Complementary feeding intervention benefits HIV-exposed uninfected children
Authors: Louise Kuhn
Journal: The Lancet Child & Adolescent Health (2018)

Over the past several decades, the HIV pandemic has wreaked havoc with maternal and child health around the globe. High mortality in HIV-infected infants and young children was a grim impetus for the worldwide research endeavour that established antiretroviral drugs as an effective means to prevent mother-to-child HIV transmission. These drugs are so effective that they not only save the lives of those already infected, but also raise the hope that new paediatric HIV infections can be practically eliminated.1McNairy ML Teasdale CA El-Sadr WM Mave V Abrams EJ Mother and child both matter: reconceptualizing the preention of mother-to-child transmission care continuum.Curr Opin HIV AIDS. 2015; 10: 403-410Crossref PubMed Scopus (20) Google Scholar Stemming the tide of new infections in young women, particularly those residing in sub-Saharan Africa, has been less successful. Thus, there remains a large and growing population of chronically infected young adults in their child-bearing years.1McNairy ML Teasdale CA El-Sadr WM Mave V Abrams EJ Mother and child both matter: reconceptualizing the preention of mother-to-child transmission care continuum.Curr Opin HIV AIDS. 2015; 10: 403-410Crossref PubMed Scopus (20) Google Scholar Unfortunately, acquisition of HIV is not the only danger faced by children whose mothers are HIV infected. The first of such dangers noticed were immune abnormalities, initially thought to be correlates of protection against perinatal HIV transmission.2Shearer GM Clerici M Protective immunity against HIV infection: has nature done the experiment for us?.Immunol Today. 1996; 17: 21-24Summary Full Text PDF PubMed Scopus (177) Google Scholar Thereafter, a range of adverse outcomes were found to be more frequent in HIV-exposed uninfected children than in their HIV-unexposed counterparts.3Farquhar C John-Stewart G The role of infant immune responses and genetic factors in preventing HIV-1 acquisition and disease progression.Clin Exp Immunol. 2003; 134: 367-377Crossref PubMed Scopus (21) Google Scholar The strongest demonstration of this increased risk was from the landmark ZVITAMBO study, which observed an almost double risk of infant and young child mortality in HIV-exposed uninfected children compared with HIV-unexposed children.4Marinda E Humphrey JH Iliff PJ et al.Child mortality according to maternal and infant HIV status in Zimbabwe.Pediatr Infect Dis J. 2007; 26: 519-526Crossref PubMed Scopus (241) Google Scholar Excess mortality and morbidity associated with maternal HIV status has been consistently reported across studies.5Evans C Jones CE Prendergast AJ HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination.Lancet Infect Dis. 2016; 16: e92-e107Summary Full Text Full Text PDF PubMed Scopus (168) Google Scholar Some of the excess risk was due to shifts away from breastfeeding during the era when breastfeeding was discouraged for HIV-exposed infants and some in the pre-antiretroviral therapy era as a result of maternal mortality. However, even with universal maternal antiretroviral therapy and support of adequate breastfeeding, adverse outcomes, including excess mortality, are still observed in HIV-exposed uninfected children.5Evans C Jones CE Prendergast AJ HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination.Lancet Infect Dis. 2016; 16: e92-e107Summary Full Text Full Text PDF PubMed Scopus (168) Google Scholar The Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial done in rural Zimbabwe was a bold investigation of the independent and combined effects of an infant and young child feeding (IYCF) intervention and a water, sanitation, and hygiene (WASH) intervention.6Humphrey JH Mbuya MNN Ntozini R et al.Independent and combined effects of improved water, sanitation and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster randomised trial.Lancet Glob Health. 2019; 7: e132-e147Summary Full Text Full Text PDF PubMed Scopus (223) Google Scholar These interventions were developed based on biological principles and formulated and pilot tested to be effectively implemented. High prevalence of maternal HIV infection (more than 15%) in the communities in which this cluster-randomised trial was done provided a large sample size to directly examine the effect among the vulnerable HIV-exposed uninfected child population. Using this strong trial design, SHINE observed a beneficial effect of their IYCF intervention on linear growth and haemoglobin concentration among HIV-exposed uninfected children.7Prendergast AJ Chasekwa B Evans C et al.Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on stunting and anaemia among HIV-exposed children in rural Zimbabwe: a cluster-randomised trial.Lancet Child Adolesc Health. 2018; (published online Dec 17.)http://dx.doi.org/10.1016/S2352-4642(18)30340-7Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar The IYCF intervention consisted of provision of a daily, small quantity lipid-based nutrient supplement provided between age 6 and 18 months in the context of active support of breastfeeding. It also provided behaviour change messages by local village health workers to support optimal complementary feeding. The IYCF intervention was associated with a significant reduction in the proportion of children classified as stunted (length for age Z-score <–2) at 18 months (136 [40%] of 336 children in the IYCF groups vs 165 [50%] of 329 in the non-IYCF groups; absolute reduction 10%, 95% CI 2–17), as well as a significant reduction in the proportion with anaemia (24 [7%] of 329 vs 45 [14%] of 319; 7%, 95% CI 2–12). The beneficial effect on linear growth is particularly encouraging, as stunting is a sentinel marker of the adverse effects of poverty on child health. Stunting is an intractable health problem and the most common manifestation of undernutrition. Short-term, medium-term, and long-term adverse health outcomes—including increased mortality and morbidity, and compromised neurodevelopment—accrue in this group.8Prendergast AJ Humphrey JH The stunting syndrome in developing countries.Paediatr Int Child Health. 2014; 34: 250-265Crossref PubMed Scopus (452) Google Scholar Reduced school attainment and adult economic productivity associated with stunting perpetuate cycles of poverty within generations. But it does not stop there—the next generation is also affected, further perpetuating societal health disadvantage.9Martorell R Zongrone A Intergenerational influences on child growth and undernutrition.Paediatr Perinat Epidemiol. 2012; 26: 302-314Crossref PubMed Scopus (220) Google Scholar It is sobering that the WASH intervention, so rigorously developed and implemented, did not have the hypothesised synergistic effects to accelerate the benefits of the complementary feeding intervention. The reasons for the null finding are undoubtedly complex, but a conclusion that it is unnecessary to improve water and sanitation infrastructure in impoverished communities is patently false. It is possible that the public health infrastructure provided by the trial brought the background environmental conditions, even in the non-WASH groups, to a minimum level that allowed the IYCF intervention to have an effect. It is also highly probable, as speculated by the investigators, that the extent of environmental contamination is so profound that more broad-ranging approaches will be necessary before true benefits of WASH can be observed. The HIV pandemic has led to deterioration in global child health through both direct and indirect means. Antiretroviral drugs have effectively addressed the direct effects of HIV (vertical transmission), and SHINE now provides new impetus on how to effectively address the indirect effects. SHINE showed that a modest and pragmatic complementary feeding intervention has benefits for the health of HIV-exposed uninfected children, and a key step forward is to prioritise the implementation of complementary infant feeding in areas with high HIV prevalence. I declare no competing interests. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on stunting and anaemia among HIV-exposed children in rural Zimbabwe: a cluster-randomised controlled trialSince HIV-exposed children are particularly vulnerable to undernutrition and responded well to improved complementary feeding, IYCF interventions could have considerable benefits in areas of high antenatal HIV prevalence. However, elementary WASH interventions did not lead to improvements in growth. Full-Text PDF Open Access