Breastfeeding: Getting Close to Zero for an AIDS-free generation By James Achanyi-Fontem, camlinknews camlink@cameroonlink.org

Cameroon Link joined the rest of the world in celebrating World AIDS Day. Ahead of the event was a whole week dedicated for social mobilization, advocacy, information, education and communication activities aimed at sharing updates. According to an update from the World Alliance for Breastfeeding action, WABA,thirty yearsago the first report appeared documenting transmission of the Human Immunodeficiency Virus (HIV) through breastfeeding. Breastfeeding by HIV-Positive mothers has never been as safe as it is now in 2015. So long as several easily achievable conditions are fulfilled, the risk of transmission of the virus through mother’s milk can be reduced to almost zero (0-1%).

Breastfeeding remains of crucial importance to the health of HIV-exposed infants since non-breastfed babies experience higher rates of illness and mortality. A recent study shows that the improved immunological and nutrition status enjoyed by breastfed, HIV-exposed infants is especially protective against pneumonia, diarrhoea and sepsis, leading to reduced hospitalisation during the first year of life . Two studies have also shown that when these babies have been exclusively breastfed for 6 months and continued to be breastfed while their mothers adhere to their ART, there is no increased risk of transmission up to 12 months . Breastfeeding by HIV-Positive mothers can be made safe when they: • are diagnosed before or during early pregnancy. • have received full antiretroviral therapy (ART) for at least 13 weeks prior to the birth of their babies. • have an undetectable viral load. • are adherent to their ART. • administer prescribed antiretroviral prophylaxis to their babies from birth to 4 weeks to protect from virus acquired at birth • practise exclusive breastfeeding during their babies’ first 6 months of life. • continue breastfeeding with appropriate complementary foods for up to a year, or even longer, unless or until safe replacement feeding would enhance HIV-free survival. The importance of exclusive breastfeeding for the first six months of life, and continued breastfeeding for up to two years or beyond, in accordance with current WHO recommendations cannot be too highly stressed. The evidence for promotion of breastfeeding for all babies continues to grow. The December 2015 month’s special issue of the medical journal Acta Paediatrica contains a summary and ten separate review articles, coordinated by the World Health Organisation, on different aspects of breastfeeding. Topics as diverse as how breastfeeding leads to reduced mortality, higher intelligence, improved growth, lower cholesterol, lower blood pressure and a reduced risk of type 1 diabetes in later life, lower incidence of asthma, allergies, malocclusion, dental caries and otitis media are fully discussed. The series ends with modules outlining how breastfeeding improves the health of women, and how to provide effective interventions to make breastfeeding easier. Current WHO recommendations suggest that ART should be initiated in all individuals who test HIV-positive, including pregnant and breastfeeding women living with HIV regardless of WHO clinical stage and at any CD4 cell count and continued lifelong. Effective antiretroviral treatment, currently available in most settings, can greatly reduce the infectivity of HIV-positive individuals, and antiretroviral prophylaxis is effective in protecting transmission of the virus between sexual partners and between mothers to their children. Thus girls and young women can be protected from primary infection with HIV and infants of already-infected mothers can be protected from transmission during pregnancy, during birth and during breastfeeding. However, fear of stigmatization and discrimination often leads to weak adherence to antiretroviral treatment. Outdated beliefs about the benefits of artificial feeding for HIV-exposed infants, coupled with fear of disclosure of their HIV status if they do not breastfeed, means that many HIV-Positive women will bottle-feed in secret at home, but breastfeed in public, which means that too many HIV-exposed babies are mixed-fed. Mixed feeding places babies at the greatest risk of HIV-transmission. It can be seen that effective treatment with antiretroviral drugs transforms HIV from a lethal to a chronic disease, but fear, stigmatization, discrimination and gender inequality issues are now driving the spread of HIV. Greater acceptance of people living with HIV and better understanding of HIV by society in general will be necessary to tackle current stigma. With sufficient political will, there can be virtually zero transmission of the virus from mothers to their children, including through breastfeeding, meaning that achievement of an AIDS-free generation is finally within the grasp of the global community. It should be noted that exclusive breastfeeding rate for the first si x months of life of babies in Cameroon jas moved from 20% to 28% according to research by the Cameroon Society of Paediatriciams. This was made known during a recent consultative meeting of nutrition promotion stakeholders in the economic capital of Douala. PEPFAR holds consultative meetings with Cameroon media and CSO

Cameroon Link participated in the meetings organized by PEPFAR for media and leaders of Civil Society Organisations (CSO) in Douala ahead of celebrations marking World AIDS Day 2015. PEPFAR is the President’s Emergency Plan for AIDS Relief, the U.S. Government initiative to turn the tide of the HIV/AIDS epidemic around the world. This historic commitment is the largest by any nation to combat a single disease internationally. PEPFAR investments also help alleviate suffering from other diseases. PEPFAR is driven by a shared responsibility among donors and partner nations to make smart investments to save and improve lives. PEPFAR Country Coordinator, Catherine Akom Anjeh briefed journalists on the situation of US contributions and lobbied for collaboration with the civil society organisations, so that aid can reach the right beneficiaries in the rural areas. In Cameroon, PEPFAR began in 2009-2010 and has since grown to an annual budget of about US $26 million. The initiative is administered by the U.S. Centers for Disease Control (CDC), the U.S. Agency for International Development (USAID), the Departments of Defense (DoD) and State (DoS), and the Peace Corps. About 15 Cameroonian and international implementing partners conduct field activities, often in collaboration with local sub-partners, in the areas of prevention of mother-to-child HIV transmission (PMTCT), prevention of sexual HIV transmission, blood safety, HIV testing and counseling, HIV care and support, laboratory strengthening, strategic information, and other health systems strengthening. All PEPFAR investments are aligned with Cameroon’s National HIV/AIDS Strategic Plan and work to strengthen the capacity of Cameroon’s government, non-governmental and private sectors, and civil society to respond to the HIV/AIDS epidemic. In Cameroon, support groups help soldiers live positively Here are a few testimonies of why we invest on HIV/AIDS campaigns. Sgt. Kristian Kombo, a 36-year-old soldier in the Cameroonian army, was tested HIV-positive in 2008. His father, diagnosed with HIV two years earlier, had kept his status secret, but when Kristian’s wife told him of his son’s diagnosis, he called Kristian and encouraged him not to give up on life. P-I-M-A spells access to care for pregnant women Health worker, Felix A. Andongma, left, carries out a CD4 count test on a pregnant woman using a PIMA machine installed at Mundum. Dorothy is 22 years old and pregnant. Like many women in Mundum in rural northwest Cameroon, she discovered her HIV-positive status during antenatal care, in January 2013. Though at her third pregnancy, Dorothy never tested for HIV during her first two, “because no services were offered at the nearby facility,” she says. Dorothy is not married and relies on the sale of coco yams to care for herself and her two children. When she learned of her HIV status, she felt that her world had come to an end. Partnering to Achieve Epidemic Control in Cameroon The United States (U.S.) is proud to support Cameroon’s leadership in the global HIV/AIDS response. PEPFAR provides service delivery and technical assistance in Cameroon to maximize the quality, coverage, and impact of the national HIV/AIDS response. Working together with the Government of Cameroon, PEPFAR is aligning investments to scale up evidence-based interventions in the geographic areas and populations with the highest burden of HIV/AIDS – in line with PEPFAR. Other key priorities include: • Preventing mother-to-child transmission (PMTCT) of HIV; • scaling-up access to HIV prevention, care, and treatment among those most in need, particularly key and priority populations; • Supporting health systems strengthening with a focus on improving health information systems, human resources for health, laboratory and blood safety systems, and supply chain management; and • Strengthening the continuum of care and treatment and ensuring linkages in the delivery of HIV prevention, care, and treatment across all levels of care. HIV/AIDS in Cameroon Number of people living with HIV (all ages), 20131 660,000 Deaths due to AIDS (all ages), 20131 34,000 Number of orphans due to AIDS (0-17), 20131 310,000 Estimated antiretroviral (ARV) coverage (adults ages 15+), 20142 23% Estimated percentage of pregnant women living with HIV who receive ARVs for PMTCT, 20142 66% Cameroon Country Operational Plan Executive Summary 2014 Cameroon is a lower-middle-income country with a population of 22 million representing more than 275 ethnic groups. Politically stable, Cameroon achieved economic growth of 4.9% in 2013. The country’s epidemiological profile is dominated by communicable diseases such as malaria and HIV and an increasing prevalence of non-communicable diseases such as diabetes and cardiovascular disease. Maternal mortality is 782 per 100,000 live births; under-5 mortality is 127 per 1,000 live births. Funding for health is about 5% of the Government of Cameroon (GRC) 2013 budget. In 2010, private spending accounted for 70.4% of health expenditures; 13.2% came from external resources and 16.4% from GRC funds (World Bank 2012). The provision of basic services, including HIV/AIDS services, remains a challenge for the government, especially from the regional to the district levels. HIV/AIDS is low on a long list of priorities for the GRC, whose 2014 budget focuses heavily on non-health items. Epidemiology of the HIV epidemic Despite a decrease in HIV prevalence from 5.6% in 2004 to 4.3% (DHS 2011), Cameroon is one of the highest-prevalence countries in Central Africa. Prevalence is high among men who have sex with men (MSM) (37%), female sex workers (FSW) (36%), and pregnant women (7.6%). Other at-risk sub-populations include sero-discordant couples, the uniformed services, long-distance truck drivers (LDTD), economically vulnerable women and girls, migrants, prisoners, and orphans and vulnerable children (OVC). There are marked disparities in HIV rates between women (5.6%) and men (2.9%), with prevalence five times higher among women ages 15-24 than among their male counterparts. Prevalence peaks at 10% among women ages 35-39 and at 6.3% among men ages 45-48. Geographically, prevalence ranges from 1.2% in the far North to 7.2% in the South. Prevalence is higher among urban, employed, and wealthier men and women (DHS 2011). An estimated 5.9% of couples are sero-discordant. About 46% of women and 58% of men have never received an HIV test result. About 542,000 adults (>15 years) and 58,600 children (0-14) are living with HIV, including 275,600 who need antiretroviral therapy (ART) (UNAIDS 2013). There are about 43,000 new infections per year and 333,000 orphans (ages 0-17) due to AIDS. About 31% (7,908/25,360) of TB patients tested for HIV are HIV/TB co-infected, according to the National AIDS Control (NACC) 2012 report, and TB is the leading cause of AIDS-related deaths. The NACC estimates that HIV infections are principally driven by sexual intercourse (88%), including early sexual debut, multiple concurrent sexual partnerships, and transactional and inter-generational sex; mother-to-child transmission (14%); and transfusion of unsafe blood. Women’s risk is heightened by low socio-economic status, gender inequality, and harmful socio-cultural practices. Stigma and discrimination have marginalized people living with HIV/AIDS (PLWHA) and key populations (KPs), especially MSM. Status of the national response

Cameroon’s national response to the HIV/AIDS epidemic is led by the inter-ministerial NACC, which coordinates implementation of the recently revised National HIV/AIDS Strategic Plan (NSP) 2014-2017. While this plan targets most major HIV/AIDS program areas, GRC funding has focused mostly on procurement of ARVs, with commitments amounting to more than 60% of national needs. PEPFAR funded 6% of the national HIV/AIDS response in 2012, with 45% of funding coming from the GRC; 44% from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM); and modest contributions from the Clinton Health Access Initiative (CHAI), World Bank, European Union, French Cooperation, UNICEF, and the corporate sector. HIV prevention and testing services have been integrated into all national, regional, and district hospitals in all 10 regions. The NACC estimates the number of ART patients at 130,778 as of December 2013, representing 47.4% coverage. Despite significant progress, the national response is built on a public health system that is under-resourced [REDACTED]. Uptake of PMTCT and other gateway services remains insufficient, particularly in rural areas, and only 42% of pregnant women attend antenatal care (ANC) services. The lost-to-follow-up (LTFU) rate among ART patients after one year is about 38% (GARP 2012). The government’s capacity to mobilize funds for HIV/AIDS remains a major challenge, and with new GFATM funding still in the planning stages and CHAI ending its ARV procurements, uncertain funding horizons and weaknesses in strategic information and supply-chain management continue to haunt program implementation with the specter