E.

HIV/AIDS:
Implications for Child Health and Nutrition

Newborn Health, MoHFW, GoI

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THE PROBLEM: The vulnerability of women, Girls are particularly vulnerable — in
children and young people to many countries in sub-Saharan Africa,
WOMEN, CHILDREN
HIV infection girls have infection rates 5-6 times
AND YOUNG PEOPLE higher than boys of the same age group.
ARE ESPECIALLY Women, children and young people are
especially vulnerable to HIV infection Children in households with a HIV-
VULNERABLE TO HIV
for a host of social and economic positive member suffer the trauma of
INFECTION reasons including poverty, sexual caring for ill family members. Children
exploitation and violence, and the lack may be withdrawn from schools to care
of access to HIV information and for ill parents or their siblings, thus
prevention services like counselling and losing opportunities for acquiring skills
testing services. for life and work.

Children and HIV/AIDS How is HIV transmitted from an

The most effective way infected mother to her child?
to reduce the number of In 2001, AIDS orphaned 14 million
children infected with children globally. The number risks HIV can be transmitted from mother to
HIV is to prevent HIV being doubled by 2010 if the response child at three different times — in
infection in women of to the epidemic is not scaled up. utero (i.e. inside the womb), during
childbearing age, young delivery, and during breastfeeding. The
people, and adults in An estimated 4.5 million people are presence of the virus in fetal tissues
general. Next in line is living with HIV in India. Since the first demonstrates that HIV can cross the
the prevention of case was reported in Chennai in the placenta. Half or less, of all infected
unintended pregnancies mid–80s, HIV has spread rapidly from newborns test positive for HIV shortly
in HIV infected women. urban to rural areas and from high-risk after birth; they are assumed to have
behaviour groups to the general been infected in utero. Other infected
Among women already population. HIV/AIDS has been reported infants only develop detectable levels
infected with HIV, from almost all the states and union of virus in the bloodstream after the
interventions to reduce territories of India. Currently, the first week of life; they could have been
the risk of transmission infection rate is estimated to be 0.7% infected immediately before or during
(Prevention of Mother to in the adult population (between 15 delivery. Mother-to-child transmission
Child Transmission or and 49 years of age). (MTCT) of HIV is the most significant
PMTCT, through source of HIV infection in children
prophylactic regimens, With 27 million pregnancies a year in below the age of 10 years, responsible
and safe infant feeding) India, and an overall estimated 0.3% for more than 90% of HIV infection in
are an urgent priority. prevalence rate of HIV infection among children. Two-thirds of infants infected
pregnant women, about 100,000 HIV through MTCT are infected during
infected women deliver every year. pregnancy and around the time of
Using a conservative vertical delivery, and one-third are infected
transmission rate of 30%, about 30,000 through breastfeeding.
infants acquire HIV infection each year.
How can MTCT be prevented
In 2001 alone, an estimated 800,000 and reduced?
children were newly infected with HIV
globally — almost all through mother- MTCT can be prevented only by using a
to-child transmission. combined approach, as recommended

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by the United Nations agencies. These infants offered ART therapy must be WHO recommends that issues of
include: (1) primary prevention of balanced by the benefit of preventing feasibility, efficacy and cost should
HIV infection among parents-to-be transmission of a fatal infection in the determine the local choice for ART
(2) prevention of unwanted infant. The WHO Technical prophylaxis. Other important
pregnancies in HIV-infected women, Consultation has concluded that considerations include: proportion of
and (3) prevention of HIV transmission benefit of these drugs in reducing women attending antenatal care; time
from HIV-infected women to their MTCT greatly outweighs any potential of initiation of antenatal care;
infants. adverse effects of drug exposure. frequency of antenatal visits; type of
• Drug Resistance: Drug resistance HIV voluntary counseling and testing
While the first two strategies could has been reported in some women available; logistics and acceptability of
successfully prevent HIV infection in exposed to short course ART regimens ART therapy; and the cost of drugs.
children, unfortunately many women used for MTCT prevention. The WHO
with HIV infection become pregnant Technical Consultation has concluded Prevention of HIV transmission
(usually unaware of their HIV status). that the benefit of decreasing MTCT during delivery
with these drugs greatly outweighs The following factors have been found
Proven strategies to reduce or prevent concerns related to drug resistance. to increase risk of HIV transmission
MTCT when a woman is known to be • Choice of ART prophylactic during delivery:
infected with HIV include: regimens: The drugs used in ART • High viral load
• Antiretroviral therapy (ART) prophylaxis regimens evaluated • Presence of Sexually Transmitted
• Restricting the use of invasive include zidovudine (ZDV) as a stand Infection (STI)
obstetric procedures during alone, ZDV + Lamivudine and • Rupture of membranes
delivery Nevirapine. The most complex • Artificial rupture of membranes
• Replacement feeding for the infant. regimen includes antepartum/ • Delivery more than 4 hours after
intrapartum/postpartum ZDV, while rupture of membranes
ART therapy to prevent and the simplest regimen includes single • Instrumental deliveries (i.e.
reduce MTCT dose intrapartum/postpartum forceps or vacuum)
The WHO recommends that the Nevirapine. • Vaginal delivery
prevention of MTCT using ART therapy • Advanced maternal age
should be part of the minimum Under the NACP-2, the National AIDS • First born twins born to an HIV
standard package of care for women Control Organisation (NACO) has infected mother
who are known to be HIV infected, and initiated free supply of a single dose
their infants. While the efficacy of ART nevirapine (with an approximate retail Less invasive monitoring and
regimens in reducing the risk of HIV price at the local chemist of Rs 65) to intrapartum procedures as well as
transmission has been well established HIV infected mothers registered at opting for elective Caesarian section
by international studies, other issues antenatal clinics in select hospitals in decreases the risk of HIV transmission.
need to be considered: the country; however currently this
• Practicality and effectiveness: service is available at 11 selected HIV and infant feeding
The actual reduction in the rate of centres in the high HIV prevalence HIV has been isolated in breastmilk.
MTCT achieved (effectiveness) may be states. Information on the availability MTCT via breastfeeding to uninfected
less than that observed in research of this service in individual states can infants born to women with HIV
settings (efficacy). ART regimens that be obtained from the State AIDS infection is estimated to occur in
are practical and simple to administer Control (SACS) office. 10-20% of cases due to partial
should be favoured over those that are breastfeeding. The risk of MTCT of HIV
complex and difficult to administer. Maternal antiretroviral drugs through breastfeeding appears to be
• Safety: The risks of exposure to Maternal antiretroviral drugs should be greatest during the first months of
one or more drugs for women and continued during labour. infant life but persists as long as

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breastfeeding continues. Mixed feeding WHO Recommendations Adequate numbers of people who can
is likely to lead to higher levels of When replacement feeding is
counsel HIV-infected women on infant
MTCT than either complete artificial acceptable, feasible, affordable, feeding should be trained, supervised
feeding or exclusive breastfeeding in sustainable and safe (AFASS), avoidance and supported. Such support should
of all breastfeeding by HIV-infected
the first three months of infant life. mothers is recommended. Otherwise, include updated training as new
exclusive breastfeeding is recommended information and recommendations
during the first months of life. To
Should mothers with HIV be emerge.
minimize HIV transmission risk,
advised not to breastfeed? breastfeeding should be discontinued as
soon as feasible, taking into account
local circumstances, the individual
It depends on if a mother knows she is
woman’s situation, and the risks of
infected, and if breastmilk substitutes replacement feeding (including infections
Further Reading
are affordable and fed with safe clean other than HIV and malnutrition).
1. HIV/AIDS in India, United Nations
water, and if adequate health care is Development Program Report; October
2003.
available and affordable, then the provided with specific guidance and
infant’s chances of survival are greater support for at least the first 2 years of 2. New Data on the Prevention of Mother-to-
Child Transmission of HIV and their Policy
if fed artificially. the child’s life to ensure adequate
Implications: Conclusions and
replacement feeding. Programmes Recommendations, WHO Technical
However, if infant mortality is high due should strive to improve conditions that Consultation on Behalf of the UNFPA/
UNICEF/WHO/UNAIDS Inter-Agency Task
to infectious diseases such as diarrhea will make replacement feeding safer for
Team on Mother-to-Child Transmission of
or pneumonia, or if hygiene, sanitation, HIV-infected mothers and families. HIV, Geneva; 11-13 October 2000.
and access to clean water are poor; or
3. Nutrition Essentials, A guide for health
if the cost of breast milk substitutes is HIV-infected mothers who breastfeed managers, BASICS; 1999.
prohibitively high, or if access to should be provided with specific 4. FAQ Sheet on breastfeeding and HIV/AIDS,
adequate health care is limited, then guidance and support when they cease LINKAGES; May 2001
breastfeeding may be the safest breastfeeding to avoid harmful 5. Position Statement on HIV and Infant
feeding option even when the mother nutritional and psychological Feeding, BPNI, New Delhi; February 2001
is HIV positive. consequences and to maintain breast 6. Infant Feeding Options in the Context of
health. HIV, LINKAGES; April 2004
What are the current
international recommendations
on breastfeeding and HIV? AFFASS Criteria for Replacement Feeding

Acceptable: The mother perceives no barrier to choosing replacement feeding for

A policy statement from UNAIDS cultural or social reasons, or for fear of stigma and discrimination.
supported by WHO and UNICEF Feasible: The mother (or family) has adequate time, knowledge, skills, resources and
emphasizes supporting breastfeeding in support to correctly prepare breastmilk substitutes and feed the infant 8-12 times in 24
hours.
all populations; improving access to HIV Affordable: The mother and family, with available community and/or health system
counselling and testing; providing support, can pay for the costs associated with the purchase/production, preparation,
information to empower parents to storage and use of replacement feeds without compromising the health and nutrition of
the family. Costs include ingredients/commodities, fuel, clean water, and medical
make fully informed decisions; reducing
expenses that may result from unsafe preparation and feeding practices.
women’s vulnerability to HIV infection; Sustainable: A continuous, uninterrupted supply and a dependable system for distribution
and preventing commercial pressures to of all ingredients and products needed to safely practice replacement feeding are
available for as long as needed.
provide artificial feeding.
Safe: Replacement foods are correctly and hygienically stored and prepared and fed with
clean hands using clean cups and utensils — not bottles or teats.
When HIV-infected mothers choose not
Source: Infant Feeding Options in the Context of HIV, Linkages; April 2004. Adapted from WHO;
to breastfeed from birth or stop 2003, HIV and infant feeding: A guide for health-care managers and supervisors
breastfeeding later, they should be