This document discusses research on alternative approaches to prevent mother-to-child transmission of HIV in Kenya. The researchers examined the feasibility of using nipple aspirate fluid from grandmother-aged women (ages 35-70) as a replacement or supplemental feeding for HIV-exposed newborns. Proteomic analysis found that the nipple aspirate fluid contained many of the same immune and milk proteins as breastmilk. However, concerns include the availability and health of potential surrogate caregivers, competing infant infections, and the potential risks of HIV transmission between the infant, mother and surrogate. The next step proposed is to test the acceptability and functionality of this approach within communities.

1. New Approaches to Prevent Mother-
to-Child Transmission of HIV in Kenya

2. RESEARCH TEAM
• Chandice Covington,PhD,RN
• Mohamed Abdullah, MD
• Richard Zangar PhD
• Lynne McEnroe,MA,MSN,RN

3. Estimated risk & timing of mother-to-child transmission of HIV
Transmission rate (%)
Timing No
Breastfeeding
Breastfeeding
through 6
months
Breastfeeding
through 18-24
months
During pregnancy 5 to 10 5 to 10 5 to 10
During labour 10 to 20 10 to 20 10 to 20
Through breastfeeding
Early (first 2 months) 2 to 10 2 to 10
Late (after 2 months) 1 to 5 5 to 10
Overall 15 to 30 25 to 35 30 to 45
(source: DeCock, KM, et al., 2000)

4. OTHER MTCT CONCERNS
• Risk increased /w
mixed feeding
(Coutsoudis et al., 2001)
• Risk decreased
with perinatal
antivirals
• Formula-feeding reduced
postnatal transmission by
40%, yet no ⁂ in mortality
between breast and formula
(Nduati et al., 2000)
• About 50% infants who
acquire HIV succumb in the
first 18 months of life

5. LONG TERM CONSEQUENCES
• Life expectancy for
Japan = 77 years for
women, sub-Saharan
Africa it is 32 years
• Over 1-million children
orphaned in Kenya by
AIDS, in Africa > than
12,000,000

6. LONGER TERM CONSEQUENCES
• Youth are our future
• Along with parents,
loss of teachers and
nurses—social carriers.
• Novel approaches
needed to reduce this
loss of life and our
future

7. WHO RECOMENDS EXCLUSIVE
BREASTFEEDING

8. DEFENSIVE CELLS IN BREASTMILK
COMPONENT ACTION
B Lymphocytes
Give rise to antibodies targeted against specific
microbes.
Macrophages
Kill microbes outright in the baby's gut, produce
lysozyme and activate other components of the
immune system.
Neutrophils
May act as phagocytes, injecting bacteria in baby's
digestive system.
T lymphocytes
Kill infected cells directly or send out chemical
messages to mobilize other defenses. Proliferate in
the presence of organisms that cause serious infant
illness. Also manufacture compounds that can
strengthen child's immune response.

9. Molecules in Breastmilk
Secretory IgA class
Bind to microbes in infant digestive tract, prevent
from passing through gut walls into body's tissues.
B12 binding protein
Reduces amount of vitamin B-2, which bacteria need
in order to grow.
Bifidus factor
Promotes growth of Lactobacillus bifidus bacterium in
gut., helps to crowd out dangerous varieties.
Fatty acids
Disrupt membranes surrounding some viruses and
destroy them.
Fibronectin
Increases antimicrobial activity of macrophages; helps
to repair tissues that have been damaged by immune
reactions in baby's gut.

10. PURPOSE
• Surrogate nursing is a tradition across cultures
• Grandmother/elder relatives appreciate low rates
of HIV infection & function as extended family
caregivers
• Examine the feasibility of grandmother-aged
women’s nipple aspirate fluid (NAF) as a
replacement or supplemental feeding for HIV-
influenced neonates

11. SURROGATE DEFINED
• Non-puerperal not so novel:
200,000 years old; Margaret
Mead 1950s, Slome1
described
GM in 1956.
• Slome, Cecil (1956).
Nonpuerperal lactation in
grandmothers. Journal of
Pediatrics, 49(5), 550-552.
• The process of re-lactation or
induced for the purpose of
feeding a related or non-related
child.
Grandmother ~ age 50. Natal, South Africa ~ 1956.

12. SETTING AND SAMPLE
• Clinics attended by 60 women (N=48)
• Villages coastal Kenya (Vipingo & Rabai)
• Weaned* women ≥ 35 -70 years (*) of age
• Not pregnant or hypertensive, no “wasting” disease symptoms
(n=12)
• Youthful multiparity & extensive lactation histories, some
previous surrogate nursing

13. PROCEDURES
• Clinic notices; 10 miles
• Informed consent, pregnancy
test, interview, venipuncture,
anthropometrics, breast
examination, non-invasive,
patented aspirator system
• Incentives: Dry milk, maize,
“Beads for Life”, cloth

14. ASSAYS (Proteomics)
• Mass spectrometric analysis of peptides
(Thermofinnigan LCQ Deca) with pooled NAF
• Identification parent proteins (Sequest
analysis software)
• Minimum 3 separate peptide matches (Sequest
Xcorr values > 1.5 (1/3 e > 2.0) to confirm the
presence of the parent protein in NAF

15. RESULTS
•Quantity of NAF range <10 µl to >250 µl. *
•Proteomic analysis: Most abundant proteins
Immunoglobins, accounting for ~40% of the
total protein content
Immune complements C3, C4
Several forms of casein and lactotransferrin

16. Summary of NAF Proteomic Analysis:
Milk or Immune Proteins
• Albumin
• a-1-
Antichymotrypsin
• a-1-Antitrypsin
• a-, b-, k-Casein
• Coagulation factor
II
• Complement C3
• Complement C4
• Complement C7
• Complement factor B
• Complement factor D
• Ferroxidase
(ceruloplasmin)

17. Summary of NAF Proteomic Analysis:
Milk or Immune Proteins
• Fibrinogen gamma-B chain
• Haptoglobin
• Ig alpha chain (heavy)
• Ig gamma chain (heavy)
• Ig kappa chain (light)
• Ig lambda chain (light)
• a-Lactalbumin
• Lactoferrin
• b-2-microglobulin, pI 5.3
• Polymeric-
immunoglobulin receptor
• Prolactin-induced
protein
• Transferrin

19. Grandmother Hypothesis: Re-visited
• The data support that
grandmothers may serve a
"evolutionary loophole"
function to circumvent
disasters
• Maternal-child morbidity
& mortality in AIDS-
impacted populations is a
disaster

20. OBSTACLES/CONCERNS
•Availability of female relative caretaker
(GM currently feeding grandchildren)
•Competing infections: e.g. malaria,
tuberculosis, hookworm, parasites,
hepatitis
•Health problems of elder women: e.g.
nutrition, anemia, osteoporosis,
hypertension

21. OBSTACLES/CONCERNS
•New HIV infection in surrogate
•Risk of reverse transmission HIV infection
to women low but potentially possible
•Stigma

23. Next Step: Test Feasibilty in Community
• Community Acceptability
• Potential for elder women
to re-lactate &
functionality of immune
proteins
• Risk/Cost-benefit model
for infant, mother,
surrogate, family,
community