Prevention of HIV transmission through breastfeeding Potential public health and research implicatio

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Prevention of HIV transmission through
breastfeedingPotential public health and
research implications

• François DABIS MD, PhD
• The Ghent-IAS Group on HIV in Women and Children
• and
• Unité INSERM 593, ISPED
• Université Victor Segalen, Bordeaux, France

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Prevention of HIV transmission through
breastfeeding (1) Public health

• What to do without new evidence ?
• Make the best use of available evidence at the
  largest scale possible
• Integrating PMTCT to all components of MCH
  services, including the postnatal services

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When does MTCT of HIV-1 occur?Adapted from De
Cock (JAMA, 2000)
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Probability of remaining breastfedin the DITRAME
ANRS 049a trial (1995-1999) in Abidjan (N 223)
and Bobo-Dioulasso (N 165) Log Rank test,
plt0.0001
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POOLED ANALYSIS OF 2 AFRICAN ZDV RANDOMIZED
CLINICAL TRIALS (ANRS and CDC)FOR POSTNATAL
TRANSMISSIONLeroy V. AIDS 2003 17 1493-1501.
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BHITS Collaboration READ J. CROI 2003Final
proportional hazards Model
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ALTERNATIVES TO BREASTFEEDINGArtificial milk vs
breastmilkKenya, phase III, community-based
randomised trial, 1996-1998 (Nduati R. JAMA
2000 283 1167-74)



2-year efficacy 44Higher maternal mortality in
the breastfeeding group (Lancet 2001 357
1651-5)Comparable infant mortality and morbidity
(JAMA 2001 286 2413-20)
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TYPE OF FEEDINGExclusive breastmilk vs mixed
feedingCoutsoudis A.Lancet 1999 354 471-6 and
AIDS 2001 15 379-87
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ANRS 1202 Ditrame Plus Becquet R. Paris 2003
(63) Kaplan-Meier probability of survival in the
first 12 months of life, in overall children
according to their initial feeding practice
1.00
First feeding practice FF BF
0.75
Log-Rank test p 0.83
0.50
0.25

• Follow up (in days)

0.00
0
50
100
150
200
250
300
350
400
Follow-up (days)
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ANRS 1202 Ditrame Plus Infant mortality
according to the initial feeding practiceBecquet
R. Paris 2003 (63)
Rate ratio (FF vs. BF) 0.5 0.1 1.7
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ALTERNATIVESTO BREASTFEEDING

• UNICEF / WHO / UNAIDS consensus, 1998 confirmed
  in 2000
•  The need to encourage the use of alternatives
  to breastfeeding by HIV-infected mothers with
  methods adpated to their individual situation 

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FORMULA FEEDING

• Formula feeding should be considered as a
  medicine
• Adequately subsidized
• With continuous supplies
• With appropriate support and counselling
• With monitoring of adherence
• With monitoring of side effects
• Targeted to those women and children with
  greatest needs

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ANTIRETROVIRALS AND BREASTFEEDING

• SIMBA Trial, Paris 2003 (LB 7)
• ZDV DDI gt36 wks til Day 7 postpartum
• 3TC or NVP until 1 month after cessation of
  breastfeeding
• Median CD4 427 cells/mm3
• 100 days of exclusive breastfeeding (88)
• Postnatal transmission 1.1 (3TC) vs 0.6 NVP
  (p0.60)

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Prevention of HIV transmission through
breastfeedingPublic health

• WHAT ABOUT A MODULATED STRATEGY OF PREVENTION OF
  POSTNATAL TRANSMISSION ?
• HAART Formula Feeding lt200 CD4
• Exclusive breastfeeding for 3-4 months gt350 CD4
  (gt200?)

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Prevention of HIV transmission through
breastfeeding(2) Research

• The current research agenda is quite full
• Results expected within three years
• Neonatal vaccination and sustained release NVP ?
• Joining forces of key stakeholders in PMTCT MCH
  fields

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PREVENTION OF HIV TRANSMISSIONTHROUGH
BREASTFEEDINGSTRENGTHENING THE RESEARCH AGENDAA
THINK-TANK WORKSHOPGHENT (BELGIUM), December
12-13, 2002

• International AIDS Society Elizabeth Glaser
  Pediatric AIDS Foundation

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A THINK-TANK WORKSHOP OF THE GHENT-IAS
GROUPGHENT (BELGIUM), December 12-13, 2002

• Presentations posted at
• http//www.isped.u-bordeaux2.fr/ISPED/RECHERCHE/GH
  ENT/UK-TME-accueil.htm
• http//www.GhentGroup.org
• Four summary papers
• Breastfeeding and transmission of HIV-1
• Modifying infant feeding practices
• Antiretroviral drugs from animal studies to
  randomized clinical trials
• Immunoprophylaxis

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