WASH & HIV: links with maternal & child health

Joe BrownLondon School of Hygiene & Tropical MedicineDepartment of Disease ControlFaculty of Infectious & Tropical Diseases

joe.brown@lshtm.ac.uk24 July 2012

The big picture• HIV+ mothers and children are highly

vulnerable to WASH-related co-infections

• Providing critical WASH interventions, together with ART for mother and baby, can lower the risk of child death and may lower the risk of mother-to-child transmission (MTCT)

Some common co-infections that may be prevented or reduced with WASH• Faecal-oral

– Hepatitis A,E; viral diarrheas; Campylobacter; cholera; ETEC; Salmonella; Shigella; typhoid; paratyphoid; Crypto; Giardia; Amoebas; Toxoplasma gondii and other opportunists

• Water-washed– Trachoma; scabies; conjunctivitis; louse-borne infections

• Soil helminths and tapeworms– Ascaris; hookworm; Taenia

• Water-based– Cholera; Legionella; Leptospirosis; Schisto;

• Insect vectors– Dengue, yllw fever, malaria, trypanosomiasis, filariasis, trachoma

• Rodent borne– Leptospirosis; hantavirus, Tularemia

Children with HIV• Children who are HIV+ are at much greater risk

of hospitalization, long-term illness, and death as a result of WASH-related infections

• Children who are HIV+, as well as those who are HIV- but cared for by mothers that are HIV+, are at greater risk of poor nutritional status and health which can be caused or aggravated by enteric infection (Filteau 2009)

ART and diarrhea

• Diarrheal disease and intestinal infection may cause individuals on antiretroviral therapy (ART) not to absorb therapeutic dosages of the medication (Isaac 2008, Brantley 2003, Bushen 2004).

• Implications for PMTCT

Prevention of Mother-to-Child Transmission (PMTCT)• Healthier moms are less likely to transmit

the virus to children through breastfeeding– Healthier moms are less likely to pass other

infections to baby, also • Gut infections in babies may increase the

risk of HIV infection by compromising the integrity of the intestinal wall, making it easier for the HIV virus to pass into the infant’s bloodstream

• Safe water and hygiene play a major role in the limited circumstances when replacement feeding/early weaning are indicated

Retention in care• Increased retention in

PMTCT programming as a result of VitaMeal and hygiene packages (soap, P&G packets/cloth+ storage container) offered

• Also reported “99.4% usage” of water treatment at 3 month follow up, vs 12% (disinfectant use among mothers with young children) or 20% (all households in Malawi)

Rosen S, Fox MP, Gill CJ (2007) Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review. PLoS Med 4(10): e298. doi:10.1371/journal.pmed.0040298http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040298

Cost effectiveness• Low cost of including WASH in treatment and

care programs– Pennies on the dollar! – Sustained access to safe water would be <5% of the

cost of first-line ARVs (drugs only)• Significant net savings with integrated

programming (Khan et al 2012)• Russo et al. 2012, Malawi: benefits of hygiene

and safe water programs can extend beyond antenatal beneficiaries to include friends and relatives

What we can do nowAdd WASH to HIV PMTCT programming because:

• 1. We know HIV-affected children are highly vulnerable to diarrheal illnesses

•2. We know that WASH interventions can reduce diarrhea by 50% or more• 3. We know that diarrhea in mothers and

children can contribute to lower uptake of life-saving drugs that prevent MTCT

• 4. We know it can increase retention in treatment and care, at low cost

Thank youCreative and Novel Ideas in HIV Research (NIH)

P&G

London School of Hygiene and Tropical Medicine, Environmental Health Group

University of Zambia School of Medicine

Charlie Van Der Horst & the UNC CFAR