1. Infant feeding in the context of HIV: Challenges in resource limited settings Anirban Chatterjee, MD; DSc. UNICEF New York

3. 9.2 million died before they reached their fifth birthday Loaiza E, et al. Lancet 2008

4. Total: 33 million (30 – 36 million) Western & Central Europe 730 000 [580 000 – 1.0 million] Middle East & North Africa 380 000 [280 000 – 510 000] Sub-Saharan Africa 22.0 million [20.5 – 23.6 million] Eastern Europe & Central Asia 1.5 million [1.1 – 1.9 million] South & South-East Asia 4.2 million [3.5 – 5.3 million] Oceania 74 000 [66 000 – 93 000] North America 1.2 million [760 000 – 2.0 million] Latin America 1.7 million [1.5 – 2.1 million] East Asia 740 000 [480 000 – 1.1 million] Caribbean 230 000 [210 000 – 270 000] Adults and children estimated to be living with HIV, 2007

5. Estimated number of children (<15 years) newly infected with HIV, 2007 Total: 370 000 (330 000 – 410 000) Western & Central Europe <200 [<100] Middle East & North Africa 5700 [3800 – 8000] Sub-Saharan Africa 330 000 [300 000 – 360 000] Eastern Europe & Central Asia 3200 [2400 – 4300] South & South-East Asia 21 000 [14 000 – 29 000] Oceania <1000 North America < 500 [<200] Latin America 4600 [4200 – 8300] East Asia 2000 [1200 – 3100] Caribbean 1800 [1500 – 2100]

6. Preventive interventions for improving child survival Jones et al, Lancet, 2003

7. Not breastfeeding increases risk of infectious disease mortality Relative risk Age (months) WHO Collaborative Study Team, Lancet, 2000 Nearly 6 times increased risk of death in early infancy if not breastfeeding

8. Poor hygiene increases risk of infant mortality Habicht et al, Mother's milk and sewage, Paediatrics, 1988 Nearly 5 times increased risk of death if not breastfeeding AND do not have access to safe water and toilets

9. Timing and risk of mother-to-child transmission (MTCT) of HIV

10. Timing and risk of mother-to-child transmission (MTCT) of HIV De Cock KM, JAMA 2000;283(9):1175-82 Breast-feeding Non-breastfeeding Timing 25-45 % 15-30 % Total 40 % 10-15 % - - Postnatal 40 % 10-20 % 67 % 10-20 % Intra-partum 20 % 5-10 % 33 % 5-10 % In-utero Proportion MTCT Proportion MTCT

11. Average MTCT in 100 HIV+ Mothers by Timing of Transmission Uninfected: 65 Breastfeeding: 15 Delivery: 13 Pregnancy: 7

13. Does replacement feeding always lead to better outcomes?

15. Early Mortality is Higher in Formula-Fed Infants Thior I et al. JAMA 2006;296:794-805 p=0.21 p=0.003 p=0.005 Predominant causes of infant death: Diarrheal disease and pneumonia

16. Early mortality higher in formula fed children in South Africa Coovadia et al., Lancet , 2007 15 % Replacement Feeding 6 % Exclusive BF Mortality at 3 mth of age Infant Feeding practice

17. Increased hospitalization among replacement fed children in India Phadke MA, et al. Journal of Nutrition 2003 27 86 Replacement-fed 0 62 Breast-fed Number of hospitalizations Number of children Infant Feeding Practice

18. Can HIV transmission through breastfeeding be reduced?

19. Exclusive breastfeeding carries lower risk of HIV transmission than mixed feeding (South Africa) Hazard ratio Coovadia et al., Lancet , 2007

20. Exclusive breastfeeding reduced HIV transmission: Zimbabwe Iliff et al, AIDS, 2005

21. What is the evidence on use of HAART for PMTCT?

29. Is formula feeding really acceptable? When they see me coming with the tins they laugh at me . There’s a lot of thinking within the community that the babies that are fed on formula are those who are HIV-positive She fetches the milk with a bag and she waits till the clinic is empty so they do not see what type of milk is there Doherty TD et al. Bull of WHO 2006 In settings with general access to clean water, structured antenatal counseling and sustained provision of free infant formula approximately half of HIV positive women chose replacement feeding Leroy V, JAIDS 2007 South Africa Ivory Coast

36. Progress towards the MDG target on safe drinking water, by region (1990 and 2004)

38. Usefulness of AFASS criteria for reducing risk of HIV transmission or death South Africa Doherty T et al, AIDS 2007 Criteria Piped water Fuel Status divulged