Nutrition

Nutrition and HIV/AIDS

GOAL: Reduce the proportion of infants infected with HIV by 20 per cent by 2005 and by 50 per cent by 2010.

“Today over 11 million children in Africa are orphaned, nearly 3 million children are living with AIDS in Africa and the pandemic steamrolls on with over 7,000 children and young people being infected daily.” – UNICEF Executive Director Carol Bellamy [Speech to the African Leadership Consultation, 9/9/02]

Mother-to-child transmission

An estimated 800,000 children under the age of 15 contracted HIV in 2001, around 90 per cent of them through mother-to-child transmission.  The vast majority of HIV-infected mothers live in Africa, as do the children living with AIDS.  UNICEF’s nutritional priorities with HIV/AIDS are twofold: helping HIV-infected mothers make informed infant-feeding decisions and meeting the needs of millions of children affected by the virus.

HIV-infected mothers face an agonizing choice when deciding how to feed their infants. Without preventative interventions, about 5-20 per cent of infants born to infected mothers will contract the virus through breastmilk if breastfed for two years. (Every year 200,000 infants become HIV+ in this way.)  At the same time, if a mother does not breastfeed, her infant will face a six times greater chance of dying in her or his first two months of life from infectious diseases such as diarrhoea and respiratory infections.

Several factors affect the risk of transmission, including the “viral load” or amount of virus in the mother’s body (highest right after infection and when AIDS develops), the duration of breastfeeding (the longer the period, the greater the risk), exclusivity of breastfeeding (breastmilk alone for the first three months may lower the risk), and the condition of the breasts (whether there are sores around the nipples).

This is further compounded by the fact that the vast majority of HIV+ women in developing country settings do not know their HIV status.

“Our neighbours are not like before – they have distanced themselves. They should be distancing themselves from the virus, not from us.” – Ammanuel, 13, orphaned by AIDS, Ethiopia. [SOWC, 2002]

For many women in developing countries, their situations are further complicated by poverty or social pressures. A mother may lack access to clean water needed to safely prepare breastmilk substitutes. Alternatives may be prohibitively expensive or she may live too far away from the supply to have continuous access. Finally, there may be taboos or stigma about alternative feeding. Fearing marginalization, many women may not wish to share their HIV status with their partners, family or community.

HIV’s high nutritional toll

"In the past there was always an adult around to do the work - to plant seeds and plough the fields. Now, with one in four adults in the region HIV-positive, many people are too sick to work, or have already died, and it is the children, some as young as eight or nine, who are left to cope alone.” – UNICEF Goodwill Ambassador Roger Moore in Zambia.

The HIV/AIDS pandemic, combined with drought, floods, decades of conflict, economic decline and cuts in social services, have overwhelmed families in southern Africa, leaving them with few coping mechanisms. Malnutrition rates are increasing among young children and pregnant and breastfeeding mothers. This crisis in Africa has underscored the dire nutritional needs of all children who are HIV positive or affected by HIV/AIDS, such as orphans and those living in households with infected family members. More than 13 million children under the age of 14 have been orphaned by AIDS and many are left to fend for themselves.  Many other children live with HIV-infected parents who can no longer provide food for their families.

The Solution

“Africa’s experience of HIV/AIDS over the last 10 years has diverged so dramatically and terrifyingly from that of industrialized countries, not because a plague has hit it at random, but rather because of its poverty. Any infection thrives in conditions of poverty, malnutrition and unsafe water. It is as true of HIV/AIDS as it is of tuberculosis and measles.” [SOWC, 2002]

Fighting HIV/AIDS is one of UNICEF's five organizational priorities over the next four years. Nutrition programming is focused primarily on the prevention of mother-to-child transmission in breastfeeding and on care and support for infected mothers. Strategies include: providing voluntary, confidential testing and infant feeding counselling for pregnant women, helping governments develop infant and young child feeding policies that encournage early and exclusive breastfeeding for non-HIV infected women and include HIV guidelines, protecting breastfeeding, and promoting optimal infant feeding in hospitals. More recently, UNICEF has also been concentrating on addressing the nutritional needs of the growing number of children who are infected with the virus, orphaned, or living with an HIV-infected parent.

By 2001, UNICEF and other UN agencies were supporting 80 programmes to prevent mother-to-child transmission of HIV in 16 countries. Between April 1999 and July 2001, these programmes reached over 300,000 new clients in antenatal care centres, providing counseling to 220,000 women and HIV testing to 138,000 women.

To enable mothers to carry out their decision safely and effectively, UNICEF works to expand access to voluntary counselling and testing and to train health workers, counsellors and support groups on HIV and infant feeding. UNICEF, in collaboration with WHO, has supported the instruction of more than 100 individuals on advising women about HIV and infant feeding. They, in turn, have trained more than 1,000 counsellors who, in turn, have advised thousands of mothers. New guidelines are available to support decisions on HIV and infant feeding. 

In addition to ongoing support for the International Code of Marketing of Breast-milk Substitutes and Baby-friendly Hospital Initiative, UNICEF helps governments devise infant feeding guidelines through studies  that evaluate the acceptability, feasibility, affordability, sustainability and safety of various options for HIV-infected mothers. At present, they are being conducted in more than 10 countries, including Haiti, Malawi, Namibia, Swaziland and Zambia. UNICEF also helps develop training materials and communication strategies on HIV and infant feeding.

“One of the biggest problems is the stigma around HIV/AIDS. HIV-positive people are a normal group of the population with special needs who require support, not blame or pointing fingers. As long as that is not the case, our job is going to be difficult.” – UNICEF Project Officer Nutrition and HIV, Arjan de Wagt

The Facts

Without preventive interventions, approximately one-third of infants born to HIV-positive mothers contract HIV through mother-to-child transmission, becoming infected during their mothers' pregnancy, childbirth or breastfeeding. In 2001, 800,000 children under the age of 15 contracted HIV, over 90 per cent of them through mother-to-child transmission of HIV (MTCT). Between 15 and 25% of children born to HIV-infected mothers get infected with HIV during pregnancy or delivery, while about 15% of the children get infected through breastfeeding.

Issues at a Glance

Breastfeeding saves lives

The Response: Key Principles and Strategies

WHO/UNAIDS/UNICEF infant feeding guidelines

UNICEF's Response

Factors that may decrease the risk of HIV transmission through breastfeeding include:

Shorter duration of breastfeeding. The longer a child is breastfed by an HIV-positive mother the higher the risk of HIV infection. Breastfeeding for 6 months has about one third of the risk of breastfeeding for 2 years.
Exclusive breastfeeding in the early months. Some immunological studies are finding that there are factors in human milk, especially the milk of the the HIV-infected mother, that will directly combat the cells that contribute to the transmission of the HIV infection. A study done in Durban, South Africa showed that exclusive breastfeeding during the first 3 months of life resulted in a lower risk of MTCT than mixed feeding (breastfeeding combined with other foods, juices or water)

Prevention and treatment of breast problems. Mastitis and cracked nipples and other causes of breast inflammation are associated with an increased risk of HIV-transmission.

Prevention of HIV-infection during breastfeeding. The maternal viral load is higher shortly after a new infection resulting in an increased risk of infection of the child.

Early treatment of sores or thrush in the mouth of the infant. Sores in the infant's mouth make it easier for the virus to enter the infant's body.
The risk of HIV-infection has to be compared with the risk of morbidity and mortality due to not breastfeeding. Breastfeeding is protective against death from diarrhoea, respiratory and other infections, particularly in the first months of life. Breastfeeding also provides the necessary nutritional and related ingredients, as well as the stimulation necessary for good psychosocial and neurological development, and contributes to birth spacing.

Breastfeeding saves lives

The crisis in Southern Africa has shown how far the coping mechanisms of communities and extended families has deteriorated due to HIV. At one point most could survive the periodic droughts or floods. Today, many have spent their extra resources on health care, on funerals, on taking care of orphans. Now they need basics: food, blankets, soap and money for schooling. UNICEF is providing food to people affected by the crisis in Southern Africa, specifically targeting families affected by HIV/AIDS. The next step is to assist with the nutritional counselling of those with HIV/AIDS, a growing population with significant nutritional needs.

Country snapshots:

There are currently 2,500 HIV-positive children in Viet Nam. One third of them are babies, some are orphans. UNICEF provides training to caregivers as part of its integrated response to the HIV epidemic in Viet Nam. Specific activities include the promotion of behavioural change amongst adolescents through life skills education; care and support of infected mothers and their babies; and the prevention of HIV transmission from parents to children through advocacy campaigns.

In Southern Africa, UNICEF is particularly concerned about children orphaned by HIV/AIDS and is giving them top priority in food distribution. In Lesotho, for example, a study showed that 75 per cent of all orphans, some 143,000, were children orphaned by AIDS, many of whom now live in child-headed households.

With UNICEF support, assessments of HIV and infant feeding practices have been conducted or are planned in Botswana, India, Kenya, Malawi, Rwanda, South Africa and Uganda. A study in Uganda looked at the experiences with early transition to replace feeding by HIV-positive mothers. In South Africa, a study is being conducted on a simple method for pasteurization of breastmilk and on the feasibility of using milk banks.