Emily Chambers Sharpe of the Office of the Global AIDS Coordinator discusses the importance of nutrition and the relationship between ARVs and breastfeeding in preventing mother to child transmission of HIV.

1. ADDRESSING AND UNDERSTANDING
NUTRITION AS A COMPONENT OF
GLOBAL HEALTH
INTEGRATING NUTRITION AND PMTCT PROGRAMS
RESOURCES FOR NUTRITION AND GLOBAL
HEALTH
Emily E. Chambers Sharpe, MPH
CCIH 26th Annual Conference, June 10, 2012

2. U.S. Government Approach to Nutrition
 Target the first 1,000 days:
 Critical period from pregnancy to two years of age is when infants and
children are most vulnerable and that nutrition interventions during this
period have immediate and long-term consequences.
 Improve maternal nutrition
 Promote exclusive breastfeeding
 Encourage diet quality and diversification for mothers and infants.
Source: USAID‟s Global Health Strategic Framework: Better Health for Development, FY 2012-FY 2016

3. U.S. Government Approach to Nutrition
 Balance prevention and treatment of undernutrition:
 Prevention of undernutrition in the 1,000 day window of opportunity is at
the core of USAID‟s strategy.
 Treatment of moderate and severe undernutrition is necessary.
 Nutritionally dense, ready-to-use foods enhances the capability to treat
undernutrition,
 Latest developments in nutrition science into food assistance programs
seeks to advance the opportunities to prevent undernutrition
 Scale-up of community-based management of acute undernutrition.
 Bring nutrition programs to scale: Building on earlier successful pilot
programs, USG is working with country governments to bring nutrition
programs to national scale.
Source: USAID‟s Global Health Strategic Framework: Better Health for Development, FY 2012-FY 2016

4. Key Nutrition Outcomes for US
Government
Reduce Stunting/Wasted/Underweight ……..
% Change in prevalence of stunted children
under five years of age
 % Change in prevalence of wasted children under
five years of age
 % Change in prevalence of underweight women

5. HIV & Nutrition:
“Slim”
HIV:
• Loss of appetite
• Impaired nutrient absorption
• Altered nutrient metabolism
• Increased nutrient requirements
Malnutrition:
• Weakened immune system
• Increased susceptibility to OIs &
comorbidities
• Wasting & increased mortality
• Poorer adherence & response to
treatment

6. The NACS Approach -- Nutrition
Assessment, Counseling & Support
Clinical
Mgmt &
PMTCT
Services:
ART
Opportunistic
Assessme Infections
Support:
nt: Chronic Food by
Prescription:
Anthropometri disease
therapeutic &
Community
c Counselin
management
Services:
supplementary
Biochemical g: feeding Nutrition surveillance
Clinical Adherence & clinic referrals
MN
Dietary Diet Nutrition counseling &
supplements
Food Security WASH support within home-
Livelihood &
Infant/child food security based care
feeding referrals Economic
Referral to strengthening,
Community livelihood & food
Services security support
Entry Points: Clinic
ANC/PMTCT
Clinical referral
Community
Community Referral

7. WHO 2010 Revisions
http://www.who.int/hiv/en/

8. PMTCT, Postnatal Care, and Infant
Feeding
IMPACT
Increase HIV-Free Survival (HFS) among HIV-exposed infants up to 24 months
of age
A PARTNERSHIP FOR HIV-FEE SURVIVAL TO IMPLEMENT THE WHO 2010
PMTCT, ART, & INFANT FEEDING GUIDELINES
PEPFAR, WHO, IHI, HCI, FANTA-2, UNICEF, EGPAF, M2M & Country
Implementing Partners

9. Revised WHO Recommendations on the use of
antiretroviral drugs for treating pregnant
women and preventing HIV infection in infants
(2010)
 Eligibility criteria for ART
 CD4 count <350, irrespective of clinical stage
 Clinical stage 3 or 4, irrespective of CD4 count
 The 2010 recommendations … provide two alternative
options for women who are not on ART and breastfeed:
 A) daily NVP for infants from birth until the end of the breastfeeding period.
or
 B) continued regimen of triple ARV therapy to the mother until the end of the
breastfeeding period.
 ARV prophylaxis …. should continue until one week after all
exposure to breast milk has ended.

10. Maternal health and child outcomes
100%  Strong relationship between
maternal health and both HIV
90% In the absence of any transmission risk and also child
interventions about survival
80% 36% infants will
60% become infected.  ~40% HIV-infected mothers have
70% CD4 counts <350
26 of the infants will be but account for 80% transmissions
60% born to mothers with (26/36) and 80% HIV-associated
50% CD4 counts <350 'maternal mortality'
40%
30% • Maternal ART improves child
10 survival independent of the
20% 40%
effect on transmission
10% 26
Mothers with CD4>350
0% Mothers with CD4<350
HIV-infected Infected infants
mothers

11. Mother and child survival
in the context of HIV are inextricably linked
Pathophysiology Clinical interventions
 80% HIV-related maternal deaths  ART significantly improves CD4 counts,
are in women with CD4 counts reduces maternal mortality and
<350/ml improves AIDS free survival
 Effective ARV prophylaxis and ART
 80% infants who become HIV- reduces peripartum transmission to
infected are born to mothers with less than 2%
CD4 counts <350/ml
 ARV interventions also significantly
 Infants who are HIV infected are reduce postnatal transmission
17-30 times more likely to die  HIV-infected mothers can breastfeed
 When a mother with HIV dies, her infants with minimal risk of
children are at least 4 times more transmission and thereby improve HIV-
likely to die free survival

12. National (or sub-national) health authorities should
decide whether health services will principally
counsel and support mothers known to be HIV-
infected to:
breastfeed and receive ARV interventions, or,
avoid all breastfeeding,
as the strategy that will most likely give infants the greatest
chance of HIV-free survival
This decision should be based on international recommendations and consideration
of the socio-economic and cultural contexts of the populations served by Maternal
and Child Health services, the availability and quality of health services, the local
epidemiology including HIV prevalence among pregnant women and main causes of
infant and child mortality and maternal and child under-nutrition.

13. HIV free survival
 Children of HIV-infected mothers remaining HIV
uninfected and staying alive
 Policy, interventions and programmes (including
cost-effectiveness) should be judged on their ability
to promote HIV free survival among all children and
the health and survival of mothers …
… and not just HIV transmissions averted

14. J Acquir.Immune.Defic.Syndr.
2010;53(1):28-35
Decreased survival among
infants who stopped BF early
or who were never BF.
AHR = 6.19; (95% CI 1.41–27.0,
P = 0.015)
97% infants were tested at
6 wks – none infected.
Difference was independent
of maternal health or if
receiving ART

15. Replacement feeding in PMTCT sites
 Sample of milk collected from bottles (n=94) being
offered to infants brought by mothers to PMTCT clinic
follow-up visits
 63% heavily contaminated with E.coli
 28% diluted (based on protein concentration)
In spite of
 All mothers having completed • 15-20% mothers reported free
12 years of education FF being used for something
 72% having fridges other than index child
 All received good counselling on IFP – Sold
– Exchanged
• 50-75% reported running out
– Mainly because of clinic
supply
Bergstrom. Acta Paeds 2007

16. Knowledge of nurses and counsellors about risk of BF
transmission
160
Number of respondents
Response to question: If 100 HIV-infected
140
women breastfeed until their children are
120 two years old how many children will be
100 infected at 2 years of age? (mother and child
do not receive any antiretroviral medicines)
80
60
40
20
0
0 - 20 20 - 40 40 - 60 60 - 80 80 - 100 Don't Know
Correct answer ~14 Number of infants infected
Chopra and Rollins, Arch. Dis. Child. 2008

17. Feeding at some PMTCT sites in SA
100
90
80
70
60
50 BF
40 FF
30
20
10
0
Rietvlei ZeerustShongwe COSH Durban Pmb
Rural Rural Rural Rural Urban Urban
The quality of infant feeding
counselling translated into
HIV free survival of infants
Woldenbeset. IAS 2009

18. Why does WHO recommend that national
authorities promote a single infant feeding
strategy for all HIV-infected mothers and their
infants?
 High quality evidence that ARVs very significantly
reduce the risk of HIV transmission through
breastfeeding
 Documented evidence of increased mortality
when replacements feeds are given
inappropriately in the context of HIV
 Even with good protocols and training, difficult to
assure high quality counseling and support for all
infant feeding practices
 Cost effective interventions are available that
improve survival of mothers and infants and
reduce transmission

19. What‟s happening in countries:
 Revising positions and policies around HIV
and infant feeding
 Evidence reviews
 Assessments of the type of epidemic
 Assess the contribution of infectious diseases and
malnutrition to infant mortality
 Assess quality and coverage of PMTCT/ART
services
 Consider financial and human resource costs of
options
 Formulate national infant feeding and HIV

20. How does a mother decide
whether or not to attend for
care and how she feeds her
child?
 If she considers that health
services serve her interests
and those of her child
 If benefits of attendance
are not prejudiced by the
way she is received by
health staff
 If the sentiments of
families and communities
are favourable towards the
health services

21. Mma bana study
2 randomised arms and one observational
Mothers not eligible for ART received either:
lopinavir/ritonavir and combivir } for 6m
or abacavir/AZT/3TC } while BF
Mothers eligible for ART – outcomes observed
10
9
transmission %
8
Infant HIV
7
6
5
4
3
2
1
0 1248 pregnant women referred to study
Mothers not eligible for Observational
ART sites. After counselling about study
interventions, 110 (8.8%) declined
enrolment as preferred to give formula
feeds.

22. What wins?
Effective
interventions
Risk factors
Health system
issues Gerry Boon

23. What wins?
Risk factors
Effective
interventions
Health system
issues Gerry Boon

24. Guidelines, toolkits, and training
abound…
 BUT there is little
experience on
scaling up the
postnatal continuum
of PMTCT care,
particularly around
infant and child
feeding

25. How to we go „to scale‟?
How can training bring about real change?
Affordability, equity, and sustainability?
Integrating nutrition, IMCI, TB, HIV, and other
programs?

26. “Real Life” issues:
PMTCT programme
attend Attend HAART facility
Access
ANC clinic
issues Attend facility Attend postnatal care
based delivery
Counseled and
tested for HIV, Start on
PMTCT CD4 HAART
Program referred for
delivery HAART
issues CD4 Manage
result AZT/sdNVP mother-
Started on
in labour child pairs
AZT Postnatal
Start IF and counseling, in high HIV
infant ARVs tracking burden
and testing countries

27. Gap between clinical trial and “real life” PMTCT
implementation
% HIV transmission 25
20
15 clinical trials
10 real life
implementation
5
0
NVP AZT/HAART
Rollins N,. AIDS 21: 1341–1347 2007
Horwood 2010

28. Dependence of postnatal HIV care on
reliable MNCH delivery system
Continuum Multi-step
MCH System Parts of the PMTCT
of MCH care PMTCT care
Performance programme affected
attend ANC clinic HIV
counseling, HIV,CD4
testing (M)
Attend ANC more Access to HAART and
than 4 times AZT (M)
Attend skilled Access to intra-partum
delivery NVP/AZT (M)
53%
HIV and feeding
Establish early counseling (M).
breast feeding Access to post-partum
NVP/AZT (M&I)
53%
Predicted
HIV and feeding
Attend postnatal counseling (M) Transmission
clinic for 3 x DPT HIV/CD4 testing (M&I). ???
86% Access to post-partum
NVP/AZT (M&I)

29. PMTCT and NACS Continuum of
Care
ANC Visits Delivery/Birt Early Postnatal EPI 6 months 9 months 12 months 15, 18, 21 &
h Postnatal Visits 6, 10 & 24 months
14 weeks
• PITC • CD4 & • CD4 & • CD4 & • CD4 & • CD4 & • CD4 & • CD4 &
Women: • CD4 & clinical clinical clinical mgmt clinical clinical mgmt clinical clinical
clinical mgmt mgmt • ART Tx or mgmt • ART Tx or mgmt mgmt
mgmt • ART Tx or • ART Tx or prophylaxis • ART Tx or prophylaxis • ART Tx or • ART Tx or
• ART Tx or prophylaxis prophylaxis • Maternal prophylaxis • Maternal prophylaxis prophylaxis
prophylaxis • Maternal • Maternal NACS • Maternal NACS • Maternal • Maternal
• Maternal NACS NACS • Infant NACS • Infant NACS NACS
NACS • Infant • Infant feeding • Infant feeding • Infant • Infant
• Infant feeding feeding counseling -- feeding counseling -- feeding feeding
feeding counseling -- counseling -- EBF/ERF counseling -- CF counseling - counseling -
counseling EBF/ERF EBF/ERF • FP CF • FP - weaning - weaning
• FP (AFASS) (AFASS)
• FP • FP
• Initiation of • EBF/ERF • EBF/ERF • CF • CF • CF/weaning • CF/weanin
Infants: EBF/ERF • ART • ART • ART • ART • ART g
• ART prophylaxis prophylaxis prophylaxis prophylaxis prophylaxis • ART
EBF = prophylaxis • Infant • Infant • Infant • Infant • Infant prophylaxis
exclusive NACS/Growt NACS/Growt NACS/Growt NACS/Growt NACS/Grow • Infant
breast h h monitoring h monitoring h monitoring th NACS/Gro
feeding monitoring • EID • EPI/measles monitoring wth
ERF = • CTX monitoring
exclusive
• DPT 1,2,3 • Post-
replacement
feeding
weaning
CF = comple- HIV testing
mentary
feeding

30. U.S. Government Centrally-Funded
Nutrition Programs through USAID
1. Child Survival Health Grants Program (CSHGP), Maternal and Child Health
Integrated Program (MCHIP)-Nutrition (PATH) & CORE Group
2. Food and Nutrition Technical Assistance Project 3 (FANTA)
3. Food Aid Nutrition Education Program (FANEP)
4. Iodine Deficiency Disorder (UNICEF)
5. Nutrition Collaborative Research Support Program (Nutrition CRSP)
6. Technical and Operational Performance Support Program (TOPS)
7. Strengthening Partnerships, Results and Innovation for Nutrition Globally
(SPRING)
8. Global Alliance to Improve Nutrition (GAIN)
9. Conducting Research on Moderate Acute Malnutrition in Humanitarian
Emergencies
Key Wraparound Programs
1. Livelihood & Food Security Technical Assistance Project (LIFT)
(microlinks.kdid.org/lift)
2. Alive and Thrive (BCC)

31. Nutrition Resources Online
 www.fantaproject.org
 www.basics.org/documents/pdf/ENA.pdf
 www.who.int/nutrition/publications/en/
 www.unicef.org/media/files/Community_Based
_Management_of_Severe_Acute_Malnutrition.
pdf

32. Nutrition Resources Online
 www.unscn.org/en/nut-working/
 www.thousanddays.org
 www.bread.org/hunger/maternal-child-
nutrition/women-of-faith-for-the-1000.html
 http://apps.who.int/nutrition/landscape/report.aspx
?iso=ETH&rid=161&template=nutrition&goButton
=Go