prof. thorkild tylleskär centre for international health, university of bergen
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Field experiences in scaling-up promotion of exclusive breastfeeding in the context of HIV. Prof. Thorkild Tylleskär Centre for International Health, University of Bergen. Exclusive breastfeeding (EBF). Advised up to 6 months of age Beneficial for all children (exposed and unexposed) - PowerPoint PPT PresentationTRANSCRIPT
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Field experiences in scaling-up promotion of exclusive breastfeeding in the context of HIV
Prof. Thorkild TylleskärCentre for International Health,
University of Bergen
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Exclusive breastfeeding (EBF)• Advised up to 6 months of age• Beneficial for all children (exposed and
unexposed)• Cuts mother-to-child transmission to half• Promotion must be carried out in the general
population– would fail if only promoted among HIV+
women
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Why is breast milk infective?
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Danger
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Tylleskar et al. Lancet 2011;378:420-27 + webappendix
Washington D.C., USA, 22-27 July 2012www.aids2012.org
PROMISE EBF • Promoting infant health and nutrition in
Sub-Saharan Africa: Safety and efficacy of exclusive breastfeeding promotion in the era of HIV
• Clinicaltrials.gov: NCT00397150
Objective: To assess in a cluster-randomised trial: • the impact of peer-counselling on exclusive
breastfeeding rates at 3 months of age• Data collection 2006-2008
Washington D.C., USA, 22-27 July 2012www.aids2012.org
BurkinaFaso
Zambia
Uganda
South Africa
West Africa
East
Afri
caCentralAfrica
SouthernAfrica
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Burkina Faso Uganda
S. Africa ZambiaNov 2007 – Feb 2008
Washington D.C., USA, 22-27 July 2012www.aids2012.org
InterventionPeer-counsellors were:• Women recruited from the
clusters • Trained as peer-counsellors
for 1-week according to WHO IYCF course 2005
• Unaware of the woman’s HIV status
• Regularly supervised by skilled staff
• Paid 10% of a teacher’s salary
Task:• Breastfeeding support to
pregnant and lactating mothers in her own cluster
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Intervention and data collection visits
Birth 2w 4w 6w 8w 10 12 14 16 18 20 22 24
Recruitment Intervention5 visits
Data collection 3, 6, 12, 24 wks
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Inclusion criteria
Mother:• Intending to
BF• No intention to
move in the follow-up period
• Consenting
Infant:• Singleton• Above 2 kg• No malformation
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Electronic data collection used in Uganda, Zambia, Burkina Faso
www.openxdata.org
Washington D.C., USA, 22-27 July 2012www.aids2012.orgopenXdata.org
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Analysis
• Country-specific outcomes
• Adjustment for cluster effect
• Intention-to-treat analysis (ITT)
• Outcome based on – 24-h recall and – 7-day recall
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Burkina Faso
24 clusters
894 women
Uganda
24 clusters
863 women
South Africa
34 clusters
1148 women
I
453
I
359
Randomised
3 mo follow-up
C
441
C
368
I
442
I
370
C
421
C
322
I
598
I
447
C
550
C
399
Participants
Washington D.C., USA, 22-27 July 2012www.aids2012.org
I C I C I C
Maternal age Median (± IQR) 25 (10) 25 (10) 25 (9) 24 (10) 23 (9) 23 (9)
Education years (± IQR) 0 (0) 0 (0) 6 (4) 6 (4) 10 (3) 10 (3)
Monthly income Euros (± IQR) 3 (6) 3 (5) 14 (22) 12 (19) 97 (93) 101 (94)
% % % % % %
Married 86 88 61 63 26 26
First child 18 16 22 24 48 51
ANC Attendance 71 71 71 76 99 98
Birth outside facility 62 65 55 42 6 8
Electricity 4 1 15 18 74 91
Thatched roof 58 52 12 13 15 12
No toilet or open toilet 98 98 25 18 31 16
Surface water as only water source 28 38 30 23 25 23
Wood only as cooking fuel 99 99 51 48 22 14
Burkina Faso Uganda South Africa
Baseline characteristics
Washington D.C., USA, 22-27 July 2012www.aids2012.org
EBF at 12 weeksby 24 hours recall
0
10
20
30
40
50
60
70
80
90
100
Burkina Faso Uganda South Africa
I C I CI C
(%)
2.1** 1.9** 1.8**
Burkina Faso Uganda South Africa
** p<0.01
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Conclusions• Peer-counselling for EBF increases EBF
rates at 3 months 2-fold depending on the local context
• Large country differences in – Baseline characteristics– Baseline EBF rates– South Africa is a case of its own
(Nor B, et al. J Hum Lact 2009)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Post-hoc reflections
• Complementary feeding needs to be included• Individual or group counselling? Home-based or
facility-based?• BF alone or combined with other interventions?• Focus on early BF and initiation
– Most important to be exclusive in the beginning• Golden opportunity for closer integration
between HIV-care and maternal, newborn and child care
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Victora et al. Lancet 2008; 371: 340–57webappendix
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Post-hoc reflections
• Complementary feeding needs to be included• Individual or group counselling? Home-based or
facility-based?• BF alone or combined with other interventions?• Focus on early BF and initiation
– Most important to be exclusive in the beginning• Golden opportunity for closer integration
between HIV-care and maternal, newborn and child care
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Post-hoc reflections
• Complementary feeding needs to be included• Individual or group counselling? Home-based or
facility-based?• BF alone or combined with other interventions?• Focus on early BF and initiation
– Most important to be exclusive in the beginning• Golden opportunity for closer integration
between HIV-care and maternal, newborn and child care
Washington D.C., USA, 22-27 July 2012www.aids2012.org
PROMISE PEP (ANRS 12174)
• BF advice is not enough to protect the child• A randomised controlled trial comparing the
efficacy of infant peri-exposure prophylaxis with lopinavir/ritonavir (LPV/r) versus lamivudine to prevent HIV-1 transmission by breastfeeding
• Clinicaltrials.gov registration # NCT00640263
Washington D.C., USA, 22-27 July 2012www.aids2012.org
PROMISE EBF• Steering Committee: Thorkild
Tylleskär, Philippe Van de Perre, Eva-Charlotte Ekström, Nicolas Meda, James K. Tumwine, Chipepo Kankasa, Debra Jackson
• Norway: Thorkild Tylleskär, Ingunn MS Engebretsen, Lars Thore Fadnes, Eli Fjeld, Knut Fylkesnes, Jørn Klungsøyr, Anne Nordrehaug-Åstrøm, Øystein Evjen Olsen, Bjarne Robberstad, Halvor Sommerfelt
• France: Philippe Van de Perre
• Sweden: Eva-Charlotte Ekström, Barni Nor
• Burkina Faso: Nicolas Meda, Hama Diallo, Thomas Ouedrago, Jeremi Rouamba, Bernadette Traoré Germain Traoré, Emmanuel Zabsonré
• Uganda: James K. Tumwine, Caleb Bwengye, Charles Karamagi, Victoria Nankabirwa, Jolly Nankunda, Grace Ndeezi, Margaret Wandera
• Zambia: Chipepo Kankasa, Mary Katepa-Bwalya, Chafye Siuluta, Seter Siziya
• South Africa: Debra Jackson, Mickey Chopra, Mark Colvin, Tanya Doherty, Ameena E Googa, Lyness Matizirofa, Lungiswa Nkonki, David Sanders, Wanga Zembe
• European Union 6th Framework Programme • Research Council of Norway• Sida/Sarec, Sweden• Medical Research Council, South Africa
Funding:
Washington D.C., USA, 22-27 July 2012www.aids2012.org