Page 1 of 9
Journal for Studies in Management and Planning
Available at http://internationaljournalofresearch.org/index.php/JSMaP
e-ISSN: 2395-0463
Volume 01 Issue 05
June 2015
Available online: http://internationaljournalofresearch.org/ P a g e | 243
Breast feeding and HIV Transmission- an
Overview of Delhi NCR Hospitals
Mir Shahid Satar
1 PhD Research Scholar and corresponding author, Department of Management,
Jamia Hamdard University, New Delhi, 110062,
mirshahid261@gmail.com
ABSTRACT
The HIV epidemic is showing a shift towards
women and young people in the developing
countries. The increasing HIV prevalence
among women will show an increase in
mother-to-child transmission (MTCT) of
HIV. However, there is a wide difference in
the rates of MTCT of HIV between
developing countries. This difference is
mainly attributable to different infant feeding
practices in such countries. Further, about
one to two-third of the overall vertical
transmission rate is putative to peripartum
period, depending on whether breastfeeding
occurs or not. Thus, the periods of
peripartum and breastfeeding have received
a thrust of attention in the efforts to prevent
vertical transmission of HIV. The review
paper addresses recent advances in our
understanding of mother-to-child
transmission risk factors, including maternal
viral load (in plasma, genital tract and
breast milk) and gender, and determinants
and rates of postnatal transmission. The
paper documents a thorough review to
address the difficult dilemma of infant
feeding by HIV+ mothers and the subsequent
HIV-associated mortality. Further, a review
of the records of 211 HIV+ mothers from six
different hospitals of Delhi NCR is
undertaken to supplement the core review.
Keyword: Breast-feeding, AIDS in
India, HIV, PTCT, Vertical Transmission,
WHO
INTRODUCTION
Transmission of HIV from infected HIV positive
mother to her child is called as Vertical transmission.
The transmission can occur during pregnancy, labor
delivery or even breastfeeding. In the absence of any
intervention, rates of MTCT of HIV-1 can vary from
15 to 30 per cent in developed countries and can reach
as high as 30 to 45 per cent in developing countries.
Nevertheless, the rates of vertical transmission can
radically be brought down to as low as 5%. According
to a recent report, about 90% HIV positive children
worldwide have acquired the infection from mother
through vertical transmission [1. In India, about 28
million deliveries occur annually, of which 84,000
deliveries would occur in HIV-positive women
considering a national average of 0.3 per cent
prevalence of HIV in pregnant women [1]. Without
any intervention, about 30-45 per cent of these babies
will become infected with HIV [1]. In the high
prevalence states of Maharashtra, Tamil Nadu,
Andhra Pradesh, Karnataka, Manipur and Nagaland,
with more than 1 per cent HIV prevalence amongst
pregnant women, there could be a much higher
number of vertically infected babies being born
annually [1].
EFFICACY OF TRANSMISSION
MTCT is by far the most significant route of
transmission of HIV infection in children below the
age of 15 yr. This can occur during pregnancy
especially in the last trimester, during delivery, and
postnatal during breastfeeding. The foetus can get
Page 2 of 9
Journal for Studies in Management and Planning
Available at http://internationaljournalofresearch.org/index.php/JSMaP
e-ISSN: 2395-0463
Volume 01 Issue 05
June 2015
Available online: http://internationaljournalofresearch.org/ P a g e | 244
infected in utero through maternal blood,
transplacental haemorrhage, and infection via
umbilical cord or via the gastrointestinal mucosa
while swallowing infected amniotic fluid. Contact
with the mother’s blood and/or secretions during
labour and delivery increases the risk of transmission.
‘‘Of the 30% of babies who get infected vertically, the
relative frequency of timing of transmission is said to
be as follows ‘‘ 02 per cent early in gestation, 3 per
cent late in gestation, 15 per cent during labour, 05
per cent in early postpartum period, and 5 per cent in
late postpartum period’’[2]. In the absence of any
intervention, rates of MTCT of HIV-1 can vary from
15 to 30 per cent in developed countries and can reach
as high as 30 to 45 per cent in developing countries
[2]. This difference can mainly be attributed to infant
feeding practices in the developing world that
comprise almost universally of breastfeeds for
prolonged duration [3].
FACTORS AFFECTING TRANSMISSION
Maternal factors like sero-conversion during
pregnancy, advanced stage of the disease,
concomitant malnutrition, ‘‘sexually transmitted
diseases’’ in the mother and poor adherence to
antiretroviral therapy after initiation are some
important factors which increase the transmission
during the antenatal period. As far as transmission in
the intranatal period is concerned, factors like
‘‘vaginal delivery, prolonged contact with maternal
blood and cervicovaginal secretions, prolonged
rupture of membranes, chorioamnionitis, exposure to
maternal blood like instrumentation during delivery,
episiotomy, foetal scalp electrode’’ are associated
with increased risk of transmission [4]. Further, there
is a probability of transmission from thin skin,
susceptible mucous membranes, immature immune
functions and low levels of maternal antibodies in the
premature infant etc. [4]. In the postnatal period
‘‘breast feeding, feeding in the presence of cracked
nipples or mastitis, feeding by both breast feeds and
top feeds, continuation of breastfeeds for prolonged
periods of time, seroconversion of the mother during
postnatal period, high viral load, low CD4 cell count,
all increase the risk of transmission of HIV [5].
Prolonged breastfeeding continues to expose the child
to HIV, and estimates of the additional risk of
infection after three months (known as late postnatal
transmission) are considerably high. To ensure large
scale implementation, adequate measures are devised
and revised from time to time by various concerned
agencies to address each of the above potential source
of vertical transmission ( Refer: UNAIDS,UNICEF
and WHO: Various Phases of Prevention 2010).
Based on Programme data, unprotected sex (87.4%
heterosexual and 1.3% homosexual) is the major route
of HIV transmission, followed by transmission from
Parent to Child (5.4%) and use of infected blood and
blood products (1.0%). In India, Injecting Drug Use is
the predominant route of transmission in north eastern
states, it accounts for 1.6 percent of HIV infections
[6]. INSERT TABLE 1 HERE
RATIONALE OF THE STUDY
Apart from posing the burden of HIV positive
children on the society, mother to child transmission
(MTCT) is causing a great social problem by
producing orphans after the death of one or both
parents due to AIDS.
The PPTCT (prevention of parent to child
transmission) programme entails counselling and
testing of pregnant women in the ICTCs. The PPTCT
interventions besides transitioning to multi-drug anti
retro viral prophylaxis have also heavily emphasized
over the role of peripartum and breastfeeding
practices to efficiently bring down the transmission of
HIV from mother to Child to the level of less than
5%. Government of India is now vigorously
following the option “B” of the WHO
recommendation with respect to the use of multidrug
ARV Prophylaxis and PTCT counseling and
breastfeeding guidelines [1]. [New WHO Guidelines
2013]
LITERATURE REVIEW
The Infant feeding options pose a difficult dilemma:
longer breast-feeding may increase MTCT of HIV and
subsequent HIV-associated mortality, but shorter
breast-feeding (or no breast-feeding) may increase
mortality from common childhood illnesses. Finally,
HIV-exposed but uninfected infants, who represent
30% of all children born in some areas of southern
Africa, have higher mortality rates than do infants
born to HIV-uninfected mothers, even when feeding
patterns are similar [5].
In this issue of Clinical Infectious Diseases, Kuhnet
et. al provide important data regarding the duration of
breast-feeding for HIV-exposed but uninfected infants
in Zambia. This was a new analysis from the Zambia
Exclusive Breast-Feeding Study, which previously
Page 3 of 9
Journal for Studies in Management and Planning
Available at http://internationaljournalofresearch.org/index.php/JSMaP
e-ISSN: 2395-0463
Volume 01 Issue 05
June 2015
Available online: http://internationaljournalofresearch.org/ P a g e | 245
demonstrated no benefit of early weaning for HIV- free survival. In the current analysis, a cumulative
mortality rate of 13.6% is reported among 749 HIV- uninfected infants who were followed up for 1–24
months. At each interval studied through 18 months of
age, weaning from breast milk was associated with a
significantly higher risk of infant mortality than was
continued breast-feeding beyond 18 months. The
authors call our attention to one of the most important
and modifiable risk factors for infant mortality—early
weaning from breast-feeding. Unfortunately, this
particular risk factor may also lead to late MTCT of
HIV, and balancing these risks is a difficult task that
requires knowledge of the local infant mortality rate
[5].A striking message from this study is that the
infant mortality rate is far too high. In a setting where
>13% of HIV-uninfected infants died between 1 and
24 months of age and an additional 4% died in the
first month of life, addressing the MTCT problem
alone is clearly insufficient. These findings are
generally consistent with those of other large studies
that have demonstrated that a high mortality rate is, in
part, related to HIV exposure: the 2-year mortality
rate was at least 3-fold higher in Zimbabwe and 2-fold
higher in Uganda among HIV-uninfected infants born
to HIV-infected mothers, compared with that among
infants born to HIV-uninfected mothers. The
vulnerability of these HIV-exposed uninfected infants
has been recognized for many years, but its cause
remains elusive [7]. Early investigators hypothesized
that HIV-infected women may not be able to care for
their infants as well as uninfected women. However,
the consistently higher mortality rates among HIV- exposed infants across locations and maternal
CD4+
cell counts, as well as the presence of risk even
where maternal highly active antiretroviral therapy is
available , suggest an immunologic or nutritional
explanation. Breast milk quality is an obvious starting
point, but initial attempts to find interpretable
differences between the breast milk of HIV-infected
and uninfected women have been unrevealing.
Furthermore, the results of the current study and
others suggest that, ‘‘even if the breast milk of HIV- infected women has some deficiencies, breast-feeding
remains one of the cornerstones of mortality
prevention’’ [8].
Interventions that allow for longer periods of safe
breast-feeding are an important first step, but
additional measures to reduce infant mortality both
before and after weaning are needed [9].
In the end, to fully address childhood mortality, we
need more information about the specific causes of
mortality at the local level and about the nature of the
vulnerability of HIV-exposed but uninfected infants.
The authors of the current study provide us with
valuable information about the high mortality risk
among these infants in Zambia and demonstrate that
weaning before 18 months of age is an important and
potentially modifiable risk factor [9].
OBJECTIVES OF THE STUDY
(1) To Understand the Profile Of HIV Infected
Pregnant Female.
(2) To Study the Risk of Feeding Infants by HIV
Positive Mothers.
METHODOLOGY AND STUDY DESIGN
The study being a retrospective one, has reviewed
both the primary and secondary data. Extensive
literature review was conducted from multiple
secondary data sources like websites of ministries,
WHO and journals, magazines and periodicals of
various sorts.
Besides, the records of 211 known HIV+ pregnant
(who had delivered in the time period from January
2006 to December 2013) in six PPTCT Centers
(AIIMS, Safdarjang, LBSH, Pt.Madan Mohan
Malviya Nagar Hospital, Kamla Nehru Maternity
Centre and SDH) were utilized for the review
purpose. Besides, discussions with the PPTCT
Counselors and key staff members of the hospitals
were initiated for the whole study period.
INSERT TABLE 2 HERE
ANALYSIS
The data collected from various secondary sources
was analyzed and interpreted with the help of simple
data presentation techniques like cross-tabulations,
Tables, Pie-Charts and Histograms.
FINDINGS OF THE OBJECTIVES
To Study the Profile of HIV Infected Mother and
their Spouse
This study was carried out in Prevention Of Parent To
Child Transmission Department (PPTCT) of
obstetrics and gynecology at various Government
Hospital, SafdarjangHospital ,AIIMS, LBSH,PT.M
M. M., Chacha Nehru and Swami Dayanand
Hospital Delhi. The study conducted over 211 HIV
positive pregnant women in various Hospitals and
