milk feeds and other foods, should be provided four or ve times per day. 
All children need complementary foods from six months of age. 


Conditions needed to safely formula feed

Mothers known to be living with HIV should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status when speci c conditions are met:

•    (a)  safe water and sanitation are assured at the household level and in the community; and 


•    (b)  the mother or other caregiver can reliably provide suf cient infant formula milk to support the normal growth and development of the infant; and 


•    (c)  the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and 


•    (d)  the mother or caregiver can exclusively give infant formula milk in the rst six months; and 


•    (e)  the family is supportive of this practice; and 


•    (f)  the mother or caregiver can access health care that offers comprehensive child health services. 


These descriptions are intended to give simpler and more explicit meaning to the concepts represented by AFASS (acceptable, feasible, affordable, sustainable and safe). (8).

Heat treated, expressed breast milk

Mothers known to be living with HIV may consider expressing and heat-treating breast milk as an interim feeding strategy:

•    in special circumstances, such as when the infant has 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 


•    to assist mothers in stopping breastfeeding; or 


•    if ARV drugs are temporarily not available. 


When the infants is living with HIV

If infants and young children are known to be living with HIV, mothers are strongly encouraged to exclusively breastfeed for the rst six months of life and continue breastfeeding in accordance with the recommendations for the general population: that is, up to two years or beyond.