1. POSITIVELY
BREASTFEEDING:of HIV
A descriptive study of the MTCT
following the implementation of WHO
2010 breastfeeding guidelines in Haiti
Jordan Dozier, MD
Keisha Bonhomme, MD

2. Objectives
 To describe the possible risk of HIV
transmission in pediatric patients
breastfed by HIV-infected mothers from
2008-2012
 To discuss how the implementation of the
WHO 2010 breastfeeding guidelines have
been received in other resource limited
countries.

3. BACKGROUND
 Breastfeeding involves considerable risk of HIV
transmission
 Risk of MTCT without breastfeeding is 15-25% in mothers not
on ARV prophylaxis
 Risk increases 5-20% to a total of 20-45%
 Cumulative effect
 However, not breastfeeding in resource-limited settings
present considerable risk to infant survival
 According to the MASHI study conducted by Lockman et al.
breastfeeding in comparison to breast-milk substitutes reduces
infant morbidity and mortality associated with infectious
diseases, i.e. diarrhea

4. BACKGROUND
 WHO breastfeeding guidelines over the years:
 2001- when replacement feeding is AFASS HIV-infected mothers
should avoid breastfeeding; otherwise exclusive breastfeeding
for the first few months of life is recommended.
 2006- guidelines updated to more strongly communicate need
for implementation of exclusive breastfeeding
 2009- guidelines updated to incorporate recent evidence of ARV
role in decreasing MTCT
 2010- guidelines updated to include recommendations whose
objective is to balance HIV prevention with protection from
other causes of child mortality

5. BACKGROUND
 Theory into Action!
 A study conducted between 2003 – 2007 by
Homsy et al in rural Uganda looked at the effect
HAART had on MTCT in the context of EBF.
 Out of 118 infants born, 114 of which had at least
one PCR test conducted and 93% of which were
exclusively breastfeeding, there were ZERO cases
of MTCT transmission.
 There was however a 19% mortality rate in this
cohort. (>65% due to gastroenteritis)
 Important to note however was that there was a SIX
FOLD increase risk of death associated with early
weaning (< 6 months)

6. METHODS
 Criteria:
 Four sites were chosen from a national database
solely consisting of pediatric patients. Only sites with
greater than 150 patients were included.
 Patients who received two or more PCR tests with
documented results were further assessed. Amongst
those patients the following data were observed:
 Conversion vs Non-conversion
 Delay in days between each test (Mean, Range)

7. METHODS
 Database of 794 GHESKIO HIV-exposed pediatric
patients and 911 tests from 2008-2012
 Database of HIV-exposed pediatric patients from
2010-2012
 St. Damien (244 pts / 294 tests)
 Cayes (218 pts / 237 tests)
 Cap Haitien (159 pts / 177 tests)
 Patient demographics did not include information on
infant age, breastfeeding compliance or maternal ART
compliance

8. RESULTS
Site # pts with ≥ 2 tests Mean delay between
tests (range)
GHESKIO 113 130.8 (1 to 549 days...)
St Damien 49 115.5 (11 to 362 days)
Cayes 18 147 (21 to 250 days)
Cap Haitien - Justinien 18 173 (21 to 407 days)

9. RESULTS
 In total, there were two patients who had a change in
HIV status from Negative to Positive:
 One from GHESKIO (delay: 529 days)
 One from St. Damien (delay: 144 days)
 There were no conversions noted from Positive 
Negative, reflecting the sensitivity of PCR testing
 There were 11 patients who had tests repeated but
results were not available at the time of this analysis

10. CONCLUSIONS
All conclusions are made under the presumption
that HIV+ mothers have been compliant with
both their ART treatment as well as have
exclusively breastfed their children.
Given the observed occurrence of two conversions
out of 1415 patients, the risk of transmission
may be minimal in ARV compliant mothers who
breastfeed.
However, further assessment of the benefits
involved with breastfeeding is needed to
conclusively determine if the national
recommendation has had a positive effect on the
morbidity and mortality of infants in Haiti.

11. DISCUSSION
 Possible Confounders
 GHESKIO culture vs. General practice throughout Haiti
 Maternal ART compliance
 Breastfeeding compliance within the context of cultural
change
 How to improve compliance?
 Decrease availability of free formula (nationally) in
hopes of reducing the common practice of mixed
feeding
 Prospective, controlled study needed to draw
definitive conclusion

12. DISCUSSION cont’d
 Home Visits?
 Study in Uganda showed that home-based peer
counseling improved levels of exclusive breastfeeding
 Mothers appreciated non-dogmatic, non-didactic
approach of peer-counselors (71%) vs health-care
worker (16%)
 Women felt empowered by lessons learned and
justified in decision to refuse old formula feeding
practices

13. DISCUSSION cont’d
 Standardized counseling sessions?
 Weakness in success of PMTCT programs is the
continuous change of policy framework
 In a study conducted by Doherty et al in South Africa,
poor quality of counseling, unclear counselor
messages and availability of free formula provided
incentive to choose formula
 Partner involvement; in a study conducted by Moland
et al modifications to infant feeding were shown to be
highly dependent upon male support in some settings

14. References
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postpartum HIV-infected women would improve maternal health and decrease
epostnatal HIV transmission. AIDS. 2010; 24:8.
 Doherty T, Sanders D, Goga A, Jackson D. Implications of the new WHO guidelines
on HIV and infant feeding for child survival in South Africa. Policy and Practice. 2011;
89:62-67.
 Homsy J, Moore D, Barasa A, et al. Breastfeeding, Mother-to-Child HIV
Transmission, and Mortality Among Infants Born to HIV-Infected Women on Highly
Active Antiretroviral Therapy in Rural Uganda. J Acquir Immune Defic Syndr.
2010;53:1
 Lutter C, Daelmans B, Onis M, et al. Undernutrition, Poor Feeding Practices, and Low
Coverage of Key Nutrition Interventions. PEDIATRICS. 2011; 128;e1418
 Moland k, Paoli M, Sellen D, et al. Breastfeeding and HIV: experiences from a
decade of prevention of postnatal HIV transmission in sub-Saharan Africa.
Internaional Breastfeeding Journal. 2010; 5:10
 Nankunda J, Tumwine J, Nankabirwa V, Tylleskar T. “She would sit with me":
mothers’ experiences of individual peer support for exclusive breastfeeding in
Uganda. International Breastfeeding Journal. 2010; 5:16
 Parela D, Blanda R, Hoosen C, et al. Breastfeeding, HIV status and weights in South
African children: a comparison of HIV-exposed and unexposed children. AIDS 2010,
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 Saloojee H, Gray G, McIntyre J A. OPINION: HIV and infant feeding – one step
forward, two steps back. The Southern African Journal of HIV Medicine. Dec. 2011.

15. Any Questions?

16. Thank you
Merci pour prêter votre attention