Effect of a sanitation & nutrition intervention on HIV-exposed infant health

描述(由申请人提供)：高达40%的艾滋病毒母婴传播(MTCT)发生在母乳喂养期间，与BF相关的MTCT有三分之二发生在6个月后的婴儿中。世卫组织建议及早停止BF，以此作为减少母婴传播的一种方法，但发展中国家的几项研究发现，相关胃肠炎、生长迟缓和死亡率很高。这并不令人惊讶，因为6至24个月的生命周期是发育迟缓的时期，即使在艾滋病毒阴性母亲的BF子女中也是如此。在此期间，生活在非洲和亚洲的儿童的平均年龄体重Z分数(WAZ)和年龄长度Z分数(LAZ)暴跌至-1.5至-2.5，此后几乎没有恢复。由此导致的体重不足和发育不良分别占所有5岁以下儿童死亡率的50%和35%，并导致认知发展的长期缺陷、学习成绩下降和成人经济生产力下降。6至24个月期间的特点是逐渐添加或其他食物和液体，腹泻发病率高。通过改善6-24个月儿童的补充喂养方式来促进生长的努力通常取得了一定的成功：大多数儿童在18-24个月时将WAZ和LAZ的Z分数提高了0.1-0.5Z。另一份文献表明，提供水，特别是卫生服务，可以减少腹泻和促进儿童生长，使WAZ和LAZ的增长幅度与补充喂养干预措施相同。此外，对生长的影响大于对腹泻的影响，并且独立于对腹泻的影响，这表明这些服务减少了亚临床肠道疾病，这种疾病抑制了生长，并且比腹泻更普遍。这项研究将测试对500名艾滋病毒阳性母亲及其子女从怀孕中期到24个月进行干预的有效性。干预措施将包括卫生服务(提供厕所)、改善个人卫生(推广洗手)和改善营养(促进所有婴儿从出生到6个月的专属BF；对6个月后PCR检测为阴性的艾滋病毒暴露婴儿推广表达和加热母乳(无直接BF)，对6个月后PCR呈阳性的暴露婴儿继续BF；改进喂养做法；以及提供一种微量营养素强化食品Nutributer)。所有干预措施都将由社区现有的(虽然得到加强的)乡村卫生工作者网络提供。主要的婴儿结局将是：6个月的PCR阴性婴儿24个月无感染存活；12个月和18个月的血红蛋白；以及线性和有质量的生长。 公共卫生相关性：每年有20万婴儿在母乳喂养期间感染艾滋病毒，因此世界卫生组织建议艾滋病毒阳性的母亲停止母乳喂养，以减少这种传播。不幸的是，在资源有限的环境中不母乳喂养会导致高腹泻、生长不良和死亡。这项研究将测试提供营养、卫生和个人卫生干预措施，作为一种将艾滋病毒暴露降至最低的方法，同时还促进发展中国家艾滋病毒阳性母亲所生幼儿的成长和健康。

DESCRIPTION (provided by applicant): Up to 40% of mother-to-child transmission (MTCT) of HIV occurs during breastfeeding BF, and two-thirds of BF-associated MTCT occurs among infants after 6 mo of age. Early BF cessation is recommended by WHO as one way to minimize MTCT, but several studies in developing countries have observed high rates of associated gastroenteritis, growth faltering, and mortality. This is not surprising since the 6 to 24 month period of life is a time when growth faltering is prevalent even among BF children of HIV-negative mothers. During this period, mean weight-for-age-Z scores (WAZ) and length-for-age-Z-scores (LAZ) of children living in Africa and Asia plummet to -1.5 to -2.5, followed by little or no recovery thereafter. The resulting underweight and stunting malnutrition underlies 50% and 35%, respectively, of all under-5 mortality, and results in long-term deficits in cognitive development, reduced school performance, and lower adult economic productivity. The 6 to 24 mo period is characterized by the gradual addition or other foods and liquids and with high rates of diarrheal disease. Efforts to enhance growth by improving complementary feeding practices among 6 to 24 mo old children have generally met with modest success: most improve WAZ and LAZ by 0.1 - 0.5 Z scores at 18 - 24 mo. Another literature indicates that provision of water and especially sanitation services, reduces diarrhea and enhances child growth, producing increases in WAZ and LAZ by the same order of magnitude as complementary feeding interventions. Furthermore, the effects on growth are greater than and independent of the effects on diarrhea, suggesting these services reduce subclinical enteric disease, which suppresses growth and is much more prevalent than diarrhea. This study will test the effectiveness of an intervention delivered to 500 HIV-positive mothers and their children from mid-gestation to 24 mos. The intervention will include sanitation services (provision of a latrine), improved hygiene (promotion of hand washing), and improved nutrition (promotion of exclusive BF from birth to 6 mo for all infants; promotion of expressed and heat-treated breast milk (no direct BF) for HIV-exposed infants testing PCR-negative at 6 months and continued BF for exposed infants testing PCR-positive at 6 months; improved feeding practices; and provision of Nutributter, a micronutrient fortified food). All interventions will be delivered by an existing (albeit strengthened) village health worker network in the community. Primary infant outcomes will be: infection-free survival at 24 months among 6-mo PCR- negative infants; hemoglobin at 12 and 18 months; and linear and ponderal growth. PUBLIC HEALTH RELEVANCE: Each year, 200,000 infants are infected with HIV during breastfeeding, so the World Health Organization recommends that HIV-positive mothers stop breastfeeding to reduce this transmission. Unfortunately, not breastfeeding in resource-constrained settings is associated with high rates of diarrhea, poor growth, and death. This study will test provision of a nutrition, sanitation, and hygiene intervention as an approach to minimize HIV-exposure while also promoting growth and health in young children born to HIV-positive mothers in developing countries.