for AIDS -patients
see also : "HIV and nutrition" (1998)
|Nutrition for AIDS -patients||Marti J. van Liere||28.05.99|
|Re: Nutrition for AIDS -patients||Dominique Bounie||29.05.99|
|Nutrition for AIDS -patients||Arabella Duffield||31.05.99|
|Re: Nutrition for AIDS -patients||Marlou Bijlsma||08.06.99|
|Nutrition and HIV||Veronique Priem||06.08.99|
|Re: Nutrition and HIV||Carlo Agostoni||06.08.99|
|First evidence that exclusive breastfeeding does not transmit HIV||Ted Greiner||08.08.99|
|no title||Lilian Marovatsanga||10.08.99|
|HIV/AIDS and breastfeeding||Florence Egal||26.08.99|
|Breastfeeding "trainers"||C. Schuftan + T. Greiner||30.08.99|
|HIV and infant feeding||Jay Ross||04.10.99|
|Nutrition education for HIV/AIDS||Florence Egal||15.11.99|
|Community Projects for malnutrition and HIV mothers||Annatjie Smith||15.11.99|
|Food supplementation to HIV+ patients in 3rd world countries||Liana Steenkamp||16.11.99|
|nutrition guide for people with HIV - Zimbabwe||Marlou Bijlsma||18.11.99|
|Re: Food supplementation to HIV+ patients in 3rd world countries||George Kent||18.11.99|
From: "M.v.Liere" <M.v.Liereatkit.nl>
Subject: Nutrition for AIDS -patients
Date: Fri, 28 May 1999 15:59:41 +0200
Can somebody give me some scientific references (or mail their papers?) concerning Nutrition (advice, considerations) for AIDS-patients.
I am preparing a talk on the impact of AIDS on the health and nutritional status of PLWHA and their families.
Thank you for your help
Marti J. van Liere (PhD), nutritionist
Department of Health Care and Disease Control Royal Tropical Institute (KIT), Maurits kade 63, PO Box 95001, 1090 HA Amsterdam, The Nethrlands
phone : +31 20 5688 497, fax : +31 20 5688 444
Date: Sat, 29 May 1999 08:34:39 +0200
From: Dominique.Bounieatuniv-lille1.fr (Dominique Bounie)
Subject: Ngonut: Re: Nutrition for AIDS -patients
Last year, there were some contributions about this subject on NGONUT. To consult them, go to : http://www.univ-lille1.fr/pfeda, then go to the NGONUT page, then 1998, then click on "HIV and nutrition"
Date: Mon, 31 May 1999 10:56:18 +0100
Subject: Nutrition for AIDS patients
The latest issue of the SCN news is concerned with nutrition and HIV/AIDS.
Although this is by no means a comprehensive review there may be some articles and/or references of interest to you. This publication can be downloaded from the ACC/SCN website (see address below). If you would like a hard copy please let me know.
UN SYSTEM'S FORUM FOR NUTRITION - UN ACC Sub-Committee on Nutrition, c/o World Health Organization
20 Avenue Appia, 1211 Geneva 27, Switzerland
phone: + 41-22-791 04 56, fax: + 41-22-798 88 91
EMail: accscnatwho.ch , http://www.unsystem.org/accscn/
Date: Tue, 08 Jun 1999 17:45:57 +0100
From: Marlou Bijlsma <pzaagatmango.zw>
Subject: Nutrition for AIDS patients
Dear Marti van Liere
Some references I found useful:
I haven't seen the book but read a reference of 'Nutrients and Foods in AIDS', by R Watson (ed) CRC Press, Boca Raton, 1998. The reference says it is more on nutrients than on foods, though.
I have an earlier book edited by the same Ronald Watson: Nutrition and AIDS, 1994 (same publishers) which is very useful. In the same series (CRC series on modern nutrition) is also a more practical book by S Bahl and ???, called something like 'nutritional support for patients with HIV and AIDS, a guide for patients and their care givers', 1995 (same publishers). It is more practical but very american (for us in Zimbabwe).
I think you have or the KIT has our booklet 'Living positively, nutrition guide for people with HIV', which applies more to resourse poor settings.
PO Box MP 600, Mount Pleasant, Harare, Zimbabwe
phone +263 4 336421, fax +263 4 336491
Date: Fri, 06 Aug 1999 11:17:05 +0100
Subject: Nutrition and HIV
Medecins sans frontičres is managing several programmes on HIV control and treatment in the developing world.
As such, we are very interested, among other actions, in the nutriment (vitamins and oligo-elements) supplementation of HIV + patients. Yet we have more questions than answers. We would very much appreciate your advice on the following points.
At first, a short summary of what is currently known:
1. Micronutriments are very important in the immune system function. The anti-oxydative properties of some of them could even have a specific action on the HIV viral replication by inhibition of the viral reverse transcriptase.
2. Blood measurements of micronutriments in asymptomatic, well nourished infected adults show a frequent and important deficit even at an early stage of the infection and even if the daily input is equal or superior to what is usually daily recommended. This could be explained by a chronic malabsorption, linked to the HIV specific enteropathy.
3. Prospectives cohortes, in Miami and Baltimore showed that this deficit is correlated to higher mortality rates (vit.A, B12, Zinc, selenium) and to a faster progression towards the AIDS stage (Vit A, B6, B12, D, E, Zn).
4. Restoration of normal blood contents can be obtained only if oral intake are far superior to the usual daily recommended intake, for vit A, B1, B2, B6, C, E, and Zn (5 to 6 times the daily recommended intake). Vit B12 necessitates parenteral administration.
5. Studies in the USA showed a strong correlation between levels of nutriment intake and patient's survival. But each nutriment has to be thoroughly measured: thresholds and narrow ranges are important to consider: B Vitamins are efficacious over a certain threshold A vitamin has to respect a U shaped curve. Zinc is necessary, within narrow margins. Multivitamins and oligo-elements are more promising than one alone.
For HIV + pregnant women, the Harward's team (main investigator, Dr Fawzi) showed in a randomized placebo-control study in Tanzania, a better pronostic for the newborn (less hypotrophia, premature births and perinatal mortality) with micronutriments supplementation given from the second trimester until delivery.
From the litterature, here is a possible recommended regimen for HIV+ patients, and for HIV + pregnant women.
HIV + Patients
HIV + & pregnant
9000 - 20 000 IU
Due to lack of controlled studies and heterogenous characters of the descriptive studies, even if strong presumption does exist, it is not yet possible to establish formally the causal link(s) between nutriment deficiency and progression of the HIV infection.
Question 1: Following the current knowledge, can we propose a daily supplementation to "our" HIV + patients using the formula 1 dosage, without fearing any toxicity?
This question is of major concern for the population we care for, as most of the time, they are chronically deficient in several nutriments.
Question 2: If the risk of toxicity is zero with this dosage, is it absolutely necessary to conduct a randomized placebo-control study to evaluate formally its efficacy, knowing that this will be very complicated to realize, that the importance of this therapy has no common grounds with the antiretroviral one and that manufacturing costs can be reduced to a mimimum?
Question 3: HIV + pregnant women supplementation showed a major impact on birth outcome. This supplement (formula 2) is somehow different from the one for the HIV + adults (formula 1). Could we think of a unique formula, useful for both population, without any toxic risk? Which one?
Question 4: Dr.Fawzi's study showed a major impact for birth outcomes of children born to HIV + women. Do you think that it would be reasonable to propose this supplementation to all pregnant women, regardless of their HIV status?
Be sure that these questions are very important for us and our patients. It does'not replace the problem of access to HAART. It is complementary.
Thank you for all the support you can give us.
Answers can be send to Elisabeth Szumilin and/or Veronique Priem.
MSF - Paris
Elisabeth Szumilin: eszumilinatmsf.org
Veronique Priem: vpriematmsf.org
Date: Fri, 06 Aug 1999 13:04:09 +0200
From: carlo agostoni <agostocattin.it>
Subject: Re: Nutrition and HIV
I have just read these stimulating questions, so I give a further input before any comment (I need more time to reflect..).
Please do not forget that:
1. HIV-infected children at various stages of disease have low levels of arachidonic acid and docosahexaenoic acid
2. HIV-infected children (published data) and even uninfected infants (personal preliminary observations) born to HIV- infected mothers (in good nutrtional status) have 10-15% less linoleic acid than healthy counterparts of the same age. This is another relevant point due to the connections between mineral and vitamin metabolism with the essential fatty acid status.
So, I would like to underline the opportunity to enrich supplements for pregnant HIV women and HIV infants with a quote of polyunsaturated fats, at least linoleic acid, not only to improve the nutritional status but to maximize also the effects of the micronutrient supplementation.
Date: Sun, 08 Aug 1999 12:00:17 +0100
Subject: First evidence that exclusive breastfeeding does not transmit HIV
Finally a prospective study has been done on mother-to-child transmission of HIV through breast milk using the correct definition for exclusive breastfeeding. The study concluded that when breastfeeding is exclusive the entire time from birth, it does not appear to transmit HIV from an HIV-positive mother to an HIV-negative baby.
The paper is entitled "Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study" and is published in the August 7, 1999 issue of the medical journal Lancet. the authors, A. Coutsoudis et al., found that transmission rates among those who were exclusively breast fed from birth were actually lower at three months than among those not breast fed at all, and much lower than those breast fed but not exclusively. Though the difference was not statistically significant for those not breast fed at all, the authors write that this "raises a possibility that virus acquired during delivery could have been neutralised by immune factors present in breastmilk but not in formula feeds."
In any case, infants who were non-exclusively breast fed (receiving water, tea, juice, milk, solids or other things in addition to breast milk) suffered statistically higher rates of early postnatal transmission of HIV.
The most likely explanation for this is that anything except breast milk can damage the lining of the infant's alimentary tract in various ways. The authors point out that "once the integrity of mucosal surfaces has been compromised by infection, allergens or trauma, the passage of HIV-1 across mucous membranes into body tissues is facilitated."
Obviously more studies are needed, but I see two implications that emerge already and should be given serious consideration by UNAIDS/WHO/UNICEF in their continued implementation of their new guidelines on HIV and breastfeeding:
1. In ongoing counselling and pilot testing in poorer areas, much more emphasis should be placed on an option that so far has received little attention: exclusive breastfeeding for a few months followed by either heat treatment of expressed breast milk or rapid cessation of breastfeeding.
Relative risks for morbidity and mortality among infants not breast fed are much greater in these first months. After a few months, it is much easier for the child to do relatively well on homemade formulas or other substitutes more affordable to poorer families, and the child can better tolerate solid foods.
Also, research should be done to determine what rates of transmission occur among women who continue breastfeeding with solid foods after varying periods of exclusive breastfeeding. For example, after six months or longer or exclusive breastfeeding, the child may better be able to tolerate other foods and resist infection and thus less gut mucosal injury and disruption of immune barriers may occur.
2. The best way to reduce overall rates of postnatal mother-to-child transmission of HIV in developing countries is to promote exclusive breastfeeding from birth for all newborns. Most women who are HIV positive during pregnancy do not know it and this is not likely to change for a long time in many countries, for both cultural and economic reasons.
The same issue of Lancet also contains a commentary on this article by M-L Newell who believes that "further research is urgently needed to confirm and elucidate the findings" before changing public health recommendations, but calls for a "re-evaluation of the role of breastfeeding in the transmission of HIV-1."
Sadly, we have no agreed-upon indicator to tell us how many infants are "exclusively breast-fed from birth." This is needed to inform policy makers on the current situation and as a baseline to judge the success of promotional efforts.
Such an indicator would be easy to obtain data on. In any breastfeeding survey, whenever a mother says she gave nothing but breastmilk to her baby in the past 24 hours, the interviewer would ask, "Have you EVER given anything besides breast milk?"
I recently corresponded with the person responsible for developing the breastfeeding component of the new Demographic and Health Survey questionnaire about adding it. Unfortunately, she would not agree to use it, partly out of fear that the resulting figure would be so low that it might discourage policy makers from trying to do anything about it.
With best regards,
Ted Greiner, Coordinator
World Alliance for Breastfeeding Action (WABA) Research Task Force WABA website: http://www.waba.org.br
Personal website: http://www.welcome.to/breastfeeding
From: Lilian Marovatsanga
Date: Tue, 10 Aug 1999 11:51:07 +0100 (BST)
Thank you for all this valuable information on AIDS. The IFNFS has experience in running AIDS and nutrition training programmes to train the trainers. The courses are normally 1-2 weeks depending on the materials to be delivered and also the background and level of the participants. We can tailor make the courses to suit individual or organization's requirements. The costs do not vary much and can be negotiated for large number of participants. The materials can be adjusted to suit individual or organizational requirements.
We have 60-100 page modules, posters, leaflets, newsletters, pamphlets, videos and posters etc. These can be a purchased at a nominal fee to cover the costs of preparation. bulk orders are accepted even on short notice.
We also can visit clients and offer courses and provide course materials, show video etc and also do video filming of AIDS cases etc.
We also raise funds for training materials or equipment or any other equipment or anything that may alleviate the plight of the suffering people in our communities. if you know the contact address of people or organization which fund courses of this nature , please contact our office on 263 4 307762 or fax 336491 or 303211 ext 1413 o 1909.
thank you in advance.
Lilian Marovatsanga (DR)
Date: Thu, 26 Aug 1999 16:55:33 +0200
From: "Egal, Florence (ESNP)" <Florence.Egalatfao.org>
Subject: HIV/AIDS and breastfeeding
I hope some of you are not on holidays...
We are looking for information on the effect of breastfeeding on the evolution of HIV/AIDS in the mother. All publications we have reviewed so far are concerned with the child.
Breastfeeding after all does draw on the mother's nutritional reserves. As such one could wonder whether breastfeeding may not accelerate the onset of the disease in a sero-positive mother and the fatal outcome in an AIDS mother. Help welcome.
Nutrition Programmes Service, FAO
Date: Tue, 31 Aug 1999 15:33:26 +0100
From: Michael Golden <refugeesatabdn.ac.uk>
Subject: Breastfeeding "trainers" - Claudio Schuftan answered by Ted Greiner
You say, lack of much specific knowledge and skills among health workers may be a major reason why nothing much has happened and is happening in improving breastfeeding and exclusive breastfeeding rates in most of the world now.
Aren't you putting too much trust in the training as such? What about the A+P in the KAP? Isn't the bottleneck rather found at the earlier (or even post-training) stage of enough of us (threshold) giving a damn?
And that's not only true for breastfeeding... Withouit playing down the importance of contents, words like commitment, creative anger, motivation, dedication, wanting to make a difference, militancy flash in front of me when I say this...
You also say that being a professor, a journal editor or an advanced researcher makes no difference. Being a professor of breastfeeding would then fall under a different category?
Nice to hear from you! Well, probably writing within that state of creative anger that you refer to led me to be a bit unclear. Also I am always assuming that people dealing with other aspects of nutrition find breastfeeding boring, so I try to be very short in what I write.
First, I can say that, starting with meetings at the end of the 1970s, I have been advocating that community-based efforts to protect and support breastfeeding deserve priority ahead of health-worker based approaches. An empowered mother who meets an ignorant health worker will at least not get harmed. Just training health workers gives them even more power to lord over mothers and order them around and I fear that in the case of breastfeeding this will often do harm. Women need to be confident in their own bodies and their own skills for it to work well. (This is not to say that they sometimes lack these skills and can benefit from help from a trained health worker.)
Please don't jump to the conclusion that I am then saying we should not train health workers. The WHO 40-hour course for example gives a lot of attention to teaching health workers to listen to mothers and observe them before intervening. Others at UNICEF and elsewhere also seem to agree that a "hands off" approach is a good idea--intervene only when you see it is necessary.
But health workers often make their living from having more knowledge (power) than their patients (customers) and thus I am still doubtful, no matter how good the training, that we can turn health workers into people who empower mothers in ways that help mothers who need help to successfully breast feed and avoid disrupting breastfeeding when it is going well.
I have worked myself very little with breastfeeding training, however, and have no research findings to support my fears I must admit. I work more with NGOs, IBFAN and now a lot in recent years with WABA. I am hoping to be able to do some research in the Recife area where the NGO Origem has been doing community-based breastfeeding work in slum areas for over a decade but it has never been evaluated.
Thus may main purpose in that short message was to raise awareness that the usual cop-out of saying breastfeeding can just in integrated into other ongoing things probably never works. Everyone thinks they are already doing everything possible and if anything more can be done it is usually to tell mothers "breast is best." An Ethiopian woman once told me that in her culture that carried a hidden message: "Therefore the alternative is also good."
Indeed, I have seen a number of side-effects that can result from "breastfeeding promotion", particularly where protective and supportive measures are not already in place. Diane Wiessinger (http://www.geocities.com/Heartland/Plains/4072/wylang.html)has pointed out that praises for breastfeeding are actually an incorrect use of language.
What I also meant of course was that the training someone might get to be a professor, researcher or whatever, like in the case of a health worker, did not necessarily mean they have even common sense about breastfeeding. I was at the first WHO expert meeting on breastfeeding and HIV in 1987. Sida sent me as an observer. USAID sent an observer also. None of the 20 odd experts brought by WHO had any particular expertise on breastfeeding. At lunch on the final day of the meeting, she and I got the most "breastfeeding friendly" of the experts to threaten WHO with a minority statement if they did not agree to what later became the final sentence of the statement that emerged from that meeting (and was repeated in the formal WHO statement in 1994) which said that in areas where infection is the main cause of infant death, women should breast feed irrespective of their HIV status. I am horrified how the research on HIV and breastfeeding since 1987 has been so poorly done, basically repeating the mistakes made in the 60s which led to the conclusion widely shared among physicians and researchers at that time that breastfeeding had no advantages over bottle feeding.
So far I have yet to see a large-scale breastfeeding survey that includes the variable we need: "% exclusively breastfed from birth" by age. The DHS surveys use variations of the WHO indicator (% exclusively breast-fed yesterday among babies 0-4 months of age). Policy makers and even many researchers do not realize the huge difference bewteen the two. The latter is about 50% in India whereas I imagine that by about two months of age it would be close to zero in the former case. We at Uppsala University will soon publish a paper comparing the two indicators and showing the big difference it makes in a sample of Swedish women who actually come closer to exclusive breastfeeding than is the case in any developing country I have seen good data from.
With all best regards,
Ted Greiner, PhD
Section for International Child Health, Department of Women's and Children's Health Uppsala University, Entrance 11
751 85 Uppsala, Sweden
Date: Mon, 04 Oct 1999 11:10:39 +0100
From: jay.rossatns.sympatico.ca (Jay Ross)
Subject: HIV and infant feeding
Highlights from the 2nd Conference on Global Strategies for the Prevention of HIV
Transmission from Mothers to Infants. (September 1-6, 1999, Montreal)
Jay Ross, LINKAGES and Ellen Piwoz, SARA Project The Academy for Educational Development
In this second conference on Global Strategies for the Prevention of HIV Transmission from Mothers to Infants most discussion centered around two issues:
1) the relative efficacy of nevirapine, given at the onset of labor and to the newborn breastfeeding infant, which at US$4 per treatment course is substantially less expensive than short course regimens of zidovidine (AZT); and
2) the need to understand more fully the transmission and mortality risks associated with different infant feeding patterns (e.g., exclusive breastfeeding, early weaning) and to identify effective strategies for making breastfeeding safer for HIV+ women (e.g. drug regimens, other non-ARV (anti-retro-viral) behaviors/interventions). These issues emerged from growing evidence that it is difficult, if not impossible, for the majority of HIV+ women in Africa (and other resource-poor settings) to safely and continuously formula-feed (not breastfeed) their babies; that exclusive breastfeeding may reduce the risk of HIV transmission through breastmilk (and that mixed feeding may convey the highest risk); and that avoiding and managing breast infections in early infancy may reduce transmission risks associated with breastfeeding.
Experience with HIV voluntary counseling and testing services for pregnant women and their partners; the impact of non-antiretroviral drug interventions; studies on ARV drug toxicity in infants; progress with the UNAIDS pilot projects and other programs to reduce MTCT in several countries were discussed.
Several new constructs, such as the proposed change of terminology from mother-to-child transmission of HIV (which places the responsibility on the mother alone) to parental transmission of HIV (which also emphasizes the importance of primary prevention and the role of the father), were suggested by keynote speakers, who included the Ministers of Health from Canada, Uganda, and Zambia among others. An official "Call to Action" to commit resources to implementing "what we know works" was circulated among conference participants and a US$ 1 million contribution was made by the Elizabeth Glaser Pediatric AIDS Foundation. Throughout the meeting, most speakers emphasized the need to enhance efforts at primary prevention as a major strategy for reducing pediatric HIV infection.
The key presentations on issues of interest to nutrition and child survival programs were as follows:
1) Dr. Anna Coutsoudis presented the results of a longitudinal, observational study, reported recently in the Lancet (354:471-476, 1999), on the association of transmission risk with breastfeeding patterns. A group of infants exclusively breastfed to at least three months had a lower transmission risk at three months (14.6%) than did those who also received other fluids or foods (24.1%). Coutsoudis pointed out that this is a 48% reduction, similar in magnitude to the nevirapine trial results. Moreover, the 14.6% risk among exclusively breastfed infant was statistically not different than that among infants who were formula fed (18.8%). Coutsoudis presented new data on the infection status of babies at 15 months, when 21.8% of the exclusively breastfed babies were HIV+, compared to 28.2% of the mixed fed babies, a statistically significant difference suggesting continued protection by early exclusive breastfeeding. Again, the transmission risk among exclusively breastfed infants was not statistically different from that among formula fed infants (19.4%).
There was considerable discussion: questions remain about whether illness associated with HIV infection may have resulted in mixed feeding. When asked about the possibility of reverse causality, Coutsoudis replied "when asked why they introduced other fluids or foods, most mothers responded that the baby was hungry or that there was not enough breastmilk, rather than that the infant was sick". Maternal illness was too rare to account for the findings. Further analysis of infant and maternal morbidity data is currently being conducted.
WHO and UNICEF issued a statement (dated August 27) in response to the paper's publication in Lancet indicating that while important, the findings of this study were not going to result in a change in their current policy on informed choice about HIV and infant feeding. Although we are hopeful that these findings will be confirmed, there is understandable reluctance to jump too quickly to the conclusion that exclusive breastfeeding is as protective as it may seem. It is hopeful that these findings will stimulate new research on exclusive breastfeeding and MTCT, and ways to promote safe breastfeeding among HIV+ women who make the informed choice to breastfeed their babies. [This study was part of a vitamin A intervention trial. The results of this trial, reported recently (AIDS 13:1517-1524,1999) and at this meeting suggest that vitamin A given to the mother has no effect on the overall risk of MTCT.]
2) Dr. Ruth Nduati presented final but as yet unpublished results from the Nairobi randomized controlled trial of the use of formula (fed by cup) to prevent MTCT. This trial screened over 16,000 mothers, among which about 14% were HIV+. Relatively few HIV+ women (17%) returned for the HIV test results, and only 425 women met the project's eligibility criteria and agreed to be randomized into the study. Eligibility criteria included having access to clean water but refrigerators were present in only 5% of households. Randomization took place at 32 weeks gestation. Data analysis was based on intent to treat among 401 live-born infants (197 were in the breastfeeding and 204 in the formula feeding groups). Of these infants, 17% (68) were lost to follow-up before HIV status could be determined, and 7% (30) were lost before mortality data could be ascertained. Those lost to follow-up were reported to be similar to the remaining mother-infant pairs on various enrollment characteristics.
Mothers in the formula group were instructed (through demonstrations) on how to prepare the infant formula, including boiling water and cup-feeding on demand. Women in the breastfeeding group were instructed to breastfeed exclusively for 4-6 months, on demand, and in accordance with Ministry of Health feeding recommendations. Compliance with the randomized feeding regimens was problematic. In the breastfed group, there was 96% compliance with "any breastfeeding" but only 56% breastfed exclusively for at least 3 months (the definition used for exclusive breastfeeding and how it was measured were not described). In the formula-fed group, only 70% of women completely avoided breastfeeding.
The risk of HIV-transmission, calculated at 24 months, among breastfed infants was 36.7% vs 20.5% for the formula fed group, a risk difference of 16.2% (p=0.001). Although overall mortality was not significantly different among the formula fed (20.0%) and breastfed infants (24.4%), HIV-free survival at 2 years was significantly greater in the formula fed group (70% vs 58%). Dr. Nduati noted that the risk of postnatal transmission was not linear: 63% of all postnatal infections occurred by 3 months; 75% by 6 months; and 87% by 12 months of age.
When asked about ability to compare transmission risks between exclusively breastfed and mixed fed infants within the breastfed group, Dr. Nduati expressed reluctance to do this analysis because it may be subject to confounding and reverse causality biases.
3) In a pre-conference satellite meeting, Dr. Paolo Miotti presented results of a study recently reported in JAMA (282:744-749, 1999) on the timing of transmission during breastfeeding in Malawi. Based on their assessment of the timing of new infections, the authors' conclusion was that "the risk of HIV infection is highest in the early months of breastfeeding." However, if this information is passed on to mothers or to policy makers without qualification it could be misleading because a) the risk in the first month could not be assessed at all, b) the difference between months 1-5 (0.7% per month) and months 6-11 (0.6% per month) was very small, and c) this difference may be an artifact of interindividual variation in maternal infectivity or infant susceptibility. The risk of transmission during breastfeeding for the individual mother-infant pair across time may still be constant.
4) Dr. Richard Semba presented his recently published study (Journal of Infectious Diseases 180:93-98, 1999) on mastitis and MTCT of HIV. In this study, 334 HIV+ and 96 HIV women were followed from pregnancy to 12 months post-partum. At 6 weeks post-partum, breastmilk samples were obtained and examined for elevated sodium concentrations, indicative of breast infection or inflammation. Semba found that HIV infection itself was not a risk factor for mastitis, as 16.4% of HIV+ and 15.6% of HIV women had elevated breastmilk sodium concentrations. HIV+ women with mastitis had higher plasma HIV levels; lower CD4; higher HIV viral loads detected in their breastmilk; and increased rates of MTCT at 6 weeks (45.4%) and 12 months of age (50.9%). After adjusting for maternal viral load and breastmilk HIV, women with mastitis at 6 weeks were 2.3 times more likely to have HIV-infected infants at 12 months than women without mastitis inflammation.
Causes of mastitis and other clinical indicators of mastitis were not assessed in this study. Nonetheless, Semba concludes that it is important to counsel women about proper breastfeeding and lactation management to avoid breast and nipple problems, and to monitor and treat breast infections when they occur to prevent possible transmission of HIV through breastfeeding.
5) Drs. Philippe Van de Perre, Laura Guay, Andrea Ruff, Glenda Gray, and Mary Bassett all presented overviews of various aspects of breastfeeding-related HIV transmission, and alternative feeding options for HIV+ women.
6) Dr. Laura Guay presented the results of the much-discussed, randomized controlled trial in Uganda of nevirapine, a relatively simple and inexpensive alternative antiretroviral drug for the reduction of MTCT.
Although the news has been out for a couple of months, the publication appeared only in the September 4 issue of the Lancet (354:795-802, 1999).
Nevirapine, is a non-nucleoside reverse transcriptase inhibitor (NNRTI) which, when given as a single dose to the mother at the beginning of labor and to the infant in the first 72 hours after birth, reduced transmission by 47% (at 14-16 weeks) in comparison with an equivalent intrapartum and post partum regimen of AZT. Nearly all babies were still breastfeeding at this age, although specific breastfeeding practices were not assessed. At 14-16 weeks, 13.1% of infants in the nevirapine trial group were HIV+, compared to 25.1% in the intrapartum/postpartum AZT group.
There are several advantages of the Nevirapine regimen: a) it costs about $4 per treatment in comparison with $60 for the similarly effective Thai short course regimen; b) compliance is likely to be better than regimens that are more complex and that require antenatal contact; c) the single dose is less likely to induce resistance; d) this class of drugs (NNRTIs) is relatively safe; e) the efficacy reported is for a breastfeeding population.
The availability of this cost-effective preventive therapy radically changes the options available for the prevention of MTCT in low-income countries. CDC trials are underway in Durban and Zimbabwe to examine the safety and efficacy of several post partum regimens of nevirapine to the infant for 6 months to reduce the risk of transmission through breastfeeding.
7) A cost-effectiveness analysis of the Uganda Nevirapine regimen (published in the same issue of the Lancet 354:803-809, 1999) was also presented by Dr. Elliot Marseille. Not surprisingly, given the low cost of the drug, the regimen proved highly cost-effective. At 30% prevalence, a targeted intervention would cost $298 per case averted or $11.29 per DALY saved. Because of the low cost of treatment relative to testing, universal treatment (blanket coverage without testing) would be even more cost- effective ($138 per case averted or $5.25 per DALY saved) -- but there are many other reasons why VCT might be favored despite the cost-effectiveness arguments.
The model used to generate these estimates was presented in a workshop by Drs. Elliot Marseille and James Khan. Interestingly, this model has a component that compares the month-by-month risks of transmission with the risk of death due to artificial feeding and estimates the optimum number of months of breastfeeding before switching to replacement feeding. In the LINKAGES risk analysis model, we have been reluctant to make such estimates for lack of data. When asked about their assumptions, they said they used estimates of relative risks from Glenda Gray (Soweto, South Africa, where IMR is about 32-39/1000 live births) as if they apply everywhere. This raises the concern that the "optimum duration of breastfeeding" calculated by the model may be misused by policymakers unaware of the frailty of the assumptions.
It is noteworthy that the question of whether to offer universal nevirapine to all pregnant women was also much discussed in the corridors.
Whereas some people felt that women should have access to this therapy and "not be held hostage to VCT", others felt that it was clearly premature to consider this option without further studies on safety, delivery mechanisms, etc. A middle view was that there may be some contexts where universal treatment is appropriate but only with careful monitoring of safety and effectiveness.
8) Preliminary PETRA trial results to 6 weeks postpartum were presented by Dr. Joseph Saba of UNAIDS. These were the same as those presented at the retrovirus meeting in Chicago in February, 1999. Final results from this multicenter trial of dual therapy with AZT and 3TC will be reported in the first half of next year. Three different arms were designed to compare the efficacy of different combinations of prepartum, intrapartum and postpartum therapy. Compared with the placebo group (17.2% transmission at 6 weeks) the efficacy of the different combinations (adjusted for site and other potential confounders) was:
- Arm A (pre, intra, post): 52% relative efficacy (8.6% transmission) - Arm B (intra, post): 40% relative efficacy (10.8% transmission) - Arm C (intra only): not significantly different (17.7% transmission)
The instruments used in this study do not allow a clear distinction to be made between exclusive and mixed feeding (again underscoring the missed opportunities to learn about breastfeeding- related transmission from clinical trials that report on transmission in breastfeeding populations).
9) Dr. Francois Dabis presented the efficacy results from the DITRAME trial in Cote d'Ivoire and Burkina Faso of an AZT short course (the "Thai regimen") compared to a placebo in these breastfeeding populations.
Efficacy at 6 weeks (45 days), 6 months (180 d), and 15 months (450 d) was 32%, 35% and 30%, respectively. Transmission rates ranged from 14.8% at 6 weeks and 21.5% at 15 months in the AZT group (this is nearly identical to the MTCT rate in the exclusively breastfed Durban infants reported by Coutsoudis at 15 months). Transmission was 21.7% at 6 weeks and 30% at 15 months in the placebo group. 43% of study infants were still being breastfed at 15 months. This trial (and the PETRA preliminary results) appear to dispel concerns that the long term efficacy in a breastfeeding population will be significantly reduced due to "rebound" in maternal viremia after discontinuing AZT and a consequent increase in transmission through breastfeeding.
10) Dr. Eric Mercier (UNICEF) presented a status report on the UN pilot projects. These projects are intended to examine the feasibility and cost-effectiveness of a package of services including improved obstetric care, VCT, short course AZT, infant feeding counseling, breastmilk substitutes (for mothers who choose not to breastfeed), and follow-up support. Eleven countries are included in the pilots. Pilots are already underway in Botswana, Cote d'Ivoire, Rwanda and Zimbabwe and are ready to start in Kenya, Zambia, Tanzania and Uganda. Burkina Faso, Honduras and Cambodia are still getting organized. Future sites may include Haiti, Namibia, Malawi and Thailand. Although the cost-effectiveness and sustainability of this intervention has been questioned, the arrival of Nevirapine (see item 6, above) could change this situation, especially if a dose to the infant proves effective in reducing the risk of breastfeeding transmission.
11) Dr. Christiane Welffans-Ekra reported on 6 months of experience in the UN Cote d'Ivoire pilot study that began October, 1998. Of 3756 mothers engaged in pre-test counseling, 63% both accepted testing and returned for results. 19 % of these were positive. Of the 51 births to these mothers so far, only half have accepted the offer of free formula.
12) Dr. Nicol Coetzee described a pilot MTCT prevention program being carried out in Khayelitsha District (a peri-urban low-income area) of the Western Cape Province in South Africa. The procedures for the program are similar to the UNAIDS pilot project (except that AZT and formula are provided by the provincial government). Of mothers attending antenatal care and offered VCT, 82% accept to be tested. 11% of these women have been HIV+ positive, and 89% of their infants start formula. However, only 64% of the calculated formula needs are actually distributed -- apparently a demand problem but the reasons are not known. A formative research study has recently begun (with technical assistance from the SARA Project) to explore infant feeding options in this population and better understand the factors influencing the feeding decisions of HIV+ women participating in this program.
13) Dr. Wafaie Fawzi reviewed what is known about the effect of micronutrients, particularly vitamin A, on MTCT. Looking at results now available from intervention trials in Tanzania, South Africa (see item 1) and Malawi, there appears to be no effect of maternal supplementation with vitamin A on MTCT in any of these settings. Results from the Tanzania multiple micronutrient supplementation trial on MTCT, fetal deaths, and other birth outcomes (published last year) were discussed. Vitamin A supplementation of pregnant HIV+ women reduced preterm delivery rates (but not birth weight), and in Malawi supplementation reduced low birth weight.
Therefore, although vitamin A supplementation (and other micronutrient supplementation) does not appear to reduce MTCT, it does improve other important birth and child survival outcomes.
Jay Ross, Policy Coordinator
LINKAGES, 31 Macken Rd., RR4, Antigonish, NS B2G 2L2, CANADA
phone: (902) 863 8361, fax: (902) 863 0426
Date: Mon, 15 Nov 1999 11:46:53 +0100
From: "Egal, Florence (ESNP)" <Florence.Egalatfao.org>
Subject: Nutrition education for HIV/AIDS
We are presently considering developing nutrition education material for use by HIV/AIDS patients and families. Many initiatives have been taken in this field in recent years and before embarking on this activity, we would like to know who has done what, in order 1/ to see if this, after all, is reallyl needed 2/ to review existing material and strategies to assess their strengths and weaknesses and c/ to liaise with people/institutions who have gained experience in this area and decide together what is the best course to take.
Thanks for your help.
Nutrition Programmes Service
From: "Smith" <jamsmithatintekom.co.za>
Subject: Community Projects for malnutrition and HIV mothers
Date: Mon, 15 Nov 1999 17:54:26 +0200
We are based in a low social economic area with rising HIV-figures with associated unemployment etc.
We are currently planning intervention projects for community involvement for income generation and impact on household security, for this mothers. We would like ideas of sucessful, sustainable projects in third world countries. Which factors influence the sucess?
It need not be only food and foodgarden related.
Annatjie Smith and Liana Steenkamp RDSA Dietitians Port Elizabeth South Africa, PO Box 28500, Sunridge Park 6008, Port Elizabeth, Rep of South Africa
From: "Liana Steenkamp" <lianastatiafrica.com>
Subject: FOOD SUPPLEMENTATION TO HIV+ PATIENTS IN 3RD WORLD COUNTRIES
Date: Tue, 16 Nov 1999 22:41:08 +0200
We recently have been approached to look into development of affordable food supplements for HIV+ patients. Taken into account that no formal treatment protocols exist for these patients due to lack of funding, deficient diets partly due to household food insecurity and limited trained staff for HIV counselling, patients might benefit from food supplementation programmes providing macro-and micronutrients. Due to limited prospective intervention studies on food supplementation in third world countries, I would appreciate some direction as to which micronutrients to include in these products and what the levels of supplementation (in relation to the RDA) should be.
Thanking you in anticipation.
Date: Thu, 18 Nov 1999 10:25:34 +0000
From: Marlou Bijlsma <pzaagatmango.zw>
Subject: nutrition guide for people with HIV - Zimbabwe
Thanks for the interest in the nutrition guide for people with HIV that we developed in Mutare, Zimbabwe.
Some people have requested copies. I am very interested in your comments, and on whether or not and how you are using the information.
I would like to add one comment/ experience myself. Here in Zimbabwe it has been difficult to convince doctors and other health professionals of the role of nutritional support for people with HIV. This partly is because of a different paradigm; looking for treatment for a sick person vs trying to maintain health.
But also on the treatment of malnutrition you will definitely get comments from some of your doctors/ nurses. They have been treating malnutrition with high energy milk and similar concoctions, that are based on cooking oil. They will claim that despite the diarrhoea some people will benefit from the high energy food. This is somehow contradictious to when I say that malnutrition caused by malabsorption, and especially in the presence of diarrhoea should be treated with easily digestible food (that is low in fat). Most of the malabsorption in people with HIV is fat malabsorption. If only 5% of the fat consumed is not absorbed it causes fat-malabsorption, and the bacteria in the gut feast on the fat and cause diarrhoea. Our emphasis has been very much on restoring the absorbing capacity of the digestive system before increasing the energy content of the food. Our experiences with people with HIV in our AIDS support organisations and our clients in the Infectious Diseases Hospital and TB hospital support our approach. In-patient days of people with gastro enteritis were reduced by 50% just by changing their diet to low fat vegetable soups.
Also in-patient days of other patients (herpes zoster tb etc) were reduced by 20% with the same measure (giving those with diarrhoea low fat food). From the people from the AIDS support organisations we learned that to control the diarrhoea is a very important way of improving the quality of life. When you never know when diarrhoea will start, you can't participate in normal life as even boarding a bus or shopping become risky adventures. Bringing the diarrhoea under control means giving people back a normal life. This has proved to be a good basis for interesting people to work on improving their health or even taking up exercises.
(Just a small addition)
address PO Box MP 600, Mount Pleasant, Harare, Zimbabwe
phone +263 4 336421, e-mail pzaagatmango.zw
Note added by M.Golden
There are some very controversial statements in this message which remind me of clinical anecdotes (from other conditions) heard in former decades that were not supported by any formal studies. We would particularly welcome comments by our gastroenterological colleagues, and would strongly suggest that Marlou collects and publishes the data from Harare.
Date: Sat, 20 Nov 1999 07:18:22 -1000
From: George Kent <kentathawaii.edu>
Subject: Re: FOOD SUPPLEMENTATION TO HIV+ PATIENTS IN 3RD WORLD COUNTRIES
Liana Steenkamp wrote:
> We recently have been approached to look into development of affordable food supplements for HIV+ patients. Taken into account that no formal treatment protocols exist for these patients due to lack of funding, deficient diets partly due to household food insecurity and limited trained staff for HIV counselling, patients might benefit from food supplementation programmes providing macro-and micronutrients. Due to limited prospective intervention studies on food supplementation in third world countries, I would appreciate some direction as to which micronutrients to include in these products and what the levels of supplementation (in relation to the RDA) should be.
As a specialist in the human right to food and nutrition, and having done some work on the policy dimensions of HIV/AIDS issues, I wonder what rationale might be offered for providing food supplementation programs for HIV patients that are different from those provided to others with comparable nutritional needs.
George Kent, Professor and Chair
Department of Political Science, University of Hawai'i, Honolulu, Hawai'i 96822-2281, U.S.A.
Phone: 1 (808) 956-7536, Fax: 1 (808) 956-6877
Email: kentathawaii.edu, Website: http://www2.hawaii.edu/~kent