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BF期间，三分之二的BF相关MTCT发生在6个月后的婴儿中。世卫组织建议尽早停止BF，作为最大限度减少母婴传播的一种方法，但在发展中国家进行的几项研究发现，相关的胃肠炎、生长迟缓和死亡率很高。这并不奇怪，因为6至24个月的生命期是一个时期，即使是在艾滋病毒阴性母亲的BF儿童中，生长迟缓也很普遍。在此期间，生活在非洲和亚洲的儿童的平均年龄Z值（WAZ）和年龄Z值（LAZ）骤降至-1.5至-2.5，此后几乎没有恢复。由此造成的体重不足和发育不良的营养不良分别占所有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增加或其他食物和液体，并与高发病率的腹泻病。在6 - 24个月大的儿童中，通过改善补充喂养实践来促进生长的努力通常取得了一定的成功：大多数在18 - 24个月大时提高WAZ和LAZ 0.1 - 0.5 Z评分。另一项文献表明，提供水，特别是卫生服务，减少腹泻，促进儿童生长，使WAZ和LAZ增加与补充喂养干预措施相同的数量级。此外，对生长的影响大于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，亚临床肠道疾病抑制生长并且比腹泻更普遍。这项研究将测试500名HIV阳性母亲及其从妊娠中期到24个月的孩子的干预效果。干预措施将包括卫生服务（提供厕所），改善卫生（提倡洗手）和改善营养（促进所有婴儿从出生到6个月的纯母乳喂养;促进6个月时PCR检测为阴性的艾滋病毒暴露婴儿的挤出和热处理母乳（无直接母乳喂养），并促进6个月时PCR检测为阳性的暴露婴儿的持续母乳喂养;改进喂养方法;营养素，一种微量营养素强化食品）。所有干预措施都将由社区中现有的（尽管得到加强的）乡村保健工作者网络提供。主要婴儿结局为：6个月PCR阴性婴儿24个月时的无感染存活率; 12个月和18个月时的血红蛋白;以及线性和重量生长。 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与腹泻，生长不良和死亡的高发病率有关。这项研究将测试提供营养，环境卫生和个人卫生干预措施，以尽量减少艾滋病毒暴露，同时促进发展中国家艾滋病毒阳性母亲所生幼儿的生长和健康。

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.