and Infant Feeding

A Compilation of Programmatic Evidence

July 2004 QUALITY ASSURANCE PROJECT HIV and Infant Feeding: A Compilation of Programmatic Evidence

Editors

Peggy Koniz-Booher, MPS Bart Burkhalter, PhD

Arjan de Wagt, MSc

Peter Iliff, MD Juana Willumsen, PhD

July 2004

A Compilation of Programmatic Evidence i Acknowledgements

As part of the process of updating the 1998 AED/SARA Project for additional technical international guidelines for HIV and infant inputs and review; and James Heiby and feeding, the United Nations Children’s Fund Amanda Gibbons from USAID for their (UNICEF) and the Quality Assurance Project valuable support. In addition, many of the (QAP), managed by University Research Co., authors have reviewed and provided LLC (URC), and supported by the United important assistance in finalising the sum­ States Agency for International Develop­ maries included in this document. ment (USAID), collaborated to identify, compile, summarise, and synthesise recent Of the many agencies that contributed their programme experiences relating to the pre­ documents as well as staff time, the edi­ vention of mother-to-child transmission of tors would specifically like to acknowledge HIV. The World Health Organization (WHO) UNICEF, WHO, USAID, the Centers for provided important documents and other Disease Control and Prevention (CDC), valuable technical inputs throughout the Southern African HIV and AIDS Informa­ process. Many other government agencies, tion Dissemination Service (SAFAIDS), the organisations, researchers, and authors have Population Council/Horizons, AED/Linkages, contributed their valuable time and energy and the International Centre for Research in identifying programmes, clarifying data on Women (ICRW). and reported findings, and providing feed­ back on the summaries and analysis. We would also like to thank Peter Iliff for use of the cover photograph, Kurt The editors would like to specifically thank Mulholland and James Chika for cover Miriam Labbok from UNICEF and Peggy design and layout, and Shiril Sarcar for Henderson, Constanza Vallenas, and José indexing. Martines from WHO for their technical inputs and review; Diana Silimperi, Ya-Shin The QAP/URC and UNICEF team would like Lin, Beth Goodrich, Lani Marquez, and to extend a special thanks to the women, Rachel Jean-Baptiste from QAP for ana­ children, and families whose experiences lytical input and editorial reviews; Chessa related to infant feeding informed and Lutter from the Pan American Health influenced the findings presented in this Organization (PAHO); Nigel Rollins from the publication. University of Natal, South Africa; Pauline Kisanga from the International Baby Food Action Network (IBFAN)/Africa; Ted Greiner from the World Alliance for Breastfeeding Recommended citation: Koniz-Booher P, Action (WABA); Arun Gupta from the Burkhalter B, de Wagt A, Iliff P, Willumsen Breastfeeding Promotion Network of In­ J (eds). 2004. HIV and Infant Feeding: A dia (BPNI)/International Baby Food Action Compilation of Programmatic Evidence. Network (IBFAN); Linda Sanei and Bethesda, MD: Published for UNICEF and Maryanne Stone-Jimenez from the Acad­ the U.S. Agency for International Develop­ emy for Educational Development (AED)/ ment by the Quality Assurance Project LINKAGES Project; Ellen Piwoz from the (QAP), University Research Co., LLC (URC).

ii HIV and Infant Feeding Foreword

There has been worldwide recognition of the HIV/AIDS pandemic for nearly 20 years. More recently there has been recognition of HIV transmission through breastfeeding, but our understanding of the biological and programmatic implications of this mode of transmission remain limited due to insuf­ ficient study and difficulties of interpretation. Biological studies have been hampered by ethical constraints related to concerns for the survival of the child, as well as by all of the difficulties inherent in the study of breastfeeding. These constraints include the fact that one cannot ethically or reliably assign individual mothers to specific infant feeding groups or blind the mother or investiga­ tor to the behaviour under study.

Our understanding of the programmatic issues and constraints is also limited. One might speculate that the rapid progression of the epidemic and the vast number of variables inherently associated with programme planning and evaluation preclude our waiting patiently for several years to inter­ pret operations research or practise evidence-based applied research. The cost of applied research is also a barrier. Where we do have ‘findings,’ there are often so many confounding variables that the evidence is subject to wide-ranging interpretation. In addition, ongoing field research and the study of HIV/AIDS treatment modalities have created an extremely dynamic situation, with rapidly chang­ ing ideas and directions.

Therefore, if we wish to improve our programmatic approaches, we must step very carefully among the findings and reflect on our limited understanding of programme issues from whatever data that become available. It is fortunate that many who initiated interventions, large and small, felt com­ pelled to document them and share their findings. The widely diverse reporting outlets, both pub­ lished and unpublished, are sometimes referred to as ‘grey’ literature.

This project attempted to find, summarise, and analyse reports on a wide variety of relevant programmes conducted since the 1998 guidelines were issued in order to glean lessons that can inform future programmes. The valuable experiences represented in this compilation range in scale from small community research projects to national programmes. This is the product of a collabora­ tion between the United Nations Children’s Fund (UNICEF) and the Quality Assurance Project (QAP), managed by University Research Co., LLC (URC), with funding from the United States Agency for International Development (USAID). Valuable technical inputs were also received from the World Health Organization (WHO) and many individuals and organisations directly involved in HIV and infant-feeding programmes worldwide. This review brings together a number of important experi­ ences and provides a variety of insights that should be useful to those involved in updating the international guidelines or adapting them to local settings. It should also serve as a valuable resource to those involved in developing or scaling-up programmes to prevent mother-to-child transmission.

UNICEF is grateful for this effort. We hope that some day, looking back, we will see that this chal­ lenging step toward organising current experience has aided future programme design and execu­ tion for the benefit of every child, and has helped us in our efforts to better address the complex issues associated with HIV and infant feeding.

Miriam H. Labbok Senior Advisor Infant and Young Child Feeding and Care UNICEF

A Compilation of Programmatic Evidence iii Executive Summary

The United Nations-led process of updat­ ■ Compilation: Relevant programs were The key themes also include the ing the 1998 international guidelines identified, and documents describing desired AFASS characteristics (accept­ related to infant feeding and the preven­ these programmes were obtained from ability, feasibility, affordability, tion of maternal-to-child-transmission a variety of sources. Over 100 docu­ sustainability, safety) of infant-feeding (pMTCT) of HIV called for a review of ments from 20 countries, including for­ modalities; counselling and informed recent programmatic experience in addi­ mative research, assessments and choice; the roles of partners, families, tion to a review of the new scientific and evaluations, mid-term and final reports, and communities; and behaviour medical evidence. This document represents national guidelines, conference and change and communication as a prob- an attempt to compile and synthesise meeting reports, educational and coun­ lem-solving strategy. reports on a wide variety of relevant selling materials, interviews with key programmes conducted since the 1998 informants, and a few published articles The compilation addresses numerous con­ guidelines were issued. The programmes were reviewed. Finally, 45 reports on troversial topics and constraints, including presented here range in scale from small programmes and multi-site studies human resources (inadequately trained and community research projects to national were selected for inclusion. insufficient counsellors); confused moth­ programmes. This document is the prod­ ■ Document summarisation: An edito­ ers; stigma and discrimination; spillover of uct of a one-year collaboration between rial team wrote and reviewed two-to- replacement feeding; free or subsidised the United Nations Children’s Fund four page summaries for the selected infant formula; family economics; and the (UNICEF) and the Quality Assurance Project studies, and the authors of the original difficulty in providing integrated HIV test­ (QAP), managed by University Research Co., documents reviewed many of the sum­ ing, informed-choice counselling, commu­ LLC (URC). Valuable technical inputs were maries. nity support, logistics, and follow-up care also received from the World Health Orga­ for mothers and infants. nization (WHO) and many individuals and ■ Synthesis: The editorial team also wrote organisations directly involved in HIV and a synthesis of the 45 selected reports, Efforts should be made to encourage more infant feeding programmes. This review drawing out key themes specifically documentation and dissemination of ex­ brings together in one document a num­ related to HIV and infant feeding. The periences by individual programmes and to ber of important experiences and provides key themes include the major infant continue to identify and share this infor­ insights that were useful to those involved feeding modalities: mation. To facilitate additional analysis, in updating international guidelines and ■ Replacement feeding (both com­ review, or research by interested readers, those involved in adapting them to local mercial and home-prepared for­ most of the original source documentshave settings. It should also serve as a valuable mula); been converted to digital format and are resource to those involved in developing ■ Exclusive breastfeeding (including available at www.qaproject.org. Contact in­ or scaling-up pMTCT-related programmes appropriate cessation and transition formation for editors, researchers, authors, in the future. to other feeding modalities); and organisations responsible for prepar­ ing the source material is also included to ■ Mixed feeding and its risks; and The methodology involved three phases: encourage future communication; continu­ compilation, document summarisation, and ■ Breast-milk feeding (wet nursing, ing dialogue; and the sharing of materials, synthesis of key finding organised by breast-milk banks). ideas, and lessons learned between projects, themes: countries, and regions of the world.

iv HIV and Infant Feeding Table of Contents

INTRODUCTION AND METHODOLOGY ...... 1 GENERAL BACKGROUND ON MOTHER-TO-CHILD TRANSMISSION ...... 1 THE UNITED NATIONS’ STRATEGIC APPROACH TO THE REDUCTION OF MTCT ...... 2 THE ROLE OF THIS COMPILATION IN UPDATING THE GLOBAL GUIDELINES ...... 3 METHODOLOGY ...... 4 CLARIFICATIONS ...... 5 SYNTHESIS OF MAJOR FINDINGS BY KEY THEMES ...... 6 REPLACEMENT FEEDING ...... 6 EXCLUSIVE BREASTFEEDING ...... 10 MIXED FEEDING ...... 13 BREAST-MILK FEEDING ...... 13 AFASS ...... 14 COUNSELLING AND INFORMED CHOICE ...... 17 THE ROLE OF COMMUNITY, PARTNER, AND FAMILY SUPPORT ...... 19 BEHAVIOUR CHANGE AND COMMUNICATION (BCC) ...... 20 CONCLUSIONS AND IMPRESSIONS ...... 22 SUMMARIES BY STUDY, WITHIN COUNTRIES ...... 26 BOTSWANA ...... 26 Evaluation of Infant Feeding Practices in pMTCT (pMTCT Advisory Group, 2001) ...... 26 Community Responses to pMTCT in Botswana (Thou et al, 2000) ...... 29 Adherence to Recommended IF Strategies in Botswana (Shapiro et al, 2003) ...... 30 CÔTE D’IVOIRE ...... 32 Uptake of IF Intervention in Côte d’Ivoire (Leroy et al, 2002) ...... 32 HONDURAS ...... 34 Rapid Assessment of pMTCT in Honduras (Baek et al, 2002) ...... 34 INDIA ...... 36 Rapid Assessment of pMTCT in India (Sarna, 2002) ...... 36 HIV Child Survival Project (South India AIDS Action Programme et al, 2001) ...... 37 KENYA ...... 40 Maternal Knowledge of MTCT and Infant Feeding Practices (Oguta et al, 2001; Oguta, 2001) ...... 40 MYANMAR ...... 42 Country Adaptation of Global HIV/IF Guidelines: Stage I (Williams, 2001) ...... 42 Country Adaptation of Global HIV/IF Guidelines: Stage II (Williams, 2003) ...... 43 NIGERIA ...... 45 Early and Abrupt Cessation of BF in Nigeria (Isiramen, 2002) ...... 45 RWANDA ...... 47 Rapid Assessment of pMTCT in Rwanda (Pham et al, 2002) ...... 47

A Compilation of Programmatic Evidence v SOUTH AFRICA ...... 49 Breastfeeding Promotion and IF Practices in South Africa (Bentley et al, 2002) ...... 49 Khayelitsha, South Africa MTCT Programme (Chopra et al, 2000) ...... 50 South Africa National pMTCT Pilot Sites (McCoy et al, 2002) ...... 52 Counselling Options for HIV-Infected Women in Rural SA (Rollins et al, 2002) ...... 54 Experiences of Breastfeeding and Vulnerability (Seidel et al, 2000) ...... 55 SWAZILAND ...... 57 Rapid Situational Analysis of BFHI in Swaziland (Vilakati and Shongwe, 2001) ...... 57 TANZANIA ...... 58 Counsellors’ Perspectives in N. Tanzania (de Paoli et al, 2002) ...... 58 Exclusive Breastfeeding in Era of AIDS (de Paoli et al, 2001) ...... 59 Breastfeeding Promotion Dilemma in Tanzania (de Paoli et al, 2000) ...... 60 Rapid Assessment of pMTCT in Tanzania (Swartzendruber et al, 2002) ...... 61 THAILAND ...... 65 IF Practice and Attitudes in Northern Thailand (Talawat et al, 2002) ...... 65 UGANDA ...... 66 Lessons from Early Cessation of BF in Uganda (Bakaki, 2002) ...... 66 Experience with Providing Free Formula in Uganda (Matovu et al, 2002) ...... 68 ZAMBIA ...... 70 Stigma, HIV/AIDS and pMTCT in Zambia (Bond et al, 2002) ...... 70 Formative Research on MTCT (NDHMT, 1999; Bond and Ndubani, 1999) ...... 71 Ndola Demonstration Project (Hope Humana et al, 2002; AED/Linkages Project 2002 a and b) ...... 73 Infant Feeding Practices in Zambia (Omari et al, 2000) ...... 77 Rapid Assessment of pMTCT in Zambia (Kankasa et al, 2002) ...... 78 ZIMBABWE ...... 81 Infant Feeding, which way? Zimbabwe (Chitsike, 2000) ...... 81 Education and Counselling, ZVITAMBO (Tavengwa et al, 2002) ...... 82 Feasibility of Heat-Treating Expressed Breast Milk (Israel-Ballard et al, 2001) ...... 83 MULTI-COUNTRY REPORTS ...... 85 Status of Protection, Support and Promotion of BF (Latham and Kisanga, 2001) ...... 85 Prevention of MTCT in Asia (Preble and Piwoz, 2002) ...... 86 Lessons Learned from HIV and MCH Studies (Rutenberg et al, 2002) ...... 89 HEAT TREATMENT OF MILK AND SAFE WATER ...... 91 Lipolysis or Heat for HIV in Breast Milk (Chantry et al, 2000) ...... 91 Water Safety for Infant Formula (Dunne et al, 2001) ...... 92 Pretoria Pasteurisation Bacterial Contamination (Jeffery et al, 2002a) ...... 93 Pretoria Pasteurisation and Viral Loads (Jeffery et al, 2002b) ...... 94 Pretoria Pasteurisation and Mothers’ Attitudes (Pullen et al, 2002) ...... 95 ENDNOTES ...... 96 BIBLIOGRAPHY: DOCUMENTS ON REVIEWED PROGRAMMES ...... 97 ADDITIONAL REFERENCES ...... 100 CONTACT INFORMATION FOR AUTHORS, EDITORS AND REVIEWERS ...... 101 KEY WORD INDEX ...... 105

vi HIV and Infant Feeding List of Abbreviations

AED Academy for Educational Development IBFAN International Baby Food Action Network AFASS Affordable, feasible, acceptable, safe and sustainable ICASA International Conference on AIDS and Sexually AIDS Acquired Immunodeficiency Syndrome Transmitted Illnesses in Africa ANC Antenatal care ICRW International Centre for Research on Women ARV Antiretroviral (drug) IDI In-depth interview AZT Azidothymidine (zidovudine or ZVD) ICYF Infant and Young Child Feeding BCC Behaviour change communication IEC Information, education, and communication BF Breastfeeding IF Infant feeding BFHI Baby Friendly Hospital Initiative IFC Infant-feeding counselling BM Breast milk IFP Infant-feeding practise BPNI Breastfeeding Promotion Network of India IMCI Integrated Management of Childhood Illness CBO Community-based organisation IRB Institutional review board CBoH Central Board of Health KAP Knowledge, attitudes, and practises CDC Centers for Disease Control and Prevention KHC Kicukiro Health Centre CF Complementary foods KI Key informant interview CHC Community health clinic KZN KwaZula-Natal, South Africa CHW Community health worker MCH Maternal and child health DHS Demographic health survey MF Mixed feeding EBF Exclusive breastfeeding MMF Mixed-milk feeding EBM Expressed breast milk MOH Ministry of Health EPI Expanded Programme of Immunisation MOU Memorandum of Understanding ESARO Eastern and Southern African Regional Office MTCT Mother-to-child transmission (UNICEF) MU-JHURC Makerere University-Johns Hopkins University FF Formula feeding Research Center FGD Focus group discussion NACO National AIDS Control Organization FP Family planning NDP Ndola Demonstration Project GM Growth monitoring NFNC National Food and Nutrition Commission GMP Growth monitoring and promotion NGO Nongovernmental organisation GOB Government of Botswana NVP Nevirapine HEBM Heat-treated expressed breast milk OR Odds radio HIFC WHO/UNICEF HIV and Infant Feeding Counselling PAHO Pan American Health Organization (course) PBF Predominant breastfeeding HIV Human immunodeficiency virus PCP Pneumocystis carinii pneumonia HIV- HIV-negative PCR Polymerase chain reaction (HIV test) HIV+ HIV-positive PLWHA People living with HIV/AIDS HW Health worker pMTCT Prevention of mother-to-child transmission IATT Interagency Task Team on Prevention of HIV in PTCT Parent-to-child transmission Pregnant Women, Mothers and their Children RCT Randomised control trial

A Compilation of Programmatic Evidence vii RF Replacement feeding UNICEF United Nations Children’s Fund RH Reproductive health URC University Research Co., LLC SAFAIDS Southern African HIV and AIDS Information USAID United States Agency for International Development Dissemination Service UTH University teaching hospital STI Sexually transmitted infection VCCT Voluntary and confidential counseling and testing TBA Traditional birth attendant VCT Voluntary counseling and testing TIPS Trials in improved practises WABA World Alliance for Breastfeeding Action TOT Training of trainers WHO World Health Organization UNAIDS Joint United Nations Program HIV/AIDS ZDV Zidovudine (Azidothymidine (AZT)) UNFPA United Nations Population Fund

viii HIV and Infant Feeding INTRODUCTION AND METHODOLOGY

n 1997, the World Health Organization volved in either the design or implemen­ duration of breastfeeding, recent studies I(WHO), United Nations Children’s Fund tation of programmes for HIV-related suggest that exclusive breastfeeding dur­ (UNICEF), and the Joint United Nations Pro­ services need exposure to the collective ing the first months of life may be associ­ gram HIV/AIDS (UNAIDS) issued a Joint knowledge gained through this experience. ated with a lower risk of HIV transmission Policy Statement on HIV and Infant Feed- than mixed feeding.4 More research is cur­ ing,1 followed shortly by the development This compilation aimed to contribute to ef­ rently in progress to clarify this issue. of a set of international infant-feeding forts to update the 1998 international guidelines for the prevention of mother- guidelines on HIV and infant feeding and Although the possibility of HIV transmis­ to-child transmission (pMTCT)2 of HIV in to guide future efforts to adapt the revised sion during breastfeeding has been firmly 1998. Four years later, when the interna­ guidelines to local settings. Although not established, the exact mechanisms are still tional and scientific community called for a replacement for formative studies in spe­ unknown. Central to the discussion of an update of these guidelines, interest was cific cultural contexts, this report highlights infant-feeding options, especially in re­ expressed in reviewing not only the new pertinent issues that should be useful to source poor settings, is the fact that the scientific and medical evidence but also those faced with the challenges of intro­ vast majority of infants breastfed by HIV- recent programmatic experience, as part of ducing or scaling up pMTCT-related positive mothers do not become infected the process. Many pMTCT-related activities, programmes. The editorial team hopes that despite consuming a half million HIV viri­ ranging from small-scale community this effort to gather and share experiences ons or more per day.5 The risk of HIV trans­ research projects to a number of pilot and will stimulate greater communication be­ mission continues, however, for as long as national programmes, have been imple­ tween the scientific, academic, public a child is breastfed. Another important con­ mented since the 1998 guidelines were health, private sector, and donor commu­ sideration is the timing of the mother’s in­ issued. This experience provides valuable nities on both a regional and global scale, fection. Among mothers infected while still insights and important evidence related to and that it will result in more concerted breastfeeding, the risk of transmission HIV and infant feeding in a number of set­ efforts to collect data, document results, through breast milk is nearly twice as high tings and across a range of social and eco­ and disseminate HIV and infant feeding- as for women infected before or during nomic conditions. related experience in the future. pregnancy.6 This increased risk is due to the high viral load in a mother’s system shortly To date, specific studies have been con­ after initial infection. ducted, or are currently in progress, to as­ GENERAL BACKGROUND ON sess various recommended feeding options MOTHER-TO-CHILD In addition to the duration and quality of for HIV-positive mothers and inform TRANSMISSION breastfeeding and the timing of the programme development. However, much mother’s infection are several other fac­ of this experience has not been formally he overwhelming source of HIV tors shown to contribute to MTCT. These documented. The results of programme T infection in young children is factors include the presence of systemic evaluations are often shared only internally mother-to-child transmission (MTCT) of the infections in the mother; the stage of pro­ or with donor agencies. Much of the re­ virus, with an estimated risk of 5-10% gression of her HIV disease (measured by search has only been presented to select during pregnancy, 10-20% during labour CD4 count, RNA viral load in plasma, or audiences at professional meetings. The and delivery, and 5-20% through clinical symptoms); immune factors in majority of reports have never been pub­ breastfeeding.3 Comparing data from cur­ breast milk; and infant morbidity, includ­ lished or otherwise disseminated in any rently available studies, breastfeeding may ing intestinal lesions and oral thrush. The systematic or useful way to the global com­ be responsible for as much as one third to mother’s breast health (e.g., subclinical munity, rendering access to this informa­ one half of all HIV infections in infants and or clinical mastitis, cracked or bleeding tion a challenge. Decision-makers, health young children in African settings. Al­ nipples, or breast abscess) has also been care managers, supervisors and providers, though very few reports provide detailed identified as a contributor to MTCT, with as well as academics and researchers in­ information on the mode (or quality) and an estimated 18-20% of overall postnatal

A Compilation of Programmatic Evidence 1 transmission attributable to sub-clinical retroviral (ARV) prophylaxis and infant- Box 1 and clinical mastitis.7 These breast condi­ feeding counselling. The results amplified tions are of interest because they can of­ the recommendations contained in the Terms Used Frequently in this Report✝ ten be prevented by counselling and by 1997 WHO, UNICEF, and UNAIDS Joint support for improved breastfeeding tech­ Policy Statement on HIV and Infant Feed­ Acquired immunodeficiency syn­ niques and related practises. Proper infant ing, which reiterated the substantial ben­ drome (AIDS): the active pathologi attachment to the breast, for example, pre­ efits that breastfeeding provides in the cal condition that follows the earlier, non-symptomatic state of vents nipple damage, and frequent and general population while promoting fully being HIV-positive. exclusive breastfeeding maintains milk pro­ informed choice of infant feeding meth­ Artificial feeding: feeding with duction and prevents milk stasis and in­ ods by HIV-positive women. breast-milk substitutes. flammation. Lactation management and

Bottle feeding: feeding from a immediate treatment of breast-related Given the need to minimize the risk MTCT bottle, whatever its content, which problems are considered important for HIV- to infants while avoiding increasing the risk may be expressed breast milk, positive mothers who choose to breastfeed. of other morbidity and mortality, WHO, water, formula, or another liquid. Immediate postpartum counselling has UNAIDS, and UNICEF issued the following *Breast-milk feeding: feeding been shown to reduce the risk of a mother’s recommendation: breast milk to an infant, whether breast inflammation and mastitis during her expressed or directly from the 8 For mothers who are HIV negative, or breast. Breast-milk feeding options child’s first weeks. who do not know their HIV status, ex in the context of HIV/AIDS include wet-nursing, expressing and heat- clusive breastfeeding for the first 6 treating breast milk, and the use of THE UNITED NATIONS’ months and continued breastfeeding breast-milk banks. STRATEGIC APPROACH TO for up to 2 years or longer with the Breast-milk substitute: any food THE REDUCTION OF MTCT addition of complementary food after used as a partial or total replace 6 months is recommended. If, however, ment for breast milk, whether or not a woman has tested positive for HIV, suitable for that purpose. he United Nations’ (UN) current and when replacement feeding is ac *Cessation of breastfeeding: com strategic approach to prevention of T ceptable, feasible, affordable, sustain pletely stopping breastfeeding, transmission of HIV in pregnant women, including suckling. able, and safe, avoidance of all mothers, and their children encourages ac­ breastfeeding by HIV positive mothers Commercial infant formula: a tivities in four areas: 1) prevention of HIV breast-milk substitute formulated is recommended. Otherwise, exclusive infection in general, especially in young commercially in accordance with breastfeeding is recommended during and/or pregnant women; 2) prevention of applicable Codex Alimentarius the first months of life. To minimize standards to satisfy the nutritional unintended pregnancies among HIV-in- HIV transmission risk, breastfeeding requirements of infants during the fected women; 3) prevention of HIV trans­ first months of life up to the intro should be discontinued as soon as fea mission from infected women to their in­ duction of complementary foods. sible, taking into account local circum fants; and 4) provision of care, treatment, Complementary feeding: the prac stances, the individual woman’s situ and support to HIV-infected women, their tise of giving complementary foods. ation and the risks of replacement infants, and families.9 Each of these activi­ Complementary food: any food, feeding (including infections other ties highlights the critical role of women whether manufactured or locally than HIV and malnutrition). prepared, suitable as a comple in preventing the spread of HIV. ment to or substitute for breast milk. The UN recommendations further state that In October 2000, WHO convened a Tech­ HIV-positive mothers should be counselled ✝ Most of these terms were derived nical Consultation on behalf of the Inter- on the advantages and disadvantages of from the 2003 revised WHO, UNICEF, UNFPA and UNAIDS. Agency Task Team on prevention of HIV infant-feeding options and should be as­ HIV and Infant Feeding: Guide transmission to pregnant women, moth­ sisted in selecting the best option. Empha­ lines for Decision-Makers ers, and their children. The objective was (Geneva. 2003). Terms pre sis is placed on the fact that it is the mother ceded with an asterisk (*) were to review recent scientific data and related who makes the final ‘informed’ choice on derived from other sources. policy implications and to update recom­ how to feed her child and that she should continued on page 3 mendations on the provision of anti- be supported in whatever she chooses. Also,

2 HIV and Infant Feeding ‘when HIV-infected mothers choose not to THE ROLE OF THIS Box 1 continued breastfeed from birth or stop breastfeeding COMPILATION IN UPDATING later, they should be provided with spe­ THE GLOBAL GUIDELINES Cup feeding: using an open cup, cific guidance and support for at least the irrespective of its contents, to feed. first two years of the child’s life to ensure s underscored by Stephen Lewis, *Early cessation of breastfeeding: adequate replacement feeding.’ It should stopping breastfeeding, including Special Representative to the UN be recognised, however, that in many cases A suckling prior to, at, or about six Secretary General on HIV/AIDS in Africa, months of age, as soon as replace the mother is seeking advice from some­ during his keynote address at the 2002 ment feeding is acceptable, one she is consulting for her health. Very Colloquium on HIV and Infant Feeding, feasible, affordable, sustainable, often she may, not surprisingly, ask the and safe, with the idea of avoiding sponsored by the World Alliance for counsellor what feeding method he or she mixed feeding to the greatest ex Breastfeeding Action (WABA) and UNICEF,11 tent possible. would use under her circumstances. research on breastfeeding and replacement *Exclusive breastfeeding: giving an feeding is critical and must continue. An infant no food or drink, not even After the Technical Consultation, a Global ongoing investment in research is especially water, other than breast milk, ex Strategy for Infant and Young Child Feed­ important, Lewis said, to assess strategies cept for drops or syrups of vitamins, ing (IYCF)10 was adopted by the World mineral supplements, or medi that can substantially reduce the risk of HIV cines. Health Assembly and UNICEF’s Executive transmission during breastfeeding in the Board in 2002. The Global Strategy reiter­ Human immunodeficiency virus first months of life, with emphasis on the (HIV): the virus that causes AIDS. ates that the optimal feeding pattern for relative risks of infant-feeding options in In this document, the term HIV overall survival in the general population resource poor settings. During the collo­ means HIV-1. Mother-to-child trans mission of HIV-2 is rare. is exclusive breastfeeding for the first six quium and the WABA conference that fol­ months and continued breastfeeding for lowed, interest was expressed in reviewing HIV-negative: refers to adults who have taken an HIV test and who up to two years and beyond with comple­ relevant programme experience related to mentary feeding from age six months, and know that they tested negative and HIV and infant feeding as well as the medi­ to young children who have tested related maternal nutrition and support. cal and scientific evidence. In response to negative and whose parents or However, the Global Strategy also takes into this interest and as a contribution to the guardians know the results. account children in exceptionally difficult process of updating the 1998 international HIV-positive: refers to adults who circumstances, including those born to HIV- guidelines, URC/QAP and UNICEF entered have taken an HIV test and who positive women. know that they tested positive and into a collaboration in November 2002 to to young children who have tested prepare this compilation of programme positive and whose parents or It was in the context of the Global Strat­ experience, most of which had never been guardians know the results. egy for IYCF that the joint United Nations published or disseminated in any form. HIV status unknown: refers to HIV and Infant Feeding Framework for Pri­ people who either have not taken an HIV test or do not know the ority Action was developed. The framework In February 2003, WHO convened a sec­ result of a test they have taken. proposes a number of priority actions ond technical consultation of subject ex­ HIV-infected: refers to a people who related to HIV and infant feeding to be con­ perts, field project personnel, and sidered by governments, including the pro­ are infected with HIV, whether or not programme managers from Africa, Asia, they are aware of it. vision of adequate support to HIV-positive Eastern Europe, and Latin America to re­ women to enable them to select the best HIV testing and counselling: view initial drafts of the revised guidelines testing for HIV status, preceded feeding option for themselves and their in light of the latest available medical and and followed by counselling. Test babies and to successfully carry out their scientific evidence and a review of pro­ ing should be voluntary and confi infant-feeding decisions. dential, with fully informed consent. grammatic experience, derived, to a large The expression encompasses the extent, from a draft of this compilation. following terms: counselling and The resulting guidelines were refined and voluntary testing, voluntary coun tested following the February consultation, selling and testing, and voluntary and confidential counselling and with additional review, technical inputs, and testing. Counselling is a process, field testing, before being formally continued on page 4 launched at the International Conference

A Compilation of Programmatic Evidence 3 on AIDS and Sexually Transmitted Illnesses directors, programme evaluators, train­ Box 1 continued in Africa (ICASA), in September 2003 in ers, and policy makers), Nairobi, Kenya.12 not a one-time event: For the HIV- ■ QAP conducted a worldwide web positive client it should include life (www) search on pMTCT and infant planning, and, if the client is preg The difficulty in providing clear global guid­ nant or has recently given birth, it feeding programmes, ance related to HIV and infant feeding is should include infant-feeding con siderations. highlighted by the revised guidelines. There ■ A request for documents and informa­ are no simple answers to the interdepen­ *Home-prepared formula: a breast- tion was circulated to key informants milk substitute prepared at home dent and complex questions surrounding and a number of United Nations (UN) from fresh or processed animal how best to feed infants born to HIV-posi- and USAID-related listservs by UNICEF, milks, suitably diluted with water tive women. As those guidelines state, and with the addition of sugar and WHO, USAID, and QAP, micronutrients. programme planners and managers need to be fully aware of the population ben­ ■ Authors of documents collected ear­ Infant: a child from birth to 12 lier by ESARO for their HIV and infant- months of age. efits and risks of all infant-feeding options. They must ‘take into account the global feeding CD-ROM were contacted for Infant feeding counselling: counsel updated reports. ling on breastfeeding, complemen goals and approaches related to the pre­ tary feeding, and, for HIV-positive vention of HIV infection in infants and women, HIV and infant feeding. young children, and apply them as appro­ The source materials for this compilation *Mixed feeding: feeding both breast priate in programme planning and imple­ were selected from over 100 documents milk and other foods or liquids. mentation, keeping in mind that the ulti­ from more than 20 countries and included Mother-to-child transmission mate objective is to reduce overall infant formative research and baseline studies, (MTCT): transmission of HIV to a and young child morbidity and mortality programme evaluations and rapid assess­ child from an HIV-infected woman in the general population and specifically ments, graduate theses, a few published during pregnancy, delivery, or breastfeeding. The term is used in in the HIV-infected population’. papers, expert meeting reports, conference this document because the imme abstracts, ‘lessons learned’ documents, na­ diate source of the child’s HIV tional policies and guidelines, counselling infection is the mother. The term im METHODOLOGY and educational materials, and interviews plies no blame, whether or not a woman is aware of her own infec with key informants and authors. Excluded tion status. A woman can acquire his compilation represents the first were peer reviewed literature related to HIV from unprotected sex with an T attempt of its kind to systematically medical/clinical research studies and phar­ infected partner, contaminated collect and synthesise a wide range of glo­ blood, non-sterile instruments (as maceutical trials. Most reports were gen­ is the case of injecting drug bal programme experiences related to HIV erated by pMTCT pilot programmes and users), or contaminated medical and infant feeding. A description of the research sites in Africa. Very few were iden­ procedures. process follows. tified from Asia, only one from Latin *Predominant breastfeeding: the America, and none from Eastern Europe. infant mostly receives breast milk COMPILATION: The compilation process Not all of the source materials are polished but also occasionally receives other liquids, including water and/or included the following steps: reports, nor do they all reflect the applica­ tastes (small amounts) of ritual or tion of rigorous scientific methods. Of the ■ UNICEF and WHO provided a large other foods. 45 reports ultimately selected, most are number of documents and abstracts, Programme: an organised set of fairly current and focused on programmes many of which had previously been activities designed to prevent initiated during the last three to five years. transmission of HIV from mothers identified in the development of a CD­ They represent real programme experience, to their infants. ROM by the UNICEF Eastern and South­ involving real-life situations. Reports of *Replacement feeding: feeding an ern African Regional Office (ESARO) in secondary data analysis, conference pro­ infant who is receiving no breast 2001,13 milk a diet that provides all the nu ceedings, editorial articles, background ar­ trients the infant needs until the age ■ UNICEF and WHO provided lists of key ticles, and abstracts or project reports that when he/she can be fully fed on informants (researchers, programme presented insufficient data or analysis were excluded. continued on page 5

4 HIV and Infant Feeding SUMMARISATION: Individual two- to four- SYNTHESIS: The experience compiled and page summaries were developed for each summarised was organised under several Box 1 continued of the selected reports: key issues and themes: family foods. During the first six months, replacement feeding The information highlighted in each sum­ The WABA-UNICEF colloquium mentioned should be with a suitable breast- milk substitute. After six months, mary was guided by a number of ques­ above and other technical gatherings in­ the substitute should be comple tions, issues, and themes. Where several fluenced the development of these issues mented with other foods. documents report findings from the same and themes, which were prioritised based *Spillover: a term used to designate project or programme, an overall summary on their relevance to the technical review the infant-feeding behaviour of new was prepared, combining information, and updating of the global HIV and infant mothers (who either know that they where possible, to facilitate synthesis and feeding guidelines. Experiences related to are HIV-negative or are unaware of the acceptability, feasibility, affordability, their HIV status) who do not discussion. Most of the summaries have breastfeed, breastfeed for a short been checked by the authors of the source sustainability, and safety (AFASS) of infant time only, or mix feed because of documents. Summaries were standardised feeding practises or options were included unfounded fears of HIV, misinfor to include: whenever possible. mation, or the ready availability of breast-milk substitutes. ■ A short background description of the project or intervention; CLARIFICATIONS ■ A summary of the methodology used; his document brings together the tematic critique of each programme or ■ Major reported results, conclusions. and experiences of a wide range of weigh the relative strengths of evidence. recommendations made by the authors; T organisations and individuals, reflecting Each summary presents the major and various levels of sophistication. The edito­ programme results, as well as the key con­ ■ A statement concerning methodologi­ rial team did not try to distinguish between clusions and recommendations of indi­ cal considerations, including comments correct and incorrect programme strate­ vidual authors. The document does not pro­ made by the reviewer. gies. Although the summaries often include vide overall recommendations and, except an editor’s note on the strengths and weak­ where noted, makes every attempt to Each summary has been indexed using pre­ nesses of the research methodology, no present the information from the selected defined index terms to facilitate the iden­ attempt has been made to provide a sys- reports and not our own opinions. tification of materials of specific interest to the individual reader.

A Compilation of Programmatic Evidence 5 SYNTHESIS OF MAJOR FINDINGS Box 2: BY KEY THEMES Definitions of Acceptable, Feasible, Affordable, Sustainable, and Safe (AFASS) his synthesis organises some of the he 2000 WHO Technical Consulta­ major findings of the reports in­ tion recommended that HIV-positive The WHO-convened technical con T T sultation in 2000 specified that cluded in this compilation by key themes mothers avoid all breastfeeding when re­ when replacement feeding is ac that emerged during the compilation and placement feeding is acceptable, feasible, ceptable, feasible, affordable, sus summarisation process. Note that this syn­ affordable, sustainable and safe (AFASS). tainable, and safe (AFASS), all breastfeeding by HIV-infected thesis is limited to the review of programme There are two major types of replacement mothers should be avoided. For a experience presented in the documents feeding: commercial infant formula and woman who begins exclusive thus far collected, the vast majority of home-prepared formula. For the latter, breastfeeding, the same recom which have never been published and/or animal milk is diluted with water and sugar mendation would apply when she decides whether or not, and at what subjected to peer review or other techni­ is added. In this case it is essential that the age, to practice replacement feed cal scrutiny. (This category of documenta­ child also receive a micronutrient supple­ ing. tion is sometimes referred to as ‘grey lit­ ment. Generally speaking, commercial in­ The following definitions for each erature’.) Although every attempt was made fant formula is only available in powdered of the AFASS terms were included to identify documents from all regions of form so water has to be added. Ready-to- in the revised WHO, UNICEF, the world, most of the documents repre­ use commercial infant formula is not com­ UNFPA, and UNAIDS HIV and In fant Feeding: Guidelines for Deci- sent programme experience from Africa. monly available in the studied countries. sion-Makers. They were developed Several are from Asia; one is from Latin to provide guidance, with the un America; and none is from Eastern Europe derstanding that they should be Uptake and rates of replacement adapted locally based on formative or the Western Hemisphere. The experiences feeding research. highlighted below and in the document

Acceptable: The mother perceives summaries that follow vary tremendously HIV-unknown status. The reviewed stud­ no barrier to replacement feeding. in scale and levels of sophistication, ren­ ies that addressed this issue indicate that Barriers may include cultural or so dering impossible the weighing of evidence mothers who do not know their HIV status cial reasons or be caused by fear or comparing of results. Although some of of stigma or discrimination. Accord rarely plan to replacement feed from birth ing to this concept, the mother is the findings are quantitative, most are or actually do so. In Botswana, only 9% under no social or cultural pressure based on qualitative research and are sub­ (16 of 186) of pregnant women who did not to use replacement feeding, jective in nature. Readers are encouraged not know their HIV status planned to re­ and she is supported by family and to review the original source documents community in opting for replace placement feed from birth, and when in­ 14 ment feeding, or she will be able to for additional details and further insights. terviewed up to 6 months after birth, 14 cope with pressure from family and of those mothers were actually doing so friends to breastfeed, and she can (pMTCT Advisory Group, 2001).16 In Tanza­ deal with any stigma attached to REPLACEMENT FEEDING being seen with replacement food. nia, all 500 respondents in a study of

Feasible: The mother (or family) has women attending antenatal clinics who did Definition: feeding an infant who is re adequate time, knowledge, skills, not know their HIV status expressed a and other resources to prepare the ceiving no breast milk a diet that provides strong desire to breastfeed and not replace­ replacement food and feed the in all the nutrients the infant needs until the ment feed (de Paoli et al, 2000). In Thai­ fant up to 12 times in 24 hours. Ac age at which he/she can be fully fed on cording to this concept, the mother land, 83% of pregnant women who did not can understand and follow the in family foods. During the first six months, know their HIV status planned to breastfeed structions for preparing replace replacement feeding should be with a suit and not formula feed (Talawat et al, 2002). ment feeds and with support from able breast-milk substitute. After six the family can prepare enough re months, the suitable substitute should be placement feeds correctly every HIV-positive status. Women who know complemented with other foods.15 day and at night, despite disrup they are HIV-positive are much more likely tions to preparation of family food to plan to replacement feed, and they suc­ or other work. continued on page 7 ceed in replacement feeding more often

6 HIV and Infant Feeding than women who do not know their HIV planned to exclusively breastfeed. Of the status, although the choice and successful 279 HIV-positive mothers in the study who Box 2 continued practise of replacement feeding varies initially accepted free formula, 78 never Affordabl e: The mother and family, greatly between and even within countries. returned for more formula, and 47 returned with community or health system Many antenatal women in pMTCT programs but later defaulted (Matovu et al, 2002). In support if necessary, can pay for change their minds about infant feeding Zimbabwe, 17% (32 of 188) of HIV-posi- the cost of purchasing/producing, preparing, and using replacement when they learn they are HIV-positive, tive mothers of children up to 20 months feeding, including all ingredients, switching from intending to breastfeed to in a pMTCT programme reported to coun­ fuel, clean water, soap, and equip intending to replacement feed. In sellors they were replacement feeding suc­ ment, without compromising the health and nutrition of the family. Botswana, 89% (141 of 158) of women cessfully so far (Chitsike, circa 2000). One This concept also includes access who knew they were HIV-positive planned South African study indicates that the up­ to medical care if necessary for di to replacement feed, and when interviewed take and rate of replacement feeding is arrhoea and other illnesses and the up to 6 months after birth, 139 of those higher in urban areas than rural ones cost of such care. mothers were doing so (pMTCT Advisory (McCoy et al, 2002). Sustainable: Availability of a con Group, 2001). Another Botswana study, tinuous and uninterrupted supply and dependable system of distri however, concluded that adherence to Factors that influence the bution for all ingredients and prod replacement feeding was poor in spite of selection and successful practise ucts needed for safe replacement intense follow-up (Shapiro et al, 2003). of replacement feeding by feeding for as long as the infant HIV-positive mothers needs it, up to one year of age or longer. According to this concept, In Cote d’Ivoire where free formula was there is little risk that the replace provided, 59% (151 of 255) of HIV-posi- Discovering one’s HIV-positive status. The ment food will ever be unavailable tive women planned to replacement feed above evidence indicates that the selection or inaccessible. It also means that another person, who can prepare before delivery and 81% (123 of 151) of and practise of replacement feeding is and give replacement feeds, will al those who so planned were doing so two much more prevalent in HIV-positive ways be available to feed the child days after birth (Leroy et al, 2002). A rapid women than in HIV-unknown women. This in the mother’s absence. assessment of a Honduran pilot project that evidence indicates that when antenatal Safe: Replacement foods are cor gives free formula to HIV-positive mothers women first learn they are HIV-positive, rectly and hygienically prepared found that all 30 HIV-positive women in­ many state that they intend to replacement and stored and fed in nutritionally adequate quantities with clean terviewed planned to replacement feed feed instead of breastfeed. A study in Thai­ hands and clean utensils, prefer (Baek et al, 2002). In South Africa, a study land specifically documented this change ably by cup. This concept means of HIV-positive pregnant women found of mind (Talawat et al, 2002). The studies that the mother or caregiver: that only 9% (18 of 189) planned to re­ reviewed, however, do not help us under­ ■ Has access to a reliable supply placement feed, but 12 of the 18 were still stand how long women are able to sustain of safe water (from a piped or protected well source), doing so at the end of the first week after exclusive replacement feeding. birth (Rollins et al, 2002). Another South ■ Prepares replacement feeds that are nutritionally sound and free Africa study reported that when mothers Free or subsidised formula. Several studies of pathogens, learned they were HIV-positive, they indicate that the distribution of free for­ ■ Is able to wash hands and uten stopped breastfeeding immediately (Seidel mula or subsidisation of formula by re­ sils thoroughly with soap and to et al, 2000). In Thailand, 94% (75 of 80) of search projects or government programs regularly boil the utensils to HIV-positive mothers were replacement persuades some HIV-positive women to re­ sterilise them, feeding at the time of interview, even placement feed (in Honduras: Baek et al, ■ Can boil water for at least 10 min though most had not planned to replace­ 2002; in South Africa: McCoy et al, 2002; utes to prepare each of the ment feed before learning they were HIV- in Tanzania: de Paoli et al, 2000; and in baby’s feeds, and positive (Talawat et al, 2002). In a Uganda Uganda: Matovu et al, 2002). However, ■ Can store unprepared feeds in study of a pMTCT programme providing evidence from the Uganda study suggests clean, covered containers and protect them from rodents, in free formula, 43% (375 of 870) of HIV- that availability of free formula does not sects, and other animals. positive pregnant women planned to re­ always ensure that the decision to replace­ placement feed, while the other 57% ment feed translates into successful prac-

A Compilation of Programmatic Evidence 7 tise, and such availability may lead to in­ sive breastfeeding for HIV-positive moth­ Box 3: creased mixed feeding (Matovu et al, 2002). ers (in Honduras: Baek et al, 2002; in India: Summary of Feeding Options In fact, many of the documents reviewed the South India AIDS Action Programme for Infants of HIV-Positive note that the high cost of replacement et al, 2001; in Rwanda: Pham et al, 2002; Mothers: International feeding, including the cost to clean uten­ in South Africa: Chopra et al, 2000 and Guidelines, 2003* sils, heat the milk, and buy formula, deters Seidel et al, 2000; in Tanzania: de Paoli et low-income women from selecting or suc­ al, 2002; in Zambia: Kankasa et al, 2002). The following infant feeding options for HIV- positive mothers are in cessfully practising replacement feeding. In But some counsellors and programmes were cluded in the updated 2003 inter most of the countries studied, commercial biased in favour of exclusive breastfeeding national HIV and infant feeding infant formula (and often even animal milk) and/or against replacement feeding (in In­ guidelines: are just too expensive. In the opinion of dia: Sarna, 2002; in South Africa (rural hos­ Replacement feeding (RF) for the many, this high cost is the primary factor pitals): McCoy et al, 2002). child aged 0-6 months in preventing many mothers from success­ ■ Commercial infant formula fully replacement feeding (in India: Sarna, Partner or family involvement. A study in ■ Home-modified animal milk 2002; in Myanmar: Williams et al, 2003; in Cote d’Ivoire found that women living with (Properly modified fresh animal’s South Africa: Chopra et al, 2003 and Seidel a partner were less likely to choose replace­ milk, powdered full-cream, and et al, 2000; in Zambia: Hope Humana et al, ment feeding than those not, and failures evaporated milks are recom 2002). The cost to national programmes of to comply if they did choose replacement mended. Unsuitable replacement supplying free infant formula to HIV-posi- feeds include unmodified animal’s feeding were mainly related to the family milk, skimmed and sweetened con tive mothers has also led to decisions by environment (Leroy et al, 2002). A study in densed milk, fruit juices, sugar-wa- some governments not to provide free or Uganda found that women who succeeded ter and dilute cereal gruels. Mixed subsidised formula or to discontinue this in replacement feeding had family support feeding—combining breast milk and other foods or liquids—is never component of pMTCT programmes (in Hon­ (Matuvo et al, 2002). Several studies note recommended.) duras: Baek et al, 2002; in Zambia: Kankasa that partners and family have influence Exclusive breastfeeding (EBF) for et al, 2002; in Rwanda: Pham et al, 2002; over feeding decisions (in Botswana: Tlou children aged 0-6 months in India: Sarna, 2002). et al, 2000; in South Africa: Seidel et al,

■ Exclusive breastfeeding be 2000; in Tanzania: Swartzendruber et al, tween 0-6 months Advice from counsellors or health work 2002; in Uganda: Hope Humana et al, 2002; ■ Early cessation of breastfeeding ers. The evidence indicates that in many in Zambia: Kankasa et al, 2002). (occurring over a few days to a settings mothers desire and adhere to the few weeks) advice of health workers regarding infant Mother’s fear of transmitting HIV to their ■ Transition from exclusive breast- feeding (in Nigeria: Isiramen, 2002; in South infants. Some mothers believe all babies feeding to replacement feeding Africa: Bentley et al, 2002 and Rollins et al, of HIV-positive mothers will be infected, Breast-milk feeding 2002; in Zambia: the Ndola Demonstration and some completely avoid breastfeeding to reduce the risk (in South Africa: Rollins ■ Wet-nursing Project, NDHMT, 1999, Bond and Ndubani 1999; in multiple countries: Rutenberg et et al, 2002 and Seidel et al, 2000; in Tanza­ ■ Expressing and heat-treating nia: de Paoli et al, 2000). breast milk al, 2002). However, one study found sig­ nificant dissonance of mothers towards ad­ ■ Breast-milk banks vice of doctors to replacement feeding in Mother’s educational level. Two studies Feeding from 6 months to 2 years a breastfeeding culture (In India: South indicated that better-educated women ■ All children need suitable India AIDS Action Programme et al, 2001). were more successful with replacement complementary foods from the Sometimes guidance by counsellors or feeding than less-educated women (in Cote age of 6 months programme policy shows a clear bias to­ d’Voire: Leroy et al, 2002; in Uganda: ■ Non-breastfed infants and young wards one feeding option or another and Matovu et al, 2002). Respondents in an­ children from 6 months of age rarely reflects balanced counselling that other study concurred, stating their opin­ should ideally continue to re ceive a suitable breast-milk sub includes risk assessment (in Zambia: ion that more-educated women are more stitute as well as complementary Kankasa et al, 2002). In the reviewed successful at replacement feeding (in Tan­ continued on page 9 studies, bias was most often in favour of zania: de Paoli et al, 2002). No other re­ replacement feeding and/or against exclu­ viewed studies analysed this issue.

8 HIV and Infant Feeding Mother as primary income provider. One substantial spillover effect: In the non- Box 3 continued study found that mothers who are the pri­ programme group, 37% of all mothers, re­ mary income providers are more likely to gardless of HIV status, practised exclusive foods made from properly pre replacement feed than women who are not breastfeeding, compared to only 16% in pared and nutrient-enriched fam (in South Africa: Rollins et al, 2002). the programme group, with the difference ily foods. of 21 percentage points ascribed to ■ When milk is part of the diet, complementar y foods are Mother’s participation in a structured spillover. But in Honduras, where bottle- needed 2-3 times a day at 6-8 pMTCT programme. The programmes re­ feeding is widely accepted, no spillover was months of age, and 3-4 times a viewed suggest that a higher proportion reported. The pMTCT programme there en­ day from 9 up to 24 months of of HIV-positive mothers select replacement courages HIV-negative women to exclu­ age, with additional nutritious snacks offered once or twice a sively breastfeed, and the evaluation re­ feeding and then practice it more success­ day. fully if they participate in a structured ported that the programme encountered ■ The general principles of no HIV-negative or HIV-unknown moth­ pMTCT programme, although this result is complementary feeding are the highly confounded by the several factors ers using commercial formula due to same for a child receiving a milk that typically comprise a pMTCT spillover. source, such as commercial in programme, such as testing, free formula, fant formula or animal milk, as for a child being breastfed. counselling (sometimes biased), and follow- Home-prepared formula ■ up (in Botswana: pMTCT Advisory Group, Where no suitable breast-milk substitute is available after 6 2001; in Honduras: Baek et al, 2002; in Definition: a breast-milk substitute pre months, replacement feeding Zambia: Kankasa et al, 2002). However, a pared at home from fresh or processed should be with properly pre pared, and enriched family foods pMTCT programme in India that promoted animal milks, suitably diluted with water given more frequently. informed choice among HIV-positive and with the addition of sugar and micro ■ Other milk products, such as women reported the opposite effect: ex­ nutrients. boiled animal’s milk or yoghurt, clusive breastfeeding and not replacement should be included as a source feeding increased in HIV-positive mothers Only one study among those reviewed of protein and calcium; other (Sarna, 2002). explicitly focused on the use of home- animal products such as eggs, meat, liver, and fish should be prepared formula, although several others given as a source of iron and Spillover of commercial infant examined the use of animal milks as an zinc; and fruit and vegetables formula option to commercial infant formula for should be given to provide vita mins, especially vitamins A and replacement feeding. In the India pMTCT C. Definition: a term used to designate the programme, modified cow and buffalo milk ■ Micronutrient supplements are feeding behaviour of new mothers (who is the only recommended alternative to needed, especially iron, accord either know that they are HIV-negative or breastfeeding. Formula is considered too ing to WHO** or national guide are unaware of their HIV status) who do expensive and therefore is not recom­ line. not breastfeed, breastfeed for a short time mended (Sarna, 2002). Two studies that * Summary of infant-feeding op only, or mix feed, because of unfounded interviewed mothers in Kenya and Tanza­ tions derived from the 2003 re fears about HIV, misinformation, or the vised WHO, UNICEF, UNFPA and nia suggest that cow’s milk can be an ac­ UNAIDS. HIV and Infant Feeding: ready availability of breast-milk substi ceptable option for HIV-positive mothers. Guidelines for Decision-Makers tutes. In Kenya, cow’s milk was considered the (Geneva. 2003). best alternative if breastfeeding was not ** Vitamin A: 50,000 IU before 6 months and 100,000 IU between Two of the studies reviewed here specifi­ possible, but only for those who owned a 6 and 12 months (with a mini cally attempted to measure or address cow, making milk affordable (Oguta et al, mum of a 1-month interval); from spillover (in Botswana: pMTCT Advisory 2001). In this study, other alternatives, such 12 months on: 200,000 IU every 4 to 6 months. Iron: where the Group, 2001; in Honduras: Baek et al, 2002). as the use of infant formula, wet nursing, diet does not include foods forti Several others mentioned concerns and the expression of breast milk, and goat’s milk, fied with iron or where anaemia prevalence is about 40%, 2mg/ need to monitor the use of infant formula were considered less desirable than cow’s kg body weight/day of iron from among HIV-negative and unknown-status milk. In Tanzania, all alternatives to 6 months of age up to 23 months women. The Botswana study reported a breastfeeding were considered too expen- of age.

A Compilation of Programmatic Evidence 9 sive, but cow’s milk was thought to be the programme group exclusive breastfeeding 3 months and none by 5 months (Shapiro best option (de Paoli et al, 2000). However, was reported by 2.7% of the HIV-positive et al, 2003). a Myanmar study found that although cow mothers and 18.4% of the HIV-negative and goat milk may be acceptable options ones (pMTCT Advisory Group, 2001). In Exclusive breastfeeding can be increased. to breastfeeding for some HIV-positive Myanmar, a survey of mothers of unknown Evidence shows that the prevalence of ex­ mothers, many families thought that modi­ HIV status (to the study team) concluded clusive breastfeeding in the first 6 months fied animal milk was too expensive and too that although the idea of exclusive of life can be increased. Following the in­ complicated to prepare several times a day breastfeeding was acceptable, convenient, troduction of a programme to promote (Williams, 2003). less time-consuming, and less expensive, exclusive breastfeeding in South Africa, the practice of exclusive breastfeeding was formula use in the first 24 hours of life uncommon, with two-thirds of the infants decreased significantly at the intervention EXCLUSIVE BREASTFEEDING receiving water (to quench thirst) by 2 to 3 site (30% to 0%), while increasing at the months of age (Williams et al, 2003). In control site (5% to 15%); and exclusive Definition of exclusive breastfeeding: another Myanmar study, document review breastfeeding for infants aged 0-6 months giving an infant no food or drink, not even and key informant interviews found evi­ increased significantly in the intervention water, other than breast milk except for dence of low exclusive breastfeeding (16% area (13.9% to 21.5%), but did not change drops or syrups of vitamins, mineral of infants 0-3 months) largely due to giv­ in the control area (Bentley et al, 2002). supplements, or medicines. ing of water, although pre-lacteal feeding, Consecutive surveys in Zambia between a traditional practice, was unusual (Will­ 2000 and 2002 show that prevalence and Definition of predominant breastfeeding: iams, 2001). In Nigeria, mothers of any HIV duration of exclusive breastfeeding in­ the infant mostly receives breast milk but status reported the following for infants creased with counselling during ANC is also occasionally given other liquids, in aged 4-6 months: 33% reported exclusive visits and post HIV-testing (AED/Linkages, cluding water and/or tastes (or small breastfeeding: 48% reported predominant 2002). In Zimbabwe, the rate of exclusive amounts) of ritual or other foods . breastfeeding (defined as giving other liq­ breastfeeding since birth, as reported by uids before one month of age): and 19% mothers of all HIV-status at 3 months Definition of breast-milk feeding: feed reported mixed feeding (Isiramen, 2002). after birth, was directly related to the in­ ing breast milk to an infant, whether ex Interviews with a random sample of South tensity of the intervention: Exclusive pressed or directly from the breast. Breast- African mothers of any HIV status found breastfeeding was only 2% in the pre-in- milk feeding options in the context of HIV/ that half reported introducing infant for­ tervention cohort but rose to 9% in the AIDS include wet-nursing, expressing and mula before one month and most before post-intervention cohort with education heat-treating breast milk, and the use of three months, and those who continued but no individual counselling and to 19% breast-milk banks. exclusive breastfeeding did so because they in the post-intervention cohort with both could not afford other milks (Chopra et al, education and individual counselling Definition of mixed feeding: feeding both 2000). A survey of HIV-positive mothers in (Tavengwa et al, 2002). breast milk and other foods or liquids. Zimbabwe reported that exclusive breast- feeding was practised by 84% at one week; Factors associated with increased Prevalence of exclusive 75% at 1 month; 40% at 3 months; and exclusive breastfeeding breastfeeding none by the 6th month (Chitsike, 2000). Programmatic experience underscores that Low prevalence and short duration of ex Some Nigerian mothers said exclusive several important factors are associated clusive breastfeeding. Rates and duration breastfeeding for 3 months is more practi­ with a woman’s ability to achieve exclu­ of exclusive breastfeeding are relatively cal than for 6 months (Isiramen, 2002). sive breastfeeding: low/brief, regardless of the HIV status of Exclusive breastfeeding was difficult to mothers. In Botswana, self-reported exclu­ achieve beyond the first weeks of life for Support and promotion of breastfeeding. sive breastfeeding since birth in a sample Cote D’Ivoire mothers (Leroy et al, 2002). Exclusive breastfeeding was higher in a of mothers of infants aged 0-6 months was In Botswana, 10% (3 of 31) of a random programme group in South Africa that in­ 33.7% in the control group (of unknown- sample of mothers who had agreed to ex­ cluded (1) trained lay counselling in clinics HIV status to the study team), while in the clusively breastfeed were still doing so by and home visits and (2) general commu-

10 HIV and Infant Feeding nity breastfeeding promotion with post­ Paoli et al, 2001). In Nigeria some mothers Two attributes are often associated with ers, pamphlets, and newspaper articles said that relatives made exclusive the cessation of breastfeeding for women (Bentley et al, 2002). In Tanzania, pregnant breastfeeding difficult (Isiramen, 2002). who are exclusively breastfeeding: (1) the women of unknown HIV status who had age of the infant when cessation occurs more knowledge about breastfeeding said Education. Mothers with more education (timing) and (2) the period of transition they were more likely to exclusively were more likely to practise exclusive from exclusive breastfeeding to no breastfeed (de Paoli et al, 2002). breastfeeding in Nigeria (Isiramen, 2002). breastfeeding, during which time mixed feeding occurs. In the revised international Cost and income. Several studies note that HIV status. A woman’s HIV status combined guidelines, the term ‘early cessation’ is used mothers practised exclusive breastfeeding with her knowledge of it affects whether to refer to the age at which the infant stops because they could not afford the alterna­ or not she practises exclusive breastfeeding breastfeeding, including suckling: gener­ tives. A sample of South African mothers or replacement feeding. In Tanzania women ally prior to or at or about six months. In of unknown HIV status said they practised who knew they were HIV-negative were the reports summarised here, however, exclusive breastfeeding by default because more likely to choose and practise exclu­ ‘early cessation’ means less than one month they could not afford other milks (Chopra sive breastfeeding (de Paoli et al, 2001). old in some cases and as long as up to one et al, 2000). Several mothers in India said year or more in others, especially in the they decided to breastfeed because they Knowledge about benefits of exclusive African context where breastfeeding for did not have the means to boil water or breastfeeding. Lack of knowledge about two years or longer is common. Although sterilise utensils, or could not afford cow’s exclusive breastfeeding in mothers and currently not recommended, the term milk (Sarna, 2002). some counsellors may have hindered the ‘abrupt cessation’ was used in several of practise of exclusive breastfeeding in some the summarised documents to describe an BFHI. Giving birth in a ‘baby-friendly hos­ cases but not others. Some Tanzanian coun­ abbreviated transition from exclusive pital’ was associated with higher exclusive sellors lacked knowledge about exclusive breastfeeding to no breastfeeding. ‘Abrupt’ breastfeeding rates in Botswana (anecdotal breastfeeding and its benefits and did not means from 2-3 days in some documents evidence from Rollins, 2003; pMTCT Advi­ believe exclusive breastfeeding was pos­ to as long as 2-3 weeks in others. Previ­ sory Group, 2001). Mothers in Nigeria were sible, while mother knowledge of the ben­ ously, it was commonly recommended that more responsive to BFHI-designated mes­ efits of exclusive breastfeeding engendered for HIV-positive women, the transition pe­ sages from hospitals (Isiramen, 2002). more of it (de Paoli et al, 2002). In Thai­ riod should be as short as possible in order land, mothers considered breastfeeding to reduce the period of mixed feeding and Stigma. Stigma associated with not more advantageous than formula for sev­ the associated higher risk of HIV infection. breastfeeding and pressure from others eral reasons, but HIV-positive mothers rated However, both early and abrupt cessation cause some women to choose exclusive formula significantly safer than other feed­ carry risks for mothers and infants and may breastfeeding over replacement feeding. ing methods (Talawat et al, 2002). raise family and/or community objections. Most women in a South African study who Given these issues, both the timing and the period for transition are still under investi­ met all conditions for safe replacement Cessation of breastfeeding and feeding still chose exclusive breastfeeding weaning17 issues gations and discussion. (25 of 28), citing family expectations, stigma, and concerns about disclosure Definition of cessation of breastfeeding: Early versus abrupt cessation. Although (Rollins et al, 2002). Sixteen HIV/AIDS coun­ completely stopping breastfeeding, includ the UN currently recommends early cessa­ sellors interviewed in Tanzania said the fear ing suckling. tion of breastfeeding for HIV-positive of stigmatisation contributed to the deci­ mothers, only two programmes included sion to exclusively breastfeed (de Paoli et Definition of early cessation: Stopping here were designed to address the issue al, 2002). breastfeeding, including suckling, prior to, specifically: A Uganda study found that or at or about, six months of age, as soon some HIV-positive mothers achieved Family support. Feeding histories from 309 as replacement feeding is acceptable, fea ‘abrupt’ cessation while others did not Tanzanian mothers found being married sible, affordable, sustainable and safe, (Bakaki, 2002), and a Nigeria study said was significantly associated with a longer with the idea of avoiding mixed feeding that ‘abrupt’ cessation (defined as occur­ duration of exclusive breastfeeding (de to the extent possible. ring over 1 to 2 weeks) was common, but

A Compilation of Programmatic Evidence 11 among women having older infants programme added single and working ■ Engorged breasts (in Botswana: pMTCT (Isiramen, 2002). Information from other mothers and baby’s negative HIV-status to Advisory Group, 2002; in Myanmar: studies reflects mixed findings. In Botswana, this list. Williams et al, 2003); mothers who had stopped breastfeeding ■ Breast inflammation (in Botswana: by the time of the interview had done so Negative factors associated with early ces pMTCT Advisory Group, 2001; in by gradually changing to other milks sation. Many studies reported that early Uganda: Bakaki 2002); (pMTCT Advisory Group, 2001). In Myanmar, cessation had proven very difficult for HIV- mothers thought that abrupt cessation was positive mothers, sometimes even when a ■ Babies getting sick (weight loss, diar­ being achieved but was cruel to the baby pMTCT programme was promoting it (in rhoea, vomiting, fever) (in Cote d’Ivoire: (Williams et al, 2003). A Zambia study says some parts of Asia: Preble and Piwoz, Leroy et al, 2002); that exclusive breastfeeding followed im­ 2002; in Kenya: Oguta et al, 2001; in mediately by replacement feeding is con­ Myanmar: Williams et al, 2003; in Tanza­ ■ Baby found to be HIV-positive (in South trary to community norms (Kankasa et al, nia: Swartzendruber et al, 2002). Problems Africa: Seidel et al, 2000); 2002). associated with early cessation identified ■ Baby found to be HIV-negative (in or discussed in these studies included: the Uganda: Bakaki, 2002); Age of child at cessation. Traditionally, development of mastitis and breast among women of unknown or negative abscesses in mothers; and distress, restless­ ■ Crying babies (in Cote d’Ivoire: Leroy HIV-status, some breastfeeding continues ness, loss of appetite, diarrhoea, and mal­ et al, 2002); for a long time (1-2 years) according to nutrition in the infant. the studies reviewed here (in Botswana: ■ Mother was not sleeping at night (in Shapiro et al, 2003; in India: South India Techniques used to achieve cessation of Cote d’Ivoire: Leroy et al, 2002); AIDS Action Programme et al, 2001; in breastfeeding. Several studies give ex­ ■ Intimidation from health workers (in Myanmar: Williams, 2003; in Nigeria: amples of how mothers stopped Cote d’Ivoire:, Leroy et al, 2002); Isiramen, 2002; in Tanzania: de Paoli et al, breastfeeding at different ages of the child. 2001). For example, the Nigeria study re­ ■ Stigma (in Cote d’Ivoire: Leroy et al, ■ ported that 81% of the mothers inter­ Applying something to the breasts to 2002); viewed ceased breastfeeding at 12-18 decrease breast milk production (in ■ months and ‘early weaning’ (under 10 Myanmar: Williams et al, 2003; in Criticism from family (in Botswana: months) was unusual (Isiramen, 2002). A Nigeria: Isiramen, 2002); pMTCT Advisory Group, 2001). Zimbabwe study notes that all HIV-posi- ■ Taking the child to a relative (in Nige­ tive mothers in a pilot pMTCT programme The Botswana evaluation (pMTCT Advisory ria: Isiramen, 2002); who chose exclusive breastfeeding ceased Group, 2001) found that these problems were more common when the mothers breastfeeding entirely by 6 months (Chitske, ■ Giving other food or milk (in Nigeria: 2000). Isiramen, 2002; in Uganda: Bakaki, stopped breastfeeding early (0-6 months) rather than later. To address questions con­ 2002; in Botswana: pMTCT Advisory cerning cessation, it was suggested that Positive factors associated with early ces Group, 2001); sation. The results of the Uganda study mothers not admit the full truth and say suggest that early cessation by HIV-posi- ■ Decreasing the number of breastfeeds that their baby was sick, the baby refuses tive mothers who chose to exclusively (in Nigeria: Isiramen, 2002; in Uganda: milk, they have problems with the breasts, breastfeed can be achieved (Bakaki, 2002). Bakaki, 2002). and/or that health worker advised stopping In this study, HIV-positive mothers who breastfeeding (in Uganda: Bakaki, 2002). were enrolled in a pMTCT pilot programme Reasons for early cessation of Mothers in Nigeria suggested the need for and had successfully stopped breastfeeding breastfeeding. Some studies give reasons psychological support during the transition before 7 months reported the factors that why mothers cease breastfeeding earlier process (Isiramen, 2002). made them successful: education about than they planned or is recommended, and MTCT, good counselling, early disclosure of some also suggested ways of overcoming Support for cessation of breastfeeding. HIV-status, and help from relatives and these problems. Both are included in the Several studies seem to suggest that sup­ friends. Health workers in the Uganda following list: port on early and/or abrupt cessation of

12 HIV and Infant Feeding breastfeeding by health workers is poor. In or other liquids early (South India AIDS A Cote d’Ivoire study found that 69% of Tanzania counsellors lacked knowledge of Action Programme et al, 2001). In HIV-positive mothers who selected replace­ how to advise mothers to feed an infant Myanmar, most HIV-positive mothers ini­ ment feeding reported still doing so suc­ after cessation and gave incorrect advice tiated breastfeeding but gave rice and broth cessfully at 3 months (Leroy et al, 2002). In about early cessation of breastfeeding (de early, making exclusive breastfeeding rare Honduras, where no stigma seems to at­ Paoli 2002). The Botswana evaluation after a few months. Mothers often con­ tach to formula feeding, providers said that (pMTCT Advisory Group, 2001) found that tinue some breastfeeding, however, for a HIV-positive clients were using formula HIV-positive mothers who breastfed did not long time (Williams, 2001; Williams et al, without problems, and there were no re­ recall receiving advice about feeding their 2003). A South Africa study of women of ports or suspicions of surreptitious mixed infant after 6 months of age. unknown HIV status who started out ex­ feeding (Baek et al, 2002). On the other clusively breastfeeding found most of the hand, a study in Zambia reported that HIV- mothers introduced formula and/or solid positive women change to mixed feeding MIXED FEEDING foods early, half before 1 month and most very early, whether they start out replace­ by 3 (Chopra et al, 2000). A Tanzania study ment feeding or exclusively brestfeeding Definition: feeding both breast milk and found that 85% of HIV-positive mothers (Omari et al, 2000). other foods or liquids. started exclusive breastfeeding but 46% were mixed feeding within a few days of he current UN recommendation is delivery (de Paoli et al, 2001). In a Uganda BREAST-MILK FEEDING T that HIV-positive mothers should study, all HIV-positive mothers started out never use mixed feeding. They should ei­ exclusively breastfeeding but switched to nder the current international HIV ther breastfeed exclusively or replacement mixed feeding by 3 months (Bakaki, 2002). Uand infant-feeding guidelines, feed exclusively, but not mix the two. The In Zambia, women of unknown HIV-status breast-milk feeding includes three poten­ reason is that mixed feeding combines the who started out exclusively breastfeeding tial modified infant-feeding options: wet- risk of diarrhoea and other infections of­ usually switched to mixed feeding within nursing, expressed and heat treated breast ten associated with using infant formula a few days of delivery (Ndola District Man­ milk, and the use of breast-milk banks. The or modified animal milk to replacement agement Team, 1999). Many of these stud­ vast majority of programme experiences feeding with the risk of HIV-transmission ies found that abrupt cessation of included here do not reflect informed due to breastfeeding. A study in Durban, breastfeeding was very difficult, and mixed choice counselling on all breast-milk feed­ South Africa (Coutsoudis et al, 2001) sug­ feeding was often the result. ing options. In India, for example, these gests that mixed feeding has a higher risk options are not discussed at all (Sarna, of HIV-transmission than breastfeeding. The experience of HIV-positive mothers 2002). who initiate replacement feeding but Because of the recommendation against change to mixed feeding varies widely in Wet nursing mixed feeding, pMTCT programmes ask the summarised studies that address the antenatal HIV-positive women to choose issue. The Botswana study by Shapiro et al The compilation of programme experience between exclusive breastfeeding and re­ (2003) found that most mothers who ini­ included no concrete data on the use of placement feeding, and to avoid mixed tiated replacement feeding changed to wet nurses for the specific purpose of pre­ feeding. The reviewed studies show that mixed feeding even though the programme venting HIV transmission. In Myanmar, wet most women make a distinct choice, but used intense follow-up to prevent it. An­ nursing is common among household after delivery they often end up mixed other Botswana study said that nearly all members, but mothers expressed concern feeding early in the baby’s life, whether they the HIV-positive mothers who selected re­ in the case of an HIV infection. Thus, wet initiallly chose to exclusively breastfeed or placement feeding reported they were do­ nursing is thought to be complicated by exclusively replacement feed. ing so successfully at interview (0-6 the need to test wet nurses and ensure that months) even though many reported run­ they remain uninfected (Williams, 2003). Early mixed feeding was reported in a ning out of free formula at least once In Kenya, wet nursing was considered ac­ Botswana study (Shapiro et al, 2003). In (pMTCT Advisory Group, 2001). ceptable for older but not younger women, India, most HIV-positive mothers initiated where study participants stated that this breastfeeding but introduced cow’s milk practice was common for orphans, but not

A Compilation of Programmatic Evidence 13 for babies of healthy mothers (Oguta et al, dence in expression and heat-treatment of but confirmed that bringing breast milk to 2001). In the Indian pMTCT assessment, breast milk as an option, and may require a boil did do so (Chantry et al, 2000). One Sarna (2002) found that wet nursing was further training and support. In a South of the South Africa studies found that the not discussed as an option with HIV-posi- Africa intervention project, the proportion 10 mothers using the Pretoria tive women. of mothers who left expressed breast milk pasteurisation method who were inter­ when they had to be separated from their viewed were positive about the method and Expressed and heat-treated infants rose significantly in the interven­ felt they could use it at home as well as in breast milk tion area but not in the control area the hospital (Pullen et al, 2002). (Bentley et al, 2002). Heat-treated expressed breast milk not Breast-milk banks widely acceptable. Several studies done A Zimbabwe study conducted individual mainly among mothers of unknown and group in-depth interviews with 77 men No data or even anecdotal experience was HIV-status indicate that expressing and and women specifically about expressing found in the reviewed studies and heat-treating breast milk is not a widely and heat-treating breast milk (Israel-Ballard programmes on the use of breast-milk acceptable option for HIV-positive moth­ et al, 2002). Although knowledge was low, banks for feeding children to prevent MTCT. ers (in India: South India AIDS Action 30% of the women had expressed and Programme et al, 2001; in Kenya: Oguta et knew about manual expression. Expression al, 2001; in Tanzania: de Paoli et al, 2002; was thought to be painful but only during AFASS in Zimbabwe: Israel-Ballard et al, 2002). A a woman’s first few expressions. Reasons third of the mothers in a South Africa study given for expressing included baby not ethods of infant feeding by HIV- succeeded in expressing milk, but the idea able to suckle due to sickness, feeding for Mpositive mothers are recommended of boiling breast milk was alien and dis­ orphans, sore nipples, and acquiring breast by the UN only if they are acceptable, fea­ missed (Chopra et al, 2000). Counsellors in milk for various healing purposes. It is sible, affordable, sustainable, and safe Tanzania did not believe that heating breast considered affordable and therefore sus­ (AFASS) for the individual case being con­ milk would kill the HIV in it (de Paoli et al, tainable, but only if the husband is sidered. The risks associated with each of 2002). In Zimbabwe, mothers felt that part­ supportive. Although expressing and these five attributes of infant feeding ners and family were neither supportive of heat-treating breast milk faces numerous methods vary with the environment and nor knowledgeable about using heat- barriers that prevent it from being widely the individual circumstances of the mother treated expressed breast milk; they could acceptable, especially among rural, less- and her family. In areas where replacement not succeed with this method unless they educated people, many participants feeding is considered AFASS by local deci- had their partner’s support, but that more believed these problems can be overcome sion-makers, there is little reported debate education about heat-treated expressed with education. to the UN recommendations. Initially, in the breast milk might generate such support industrialised world and some developing (Israel-Ballard et al, 2002). Pretoria pasteurisation. Expressed breast areas, pMTCT programmes opted to actively milk of HIV-positive women must be heat- promote replacement feeding and provided Evidence exists that it can become accept treated to be safe, which can be accom­ little information or support to mothers able and used. In Myanmar, women par­ plished with the Pretoria pasteurisation about other infant feeding options. The ticipating in a trials study had a positive method. The results of several studies in experience of these programmes and oth­ response to heat-treating expressed breast South Africa on this method have con­ ers with respect to the five AFASS criteria milk. The trials study showed that this op­ firmed the efficacy and viability of inacti­ is now becoming known and is reported, tion was feasible, with many homes hav­ vating the HIV virus in the breast milk of albeit unsystematically, in some of the stud­ ing suitable pots for heating the milk. HIV-positive mothers through heating milk ies reviewed here. Mothers were purportedly amazed and to 56-62.5 degrees C for 12-15 minutes delighted to learn that there is a free (Jeffrey et al, 2002 a and b; Pullen et al, Acceptable method to feed their infant if they had to 2002). Another study in Puerto Rico found be separated (Williams et al, 2003). Never­ that lipolysis of breast milk (letting it stand Definition: The mother perceives no bar theless, the study report notes that hours at room temperature for 6) did not rier to replacement feeding. Barriers may Myanmar health professionals lack confi­ destroy HIV in most breast milk samples, be cultural or social or be due to fear of

14 HIV and Infant Feeding stigma or discrimination. According to this back malnutrition’ (Vilakati and Shongwe, water; and having no refrigerator (in concept the mother is under no social or 2001). In Tanzania, counsellors did not be­ Botswana: pMTCT Advisory Group, 2001; cultural pressure not to use replacement lieve that heating the expressed breast milk in South Africa: Chopra et al, 2000; McCoy feeding; she is supported by family and of HIV-positive mothers would destroy the et al, 2002; and Rollins et al, 2002; in community in opting for replacement feed HIV virus (de Paoli et al, 2002), and Zimba­ Rwanda: Pham et al, 2002; in Uganda: ing, or she will be able to cope with pres bwe mothers thought that expressed breast Matovu et al, 2002). Some reports conclude sure from family and friends to breastfeed, milk was unclean, associated with witch­ that formula is feasible only for educated and she can deal with possible stigma at craft, and perhaps dangerous (Israel- women living mostly in urban areas (in tached to being seen with replacement Ballard, 2001). In South Africa, however, South Africa: McCoy et al, 2002; in Tanza­ food. heated expressed breast milk was consid­ nia: de Paoli et al, 2002). Formula supplies ered acceptable (Pullen et al, 2002). A are occasionally not available (in Botswana: In many countries where breastfeeding is Uganda study concluded that exclusive pMTCT Advisory Group, 2001). Another rea­ the norm, replacement feeding is unaccept­ breastfeeding might not be a viable op­ son that formula is not always feasible is able, largely because women who do not tion for HIV-positive mothers because because follow-up support by counsellors breastfeed are suspected of being HIV-in- abrupt cessation of breastfeeding was and other health care workers to enable fected and are therefore subject to discrimi­ thought to be so bad for the baby (Bakaki, mothers to deal with family and social re­ nation and shunning. Many documents re­ 2002). sistance is not available (in Cote d’Ivoire: viewed here report fear of discrimination Leroy et al, 2002; in Rwanda: Pham et al, or actual discrimination against women In some studies, involvement of male part­ 2002; in South Africa: Seidel et al, 2000). who use formula and other methods of ners and family members in decisions about replacement feeding (in Botswana: Tlou et infant feeding was a key factor in the ac­ Preparation of modified animal milk was al, 2000, and Shapiro et al, 2003; in India: ceptability of formula by HIV-positive thought to be too complicated for some South India AIDS Action Programme et al, mothers (in Botswana: Tlou et al, 2000; in women in two studies (in Myanmar: Will­ 2001; in South Africa: Rollins et al, 2002, Zambia: Hope Humana et al, 2002). iams et al, 2003; in Zambia: Omari et al, and Seidel et al, 2000; in Tanzania: de Paoli 2000). et al, 2002, and Swartzendruber et al, 2002; Feasible in Zambia: Bond et al, 2002, Ndola District The feasibility of early abrupt cessation of Health Management Team, 2002). Definition: The mother (or family) has ad breastfeeding is questioned by several stud­ equate time, knowledge, skills, and other ies, and as a result, the option of exclusive In some studies, stigma and discrimination resources to prepare the replacement food breastfeeding with early abrupt cessation were directed at an entire pMTCT and feed the infant up to 12 times in 24 for HIV-positive mothers is not considered programme because of its relation to HIV­ hours. According to this concept the feasible (in Botswana: pMTCT Advisory AIDS (in Botswana: Shapiro et al, 2003; in mother can understand and follow the in Group; in Tanzania: de Paoli et al, 2002; in Tanzania: Swartzendruber et al, 2002; in structions for preparing replacement feeds, Uganda: Bakaki, 2002; in Zambia: Ndola Zambia: Bond et al, 2002). However, a few and with support from the family can pre District Health Management Team, 1999; studies report finding little or no evidence pare enough replacement feeds correctly and in several countries: Rutenberg et al, of stigma, and replacement feeding was ac­ every day, and at night, despite disruptions 2002). One study did find that it was fea­ ceptable (in Honduras: Baek et al, 2002; in to preparation of family food or other sible to exclusively breastfeed with early South Africa: Chopra et al, 2000; in Thai­ work. abrupt cessation (in Nigeria, Isiramen, land: Talawat et al, 2002). 2002). Many of the documents reviewed here re­ Several studies report other problems be­ port that formula is not a feasible infant Mixed views were reported on the feasibil­ sides stigma that made some infant feed­ feeding method for many mothers. Al­ ity of heated, expressed breast milk (in ing options unacceptable. India mothers though the additional cost of formula (over Myanmar: Williams et al, 2003; in South thought formula was simply bad for the breast milk) is often a key reason for resis­ Africa: Pullen et al 2002; in Tanzania: de babies (South India AIDS Action tance, other factors also contribute: inad­ Paoli et al, 2002; in Zimbabwe: Israel- Programme et al, 2001), and Swaziland equate knowledge about how to prepare, Ballard et al, 2001). mothers said that formula had ‘brought store, or give in a cup; or having no clean

A Compilation of Programmatic Evidence 15 Affordable 2001; in Rwanda: Pham et al, 2002). (in Botswana: pMTCT Advisory Group 2001; Heated expressed breast milk is affordable in South Africa: Chopra et al, 2000). Some Definition: The mother and family, with according to two studies (in South Africa: women in a free formula programme sim­ community or health system support if Pullen et al, 2002; in Zimbabwe: Israel- ply do not return for a follow-up supply necessary, can pay for the cost of purchas- Ballard et al, 2001). (in Uganda: Matovu et al, 2002). Strate­ ing/producing, preparing, and using gies used by mothers who run out of free replacement feeding, including all ingre A key issue is the fact that affordable re­ formula include buying more milk, giving dients, fuel, clean water, soap, and equip placement feeding methods for HIV-posi- sugar water and/or fruit juice between ment, without compromising the health or tive mothers implies that mothers know feeds, give fewer feeds per day, and dilut­ nutrition of the family. This concept also their HIV status, which is frequently not ing the formula (in India: South India AIDS includes access to medical care if neces the case in many countries (Preble and Action Programme et al, 2001; in South sary for diarrhoea and other illnesses and Piwoz, 2002). Africa: Chopra et al, 2000), and going to the cost of such care. the clinic earlier than scheduled to get a Sustainable new supply (in Botswana: pMTCT Advisory A key criterion, affordability is at the crux Group, 2001). of much of the debate on the use of re­ Definition: Availability of a continuous placement feeding, especially with infant and uninterrupted supply and dependable One study reported that mothers were con­ formula. Many of the studies summarised system of distribution for all ingredients cerned that wet nurses might be or might here reported that low-income mothers and products needed for safe replacement become HIV-positive and were concerned could not afford to purchase infant for­ feeding, for as long as the infant needs it, about the sustainability of wet nursing as mula, as evidenced by mother opinion, up to one year of age or longer. According an infant feeding option (Williams, 2001). health worker opinion, and behaviour in to this concept, there is little risk that for pMTCT programmes where free infant for­ mula will ever be unavailable or inacces The sustainability of the option to exclu­ mula was provided (in India: Sarna, 2002; sible, and another person is available to sively breastfeed followed by early cessa­ South India AIDS Action Programme et al, feed the child in the mother’s absence, and tion and initiation of replacement feeding 2001; in Kenya: Oguta et al, 2001; in can prepare and give replacement feeds. can be questioned because many women Myanmar: Williams 2001; in South Africa: find it very difficult to sustain exclusive Bentley et al, 2002; Chopra et al, 2000; The main issue regarding the sustainability breastfeeding very long or to successfully Rollins et al, 2002; Seidel et al, 2000; in of replacement feeding with formula seems achieve early cessation of breastfeeding. In Tanzania: de Paoli et al, 2000 and 2002; in to be the cost of formula, especially for some instances, the supply or perceived Thailand: Talawat et al, 2002; in Zimbabwe: low-income women. Programmes that pro­ supply of breast milk may be lacking due Chitsike, circa 2000). One programme that vide free formula solve this problem for to breast problems or the mother’s percep­ was short on funding provided free infant women in the programme, but only for as tion that she does not have enough breast formula to a limited number of mothers, long as the programme continues to pro­ milk (in Uganda: Bakaki, 2002). but when the programme had to stop giv­ vide free formula. Two studies report diffi­ ing free formula, the mothers could not culties in sustaining replacement feeding Safe afford to purchase it (in Rwanda: Pham et when free formula was unavailable or al, 2002). Some studies conclude that free stopped being available (in India: Sarna, Definition: Replacement foods are cor formula gave the programme needed cred­ 2002; in Rwanda: Pham, et al, 2002). rectly and hygienically prepared and ibility as well as making replacement feed­ UNICEF’s decision to discontinue distribu­ stored, and fed in nutritionally adequate ing affordable (in Honduras: Baek et al, tion of infant formula made national scale­ quantities, with clean hands and utensils, 2002; in Zambia: Kankasa et al, 2002). up of a pMTCT programme difficult in Hon­ preferably by cup. This concept means that duras (Baek et al, 2002). the mother or caregiver has access to a Some studies found that modified animal reliable supply of safe water (from a piped milk, although less expensive than com­ Free infant formula does not guarantee an or protected well source); prepares replace mercial infant formula, was still too expen­ adequate supply, because some countries ment feeds that are nutritionally sound sive for some but not all mothers (in Kenya: report that many mothers who are sup­ and free of pathogens; is able to wash Oguta et al, 2001; in Myanmar: Williams, plied with free infant formula still run out hands and utensils thoroughly with soap

16 HIV and Infant Feeding and regularly boil the utensils to sterilise eral studies, however, show this is not al­ half the Botswana mothers in the study them; can boil water for at least 10 min ways the case. In a study in South Africa, sample cleaned the bottles by boiling. In utes for preparing each of the baby’s feeds; although a standardised scoop was used in India, participants in one study mentioned can store unprepared feeds in clean, cov preparing formula, the number of scoops the need to clean bottles but not sterilise ered containers and protect them from actually used varied considerably from one them (South India AIDS Action Programme rodents, insects, and other animals. to seven (Chopra et al, 2000). In India, many et al, 2001). thought that commercial infant formula Safety in replacement feeding involves was too expensive and gave diluted fresh more than the provision of adequate quan­ cow’s milk or diluted dried milk powder COUNSELLING AND tities of breast milk substitutes that are mixed with water instead. Sometimes milks INFORMED CHOICE contamination free. Caretakers must also were over- or under-diluted. Appropriate have access to clean water, equipment, and sugar and micronutrient supplements were Is counselling effective? environmental conditions and have the not added (South India AIDS Action ability to wash hands and clean and sterilise Programme et al, 2001). In Myanmar, rec­ Assessing the mother’s personal circum feeding utensils on a continuing basis. In ommending replacement feeding was con­ stances and making informed infant feed the case of modified animal milks, a sup­ sidered problematic because there was ing choices. The objective of counselling ply of sugar and micronutrients is also re­ considerable confusion between regular on HIV and infant feeding is to assess the quired. Mothers must have the knowledge powdered milk and infant formula (Will­ mother’s personal circumstances in order and skills to prepare replacement feeds, iams et al, 2003). to help her select the best feeding option which may require proper initial instruc­ for her and her baby, one that is accept­ tion and demonstration and periodic fol- General hygiene and water quality. Water able, feasible, affordable, sustainable, and low-up by counsellors or other health care quality is discussed in several of the re­ safe. Two of the reviewed studies specifi­ workers to ensure understanding. Finally, viewed studies. In Myanmar, reluctance to cally investigated whether counsellors ad­ safe replacement feeding requires family boil water for infants is considerable (Wil­ equately assessed the mother’s situation as and community support to overcome liams et al, 2003). A Zambia study found part of infant feeding counselling. In a stigma and discrimination and provide ac­ that only about half of the interviewed Zambia study of 42 counsellors, very few cess to health care if the infant becomes households boiled water, a third added (5-10) asked the mother if she had enough sick. chlorine, and the rest took no precautions money to buy formula; could obtain ad­ (Omari et al, 2002). However, a South Af­ equate supplies of water and fuel; or had In general, the studies we reviewed sug­ rica study found that most water was disclosed her HIV status to her partner, fam­ gest that it is difficult to meet all of the boiled, although usually for less than one ily, or friends (Kankasa et al, 2002). Al­ conditions necessary for safe replacement minute, considerably less than required though most of the counsellors in the feeding. For example, in a South Africa (Chopra et al, 2000). General hygiene var­ Kankasa study ‘somewhat’ explored the study, only 28 women (15%) met the four ied. In Myanmar, domestic hygiene, includ­ feasibility and acceptability of several feed­ locally defined conditions for safe replace­ ing hand washing, is often poor (Williams, ing options, exit interviews revealed that ment feeding (access to clean water, re­ 2001). In South Africa, 17 household ob­ most of the mothers felt the counsellors frigerator, fuel for boiling water, regular servations revealed that ‘nearly all’ homes had explained one option only. On the other source of income). A majority of women had on-site soap, water, sanitary facilities, hand, in a South Africa study, counsellors (15 of 28) planned to replacement feed formula tins, and bottles that appeared who had received specific training in lo­ even though they had less than ideal living clean (Chopra et al, 2000). cally defined conditions for safe replace­ conditions, and 10 of the 15 had only two ment feeding consistently asked HIV-posi- or fewer conditions for safe replacement Use of bottles. Because cups are easier to tive mothers about their infant-feeding feeding (Rollins et al, 2002). clean than bottles and artificial nipples, cup intentions and then discussed the options feeding is recommended for infants. A available in light of the mother’s personal Preparation and nutritional adequacy of Botswana study found that over 90% of situation (Rollins et al, 2002). replacement feeds. Infant formula should mothers who used formula gave it to their be prepared according to the guidelines to 0-6-month olds using a bottle rather than Additional studies found that counsellors have a nutritionally adequate feed. Sev­ a cup (pMTCT Advisory Group, 2001). About simply did not help clients make an in-

A Compilation of Programmatic Evidence 17 formed choice on infant-feeding options Poor counsellor knowledge of pMTCT. Sev­ causing problems for several reasons, in­ or attempt to assess the feasibility of dif­ eral studies found inadequate knowledge cluding: ferent options based on the client’s circum­ of pMTCT among health providers, often ■ Lack of counsellor trust in exclusive stances (in Honduras: Baek et al, 2002; in directly compromising informed infant- breastfeeding. A few studies men­ Rwanda: Pham et al, 2002; in South Af­ feeding counselling. In some cases, the rica: Chopra et al, 2000; Seidel et al, 2000; counsellors did not have correct informa­ tioned lack of belief in exclusive breastfeeding. In Tanzania, most coun­ in Tanzania: de Paoli et al, 2002; in Zam­ tion about the issues on which they were sellors were unclear about the mean­ bia: Kankasa et al 2002). providing counselling. Some Honduran providers lacked knowledge about the ing of exclusive breastfeeding. None had breastfed exclusively themselves; Effective counselling strategies and tech probability of transmission through others questioned its safety, did not niques. The comprehensive and successful breastfeeding (Baek et al, 2002). A study in believe it was possible, and/or said they South Africa counselling programme noted South Africa found through in-depth in­ would choose replacement feeding if above used several counselling techniques terviews that providers had limited knowl­ they were HIV-infected themselves (de that appeared to work: First, they edge of optimal infant feeding and MTCT Paoli et al 2002). Chopra et al (2000) recognised that explaining the advantages risks, leading to a universal recommenda­ found a similar disbelief in South Af­ and disadvantages of many infant feeding tion of formula feeding regardless of risk rica, where four of eleven counsellors options was too overwhelming for the cli­ (Chopra et al, 2000). In Tanzania, some did not believe the results of a study ent. Instead, they started with her feeding counsellors believed the risk of HIV trans­ (Coutsoudis et al, 2001) that showed intention; assessed its appropriateness mission through breastfeeding was greater that exclusive breastfeeding reduced given her circumstances and experience; than risk of diarrhoea or malnutrition from the risk of MTCT. and, if the feeding intention was not real­ not breastfeeding (de Paoli et al, 2002). istic, the counsellor used a visual tool ■ Counsellor bias against exclusive (decision tree) to help her determine a fea­ Poor counsellor knowledge of infant-feed- breastfeeding or replacement feeding. sible option. Counselling took place over ing norms and lack of guidelines. Some Numerous studies showed a counsel­ several sessions, not just one, so that the studies pointed to lack of provider knowl­ lor bias, sometimes in favour of replace­ infant-feeding options could be explored edge of national policies or guidelines. ment feeding and sometimes in favour in depth (Rollins et al, 2002). Another South None of the 11 providers interviewed in a of exclusive breastfeeding for HIV-posi- Africa study found that HIV-positive moth­ South Africa study had seen national or tive mothers. Counsellor bias in favour ers received information and advice from provincial guidelines on pMTCT (Chopra et of replacement feeding and against many different sources, not just counsel­ al, 2000). In Rwanda, providers incorrectly exclusive breastfeeding is reported in lors, which needs to be accounted for in believed that the pMTCT programme rec­ many studies (in Honduras: Baek et al, developing a counselling strategy (Bentley ommended replacement feeding over 2002; in South Africa: Chopra et al, et al, 2002). In Rwanda, counsellors noted exclusive breastfeeding for babies of HIV- 2002; in Swaziland: Vilakati and that mothers receive off-site counselling, positive mothers (Pham et al 2002). Stud­ Shongwe, 2001; in Tanzania: de Paoli and on-site counsellors need to know the ies from Rwanda (Pham et al, 2002) and et al, 2002; in Zambia: Kankasa et al, quality and content of the off-site coun­ Tanzania (Swartzendruber et al, 2002) con­ 2002). Other studies report a counsel­ selling (Pham et al, 2002). cluded that lack of guidelines and printed lor bias in favour of exclusive material had negatively affected counsel­ breastfeeding and against replacement Do counsellors provide accurate ling performance. feeding (in India: Sarna, 2002; in South and unbiased information? Africa: McCoy et al, 2002). Bias against Counsellor attitudes, beliefs, and experi abrupt cessation of breastfeeding is Counsellors should be a source of accurate ence can undermine counselling. As a study also reported as an issue in some stud­ information about HIV and its transmission, in Botswana found, inadequate knowledge ies (in Nigeria: Isiramen, 2002; in Tan­ prevention, and care. In this role, the of HIV and pMTCT can erode counsellor zania: de Paoli et al, 2002). counsellor’s knowledge, attitudes, beliefs, confidence (pMTCT Advisory Group 2001). ■ Lack of counsellor trust in expressing and experience are important factors in the However, even if provider knowledge is up- milk and/or heat treating breast milk. quality of counselling. to-date, it can run counter to provider at­ Counsellors have not easily accepted titude, belief, and personal experience, thus

18 HIV and Infant Feeding heat-treating breast milk as an infant- the acceptability, affordability, feasibility, the amount of training needed, the mini­ feeding option. Providers in South Af­ and sustainability of the mother’s infant mum required content, methods and tim­ rica (Chopra et al, 2000) and Tanzania feeding choice, several studies recommend ing for training, mentoring and retraining, (De Paoli et al, 2002) were not con­ that they be included in counselling from and by whom. A multi-country Horizons vinced of its feasibility or effectiveness the start (in Rwanda: Pham et al, 2002; in assessment notes that the training and fol- and felt it would be very difficult to Tanzania: de Paoli et al, 2002; in Zambia: low-up training of counsellors seem to have explain to mothers. In Zambia, Kankasa NDHMT, 1999; Bond and Ndubani, 1999). a positive impact on pMTCT infant feeding et al (2002) found that although pro­ programmes (Rutenberg et al, 2002). While viders demonstrated good knowledge Help clients successfully implement proper some of the studies describe what they did of expressed heat-treated breast milk, cessation of exclusive breastfeeding. As to train counsellors, they offer little evi­ they rarely ascertained the client’s spe­ detailed above in the sub-section on ces­ dence on whether or not it was worth it cific circumstances or recommended sation of exclusive breastfeeding, proper and which aspects of the training approach expressed heat-treated breast milk. cessation of breastfeeding by HIV-positive worked well (Kankasa et al, 2002; Hope mothers is very challenging and not widely Humana et al, 2002; pMTCT Advisory Group, Follow-up support of infant feeding achieved (for example, see Botswana: 2001; Rollins et al, 2002). options pMTCT Advisory Group, 2001; in Nigeria: Isiramen, 2002; in Zambia: NDHMT, 1999; Once a mother implements an infant feed­ Bond and Ndubani, 1999; in several Asian THE ROLE OF COMMUNITY, ing strategy, she often encounters difficul­ countries: Preble and Piwoz, 2002). A study PARTNER, AND FAMILY ties that can lead to non-adherence if not in Zambia found that despite behaviour SUPPORT addressed. The reviewed documents note change communication and counselling in­ several ways counselling can help support terventions, HIV-positive mothers were still Community stigma and the chosen infant-feeding method: breastfeeding at 12 months rather than discrimination stopping at 6, as recommended (NDHMT, Help clients replacement feed correctly. In 1999; Bond and Ndubani, 1999). In Tanza­ Some of the summarised documents note countries where replacement feeding is not nia, counsellors gave incorrect advice about that pregnant women of HIV-positive or a traditional practice, counselling on the early cessation and lacked knowledge of unknown HIV status express fear of stigma preparation, storage, and giving of formula how to advise mothers to feed an infant and negative discrimination against HIV by is essential (pMTCT Advisory Group, 2001). after cessation (de Paoli et al, 2002). The partners and community (in Botswana: Tlou Household observations in South Africa did discussion above in the sub-section on ces­ et al, 2000; in India: South India AIDS Ac­ find that caregivers knew not to save un­ sation includes factors that support or tion Programme et al, 2001; in Rwanda: finished formula, despite cost, thus reduc­ hinder early or abrupt cessation, reasons Pham et al, 2002; in Tanzania: de Paoli et ing the risk of contamination (Chopra et given for early cessation, and techniques al, 2000; Swartzendruber et al, 2002; in al, 2000). Monitoring the proper prepara­ programmes use to address this challenge. Zambia: Bond et al, 2002 and NDHMT, tion of infant formula is already being done 1999; Bond and Ndubani, 1999). Fewer in Zambia (Kankasa et al, 2002). Training of health workers and studies report evidence of actual stigma or counsellors discrimination (in India: South India AIDS Monitor adherence to the infant-feeding Action Programme et al, 2001; in Tanza­ choice to help address difficulties. The Although it is generally believed that in­ nia: de Paoli et al, 2000; in Zambia: Bond monitoring of adherence applies equally to creasing the competency and motivation et al, 2002). One study reports that HIV- exclusive breastfeeding (in South Africa: of counsellors and other health care work­ positive mothers said they did not suffer Chopra et al, 2000; in Zambia: pMTCT Ad­ ers in interpersonal communication, includ­ any discrimination at all as a result of not visory Group 2001) and replacement feed­ ing counselling on all feeding options and breastfeeding, although caretakers in the ing (in Botswana: Shapiro et al, 2003; in lactation management, is a vital part of the same community were of the opinion that Cote d’Ivoire: Leroy et al, 2001). infant-feeding component of pMTCT the community did discriminate against programmes, surprisingly little evidence mothers who didn’t breastfeed (in South Partner and family involvement. Since was found about how this can best be Africa: Chopra et al, 2000). partners and family can greatly influence achieved. There is little documented about

A Compilation of Programmatic Evidence 19 Many of the same documents and others Partner and family support infant feeding. One Botswana study rec­ report a simultaneous and woeful lack of ommends that infant-feeding decisions be knowledge about HIV and infant feeding Several of the reviewed programmes re­ made in consultation with the father and in the community (in Botswana: pMTCT port a low or problematic level of partner maternal grandmother (Tlou et al, 2000). Advisory Group, 2001 and Tlou et al, 2000; and family support for HIV-positive moth­ Another Botswana study proposes that in Tanzania: de Paoli et al, 2000 and ers (in Botswana: Tlou et al, 2000; in Cote families should be more involved and sup­ Swartzendruber et al, 2002; in Zambia: d’Ivoire: LeRoy et al, 2002; in Zambia: Bond portive of infant feeding (pMTCT Advisory Bond et al, 2002; NDHMT, 1999; Bond and et al, 2002). In the reviewed programmes, Group, 2001). A Uganda study recommends Ndubani, 1999; Hope Humana, et al, 2002). this lack of family support is associated with that men be involved in the counselling negative discrimination by the family process from the time of antenatal care Will an increase in community awareness against HIV (in India: South India AIDS Ac­ (Bakaki, 2002). However, only one docu­ decrease stigma? Several studies that re­ tion Programme et al, 2001; in Zambia: ment evaluates an intervention that in­ ported evidence of either the fear of stigma Bond et al, 2002), and/or with women who creased partner involvement: Zambia’s or stigma itself, as well as low public knowl­ fear discrimination and so do not tell their Ndola project reports that an integrated edge of HIV and infant feeding in the same partners or family they are HIV-positive (in approach involving partners from the be­ community, suggest that increased com­ Botswana: Tlou et al, 2000; in Rwanda: ginning was successful in building support munity knowledge of HIV would decrease Pham et al, 2002; in Tanzania: de Paoli et for the mothers (NDHMT, 1999; Bond and stigma and discrimination (in Botswana: al, 2000; in Zambia: Hope Humana, et al, Ndubani, 1999). Tlou et al, 2000; in Tanzania: Swartz­ 2002). In Cote d’Ivoire, lack of partner in­ endruber et al, 2002; in Zambia: NDHMT, volvement or family support was associ­ 1999; Bond and Ndubani, 1999; Hope ated with failed formula feeding by HIV- BEHAVIOUR CHANGE Humana, 2002). Only one study actually positive mothers (Leroy et al, 2002). Two COMMUNICATION (BCC) tested the idea; an area that implemented studies report that wives are afraid to tell a public education and improved pMTCT their partners they are HIV-positive, but not everal behaviour change communi­ services programme was reported to have their mothers (in Botswana: Tlou et al, 2000; S cation issues were addressed in the reduced stigma (in Zambia: Hope Humana in Rwanda: Pham et al, 2002). In Tanzania, studies reviewed, outside the context of et al, 2002). In general, these documents non-disclosure of HIV-status to husbands counselling, including public education note the need for behaviour change com­ was a barrier to formula feeding, particu­ campaigns, educational materials (print and munication strategies, concerted public larly given the high cost of formula (de Paoli audio-visual), and counselling job aids for education campaigns, counselling job aids, et al, 2000). low literacy audiences. and educational materials for low-literacy audiences that address the complex issues In some places, reluctance to be tested for Components of effective public education surrounding pMTCT and infant feeding. HIV and fear of discrimination seem to be programmes. The reviewed studies offered related to lack of confidentiality, especially little documented evidence or concrete However, some studies indicate that in­ by health workers (in Botswana: Tlou et al, suggestions about the components of ef­ creased public knowledge about HIV is not 2000; in India: South India AIDS Action fective public education programs. A always associated with reduced stigma and Programme et al, 2001). Gender inequality Botswana study noted that community el­ discrimination. A study in South Africa re­ remains the major underlying force driv­ ders lacked knowledge about pMTCT that ported substantial stigma despite high pub­ ing many of these problems, according to should be improved (Tlou et al, 2000). A lic awareness about HIV (Chopra et al, some studies (in Zambia: NDHMT, 1999; review of a Tanzania pMTCT programme 2000). A study in India found significantly Bond and Ndubani, 1999; Hope Humana noted the need for more community input more community knowledge about HIV in et al, 2002; Rutenberg et al, 2002). to the programme design (Swartzendruber urban areas than in rural areas, even though et al, 2002). A Zambia document suggested a high degree of community and family Many reports call for efforts of one kind or having more community discourse as part stigma was present in both kinds of areas another to increase partner and family sup­ of the community strategy (NDHMT, 1999; (South India AIDS Action Programme et al, port for HIV-positive wives/mothers in Bond and Ndubani, 1999). 2001).

20 HIV and Infant Feeding Need for behaviour change interventions. positive clients (in Zambia: Bond et al, list to help with the AFASS assessment of As noted elsewhere in this synthesis, many 2002). infant-feeding options in Uganda. Rollins studies highlighted the need for behaviour et al (2002) conducted a study in South change interventions to address lack of Few studies reviewed included community- Africa where a visual tool was used to aid knowledge or misunderstanding of HIV/ level information, education, and commu­ in selecting an infant-feeding option. A AIDS transmission and prevention in gen­ nication interventions. Those that did gen­ simple chart (decision tree) was used to fo­ eral, as well as MTCT (in Asian countries: erally focused on other interventions with cus the counselling discussion on home, Preble and Piwoz, 2002; in South Africa: the same population (counselling), and they personal circumstances, and family expec­ Chopra 2000; in Swaziland: Vilakati and were not designed to specifically measure tations. The study objective was to test a Shongwe, 2001) and infant feeding in par­ the effect of the behaviour change and modified WHO/UNICEF HIV and Infant ticular (in Uganda: Matovu et al 2002) communication interventions versus other Feeding Counselling (HIFC) course approach among women clients, regardless of HIV or interventions. For example, behaviour to give more client-centred guidance on pregnancy status. Some studies noted that change and communication was reported selecting an infant-feeding option, because all pregnant women need infant-feeding to be a prominent component of the Ndola it was known that presenting the six HIFC information, education, and communica­ Demonstration Project, along with other options to clients was overwhelming. The tion. For instance, focus groups with ur­ interventions including the use of radio study reported that clients seemed satis­ ban community representatives in a Zim­ spots, print materials, and community ‘am­ fied with the counselling approach. babwean study (Israel-Ballard et al 2001) bassadors against AIDS.’ Infant-feeding found that participants felt strongly that counselling is the stated centrepiece inter­ Several assessments of national pilot information on all feeding options should vention of the project. programmes mention, either under find­ be given to all mothers, not just HIV-posi- ings or recommendations, the need to de­ tive mothers. Role of and need for information, educa velop or strengthen information, education, tion, communication, and other support and communication strategies that address The behaviour change and communication materials for infant feeding. A number of multiple issues related to HIV and infant needs were not limited to women clients. studies pointed to the need for and/or lack feeding with clear and targeted messages. Studies also noted the need for behaviour of infant feeding information, education, A focus on behaviour change and the im­ change and communication interventions and communication materials to support portance of educational materials for aimed at the partner, families, and com­ infant-feeding health personnel, counsel­ mothers and counselling job aids for health munity in general (in India: South India ling protocols (in Rwanda: Pham et al 2002), workers is emphasised (in Rwanda: Pham AIDS Action Programme et al, 2001) to de­ and job aids. For the latter, Matovu et al et al, 2002; in Tanzania: Swartzendruber crease stigma and increase support for HIV- (2002) developed an infant-feeding check­ et al, 2002; in Zambia: Kankasa et al, 2002).

A Compilation of Programmatic Evidence 21 CONCLUSIONS AND IMPRESSIONS

he programmes reviewed in this replacement feeding. We interpret the evi­ tive mothers would result in spillover. Al­ T compilation show that since the dence presented here to indicate that the though several programme documents ex­ development and dissemination of the AFASS characteristics of replacement feed­ pressed fear that spillover might occur, only 1998 guidelines on HIV and infant feed­ ing (accessibility, feasibility, affordability, two of the reviewed programmes specifi­ ing, much valuable work in the area of HIV sustainability, and safety) have a major in­ cally studied this issue: the Botswana study and infant feeding has been accomplished fluence on the choice and successful prac­ found evidence of spillover, while the Hon­ and documented in some way. Several tise of replacement feeding. The reviewed duras study found none. The pMTCT site in countries now have policies, guidelines, and experiences indicate that replacement Honduras attributed this to the careful training programs in place, and in many feeding is often not AFASS, especially for standards established for counselling HIV- pMTCT facilities HIV-infected mothers are poor women. Many programmes reported positive women, but these differences may receiving counselling, care, and follow-up that replacement feeding was not accept­ also be attributable to the cultural accept­ support. However, many difficult problems able to mothers because they feared stigma ability and relative prevalence of non­ remain to be solved. The findings reported and discrimination, which they felt was di­ breastfeeding in Honduras. The lack of at­ here underscore the challenges that still rected against mothers who did not tention given to the issue of spillover in exist in providing and applying clear glo­ breastfeed. Generally speaking, especially most of the documents reviewed may in­ bal guidance on HIV and infant feeding. in Africa, breastfeeding was thought to be dicate that spillover is not as big a prob­ Perhaps the biggest challenge now is the necessary for the baby’s health, and not lem as originally thought. In light of the scaling-up of successful pMTCT programs. breastfeeding was highly associated with continuing concerns, however, that have It is our belief that the most appropriate the mother being HIV-infected. Advice been raised by many infant-feeding spe­ response requires that in all maternal and from counsellors and health workers to give cialists, we urge programmes to strengthen child (MCH) facilities mothers are tested, replacement feeding was also identified as efforts to reduce the possibility of spillover receive balanced and quality counselling, a major influence on mothers in many of and encourage future research to specifi­ appropriate pMTCT services, and follow-up the documents. Such advice, however, was cally measure and address this issue. support on HIV and infant feeding. In this not always based on an adequate assess­ conclusions section, we summarize some ment of the AFASS circumstances of Home-prepared formula of the major findings from the material mother and baby. Several studies reported reviewed but also broaden our comments counsellor bias, underscoring a need for Although home-prepared formula based on to include our own views and experiences strengthening the counsellor’s knowledge modified animal milk is one of the two re­ that contribute to the interpretation of that about infant-feeding options, risk assess­ placement feeding options suggested for material and the resulting conclusions in ment, and counselling skills. HIV-positive mothers, not many select this this section. option. Our own experience plus the little Spillover of commercial infant evidence presented in the studies reviewed Replacement feeding formula here suggest that such non-selection ap­ pears to be true not only where free com­ The evidence clearly finds that women who From the start of the first programmes ad­ mercial formula is provided to HIV-posi- know that they are HIV-positive are much dressing HIV and infant feeding, there were tive mothers, but also in countries that do more inclined to replacement-feed than concerns that efforts to promote replace­ not provide free formula. UNICEF’s deci­ women who do not know their HIV status. ment feeding among women who are HIV- sion not to scale-up their programme of The choice and successful practise of re­ positive would ‘spill over’ to mothers who financial support for the procurement of placement feeding, however, varies greatly were HIV-negative or of unknown HIV sta­ free formula following the assessment of a between and even within countries. The tus, causing a decline in breastfeeding rates. number of pilot pMTCT programmes and studies reviewed do not help us to under­ There was particular concern that the pro­ the decision by several governments not stand how long women are able to sustain vision of free formula targeted to HIV-posi- to initiate or continue subsidising infant

22 HIV and Infant Feeding formula could generate more demand for practices, while increasing child survival in and practical guidance about the process, home-prepared formula. In the pilot coun­ the general population. timing, and duration of cessation, as well tries where UNICEF has phased out free as how and what to feed the child during formula, HIV-positive mothers may decide Cessation of breastfeeding the transition and thereafter. Programs to switch to home-prepared formula given need to provide better counselling on this the perception that it is a less expensive topic and more intense, targeted, and The documents reviewed make clear that alternative. It is our opinion, just as with timely support for the mother during and early cessation of breastfeeding is a major commercial infant formula, that counsel­ challenge for HIV-positive mothers who after the transition. lors should be trained to give better guid­ choose breastfeeding as the option. There ance concerning the adequate preparation is inadequate study of how to transition Wet nursing, heat-treating breast and use of home-prepared formula as a from exclusive breastfeeding to exclusive milk, and milk banks replacement feeding option and ensure replacement feeding while minimising the that it is AFASS before recommending it risks associated with mixed feeding. There None of the reviewed studies reports a sig­ over exclusive breastfeeding. is little or no information that demonstrates nificant number of HIV-positive mothers that early and abrupt cessation is feasible choosing any of the so-called ‘breast-milk Exclusive breastfeeding and/or safe. The reviewed studies that ad­ feeding options’: wet nursing, heat treat­ dress this issue indicate abrupt cessation, ment of breast milk, or milk banks. Moth­ Reported rates and duration of exclusive within a few days, is not feasible for most ers are generally unfamiliar with wet nurs­ breastfeeding are relatively low, regardless mothers, can be unpleasant, and can even ing. The AFASS of expression and heat of the HIV status of mothers. Mixed feed­ have dangerous health consequences for treatment of breast milk has not been ing is far more prevalent. HIV-positive both mother and infant. There has been widely tested. Milk banks do not exist in mothers who select to exclusively confusion about the meaning and feasi­ most countries. To date, counselling of HIV- breastfeed apparently find it difficult to bility of the prevailing guidance on early positive mothers generally pays little at­ give only breast milk and frequently add and abrupt cessation. Evidence indicates tention to any of these options. It is not other foods or liquid (resulting in ‘mixed that the success of a mother’s intent to stop clear to us from the reviewed studies or feeding’). This tendency to engage in mixed exclusive breastfeeding early depends, in elsewhere what conditions could facilitate feeding underscores the importance of ac­ part, on access to replacement foods. Ac­ the selection and success of these options. tively promoting exclusive breastfeeding ceptability, however, may be even more More formative research, and possibly op­ among the general population and suggests important than access. Continued erational research, in this area is needed to the need to provide further support to HIV- breastfeeding, into the second year of life give better guidance on how practical these positive women who choose exclusive or longer, is still the norm in many of the options are for HIV-positive mothers and breastfeeding. HIV-positive mothers should countries, so mothers may find it particu­ what factors and support are needed for be counselled not only on the importance larly difficult to deviate by stopping at 6 mothers to succeed with each. of exclusive breastfeeding but also on how months or earlier, as is generally recom­ to deal with pressure from relatives and mended. Some of the studies indicate, how­ AFASS others to only partially breastfeed. Studies ever, that women have found it easier and from South Africa and Zimbabwe showed more culturally acceptable to stop Non-breastfeeding methods of infant that exclusive breastfeeding rates can be breastfeeding at an early age (3 or 4 feeding by HIV-positive mothers are cur­ increased in the HIV-positive population. months) than to never initiate rently recommended by the World Health We suggest that programmes should not breastfeeding. All of these considerations Organization (WHO) if they are acceptable, only aim at increasing exclusive should be discussed with the mother dur­ feasible, affordable, sustainable, and safe breastfeeding rates among HIV-positive ing counselling related to the AFASS of in- (AFASS) for the particular mother-baby pair mothers who choose to breastfeed, but fant-feeding options. being considered. The documents reviewed among all mothers. This could further re­ provide a wealth of information on the re­ duce the pressure that HIV-positive moth­ Greater understanding is needed on how ality faced by HIV-positive mothers with ers feel when deviating from what is con­ to accomplish early cessation in different respect to the AFASS of infant-feeding sidered to be ‘culturally normal’ feeding cultures. The present guidelines lack clear options. Programme evidence and the ex-

A Compilation of Programmatic Evidence 23 periences of HIV-positive mothers has con­ time event, nor should it only occur dur­ The reviewed documents do not clearly tributed to the development of more pre­ ing post-test counselling when a women show whether there is real discrimination cise definitions of the five AFASS factors may be less receptive and unable to focus against HIV-positive women who deviate presented in the 2003 international guide­ adequate attention on this issue. Counsel­ from common infant-feeding practises or lines on HIV and infant feeding (WHO et ling and support that address cultural re­ only the fear of HIV-positive women that al, 2003), and it is thought that the cur­ alities and the experiences of individual they will be ‘discovered’ because of their rent review will contribute to future mothers, both successes and failures, should infant-feeding choice and subsequently guidlines. It is now essential that the train­ be provided during multiple sessions. discriminated against. No documentation ing of health workers and counselling of of actual stigma and discrimination (shun­ HIV-positive mothers include an assessment To improve the counselling and support to ning, rejection, or violence) were reported of the reality of local and individual situa­ HIV-positive mothers, clear national and to be directly associated with infant feed­ tions regarding these factors. We believe local guidelines on counselling must be ing, although discrimination against that the careful review with HIV-positive developed, including recommendations on women because they were HIV-positive has women of the AFASS of available options when and how to counsel mothers and been documented. This does not necessar­ is the only way to provide adequate guid­ what follow-up support is required. These ily mean that discrimination due to infant- ance concerning infant feeding, in combi­ guidelines should also clearly stipulate feeding practice is not happening, but it nation with the provision of adequate fol- which infant-feeding options are locally does raise the issue of whether the gener­ low-up and support. AFASS and therefore which should be in­ ally perceived prevalence of stigma and its cluded (or at least prioritised) in counsel­ repercussions are due to actual discrimi­ Counselling ling HIV-positive women. They should be nation or fear of it. The issue of fear, in and accompanied by a realistic human resource of itself, raises the question of how preva­ The studies reviewed indicate that the qual­ capacity development plan outlining who lent, serious, and widespread the repercus­ ity of counselling given to HIV-positive should be responsible for the counselling, sions might actually be. mothers makes a difference. Counsellors training, and support that should be pro­ influence mothers’ decisions and practices vided, as well as plans for monitoring and To address these issues, we propose three related to infant feeding, as well as their evaluating the impact of the counselling. strategies. First, educate the population at success in following international and na­ Adequate counselling and client materials large about infant feeding, including the tional recommendations or guidance. In should be made available to guide the importance of exclusively breastfeeding many cases, however, counsellors do not counselling process and assist individual and the relative risk of HIV transmission by adequately address the AFASS conditions HIV-positive women in selecting, under­ HIV-positive mothers during pregnancy, of feeding options and, in addition, often standing, and successfully carrying out the birth, and breastfeeding. The promotion of manifest a clear bias towards one feeding best option. Counselling should also include exclusive breastfeeding among the general option or another. The reviewed documents information on the safe and timely transi­ population must be included in this strat­ also seem to indicate that where counsel­ tion to other AFASS options, should the egy. If exclusive breastfeeding were to be­ lors did receive adequate training and sup­ need arise, as well as the appropriate and come more widely accepted and possibly port, the quality of the counselling im­ timely introduction of complementary even the ‘social norm’, then those HIV-posi- proved. According to a study in South Af­ foods by six months of age. tive women who have no realistic choice rica, the success of counselling improved other than to breastfeed will have less dif­ when the counselling process was better Community attitudes and stigma ficulty dealing with pressures to introduce structured and when the infant-feeding other foods and liquids at an early age. The options that are most AFASS in a given The people closest to an HIV-positive second strategy is to provide counselling community were identified and discussed mother—her partner and family—are cru­ to relatives and key family members of HIV- first, rather than a complete review of all cial to the acceptability of whatever feed­ positive mothers in order to create a more options currently recommended by WHO. ing option she chooses. However, only one positive and supportive environment for of the programmes reviewed here (Hope any of the infant-feeding choices that HIV- From the programmes reviewed in this Humana et al, 2002) specifically targeted positive women make. The last strategy is compilation, it is clear that counselling on relatives and families or actively included to adequately address the issues of AFASS, HIV and infant feeding should not be a one­ them in the counselling on infant feeding. stigma, and discrimination as part of the

24 HIV and Infant Feeding counselling of HIV-positive women, pro­ Furthermore, our worldwide search for terested readers, most original source docu­ viding guidance on how to deal with pos­ documents indicates that systematic evalu­ ments are available at www.qaproject.org. sible repercussions of stigma and discrimi­ ations of HIV and infant-feeding Contact information for editors, research­ nation. programmes are rare. Efforts should be ers, authors, and organisations responsible made to (1) encourage evaluations, in ad­ for preparing the source material is ap­ Documenting experiences dition to more effective documentation and pended to encourage future communica­ dissemination of experiences by individual tion; continuing dialogue; and the sharing While this review provides valuable insights programmes and (2) support continued of materials, ideas, and lessons learned be­ into programmes on HIV and infant feed­ efforts to identify and creatively share this tween projects, countries, and regions of ing, many questions remain about the information. the world. AFASS of different feeding options and how best to counsel and support HIV-positive In order to facilitate additional analysis and women and their children with the limited review of the documents in this compila­ human resources presently available. tion, and to support future research by in­

A Compilation of Programmatic Evidence 25 SUMMARIES BY STUDY, WITHIN COUNTRIES

BOTSWANA

on Infant Formula Feeding for Mothers. The fants using semi-structured interviews in Evaluation of Infant Feeding programme was formally evaluated in 1999 four programme and four non-programme Practices in pMTCT and again in 2001(Willumsen and Rollins, districts. In each study district, four facili­ (pMTCT Advisory Group, 2001) 2001). ties (clinics and hospital) were purposefully selected to provide an adequate number Document title The Botswana pMTCT programme has the of infants and a range of environs (urban, Evaluation of Infant Feeding Practices by following components: large village, rural). Interviews were also Mothers at pMTCT and non-pMTCT Sites in Botswana held with health staff in these facilities. A ■ Mothers receiving antenatal and post­ sub-sample of mothers still in the postna­ Authors natal care in the programme have their tal ward (HIV-positive and -negative) of pMTCT Advisory Group HIV status measured. programme hospitals was interviewed. Data were collected by nursing students after Institution ■ Free ZDV is given to all HIV-positive three days of training. The data collection pMTCT Reference Group, Botswana mothers from 34 weeks pregnant to Food and Nutrition Unit, Family Health delivery and to their newborns from instruments and procedures were reviewed Division, Ministry of Health Botswana by the committee and consultants, pilot birth to 4 weeks of age. Date 2001 tested using the nursing students after their ■ Recommendations to HIV-positive training, and modified appropriately. Field Country Botswana (HIV+) mothers: Replacement feed with work was done June 25–August 15, 2001. Document type Draft report formula (by cup) and avoid breastfeeding. HIV+ mothers who do Source Authors A total of 776 caretakers were interviewed: not want to formula feed are advised 283 in non-programme sites and 493 in to breastfeed exclusively for 3-4 programme sites (226 HIV-positive and 267 Background months followed by abrupt cessation HIV-negative). Caregivers were asked about of breastfeeding. feeding practice in the previous 24 hours, The Government of Botswana (GOB) started during the first week of life (focussing par­ a programme to prevent mother-to-child ■ Recommendations to HIV-negative ticularly on the first feeds) and between 1 transmission (pMTCT) in April 1999, initially (HIV-) and unknown HIV status: Exclu­ and 6 weeks (first immunisation visit) of in two districts (including all primary care sive breastfeeding for 4-6 months. life. In addition, interviews were held with health care clinics and the district referral ■ 59 mothers in postnatal wards at hospital). In July 2000, six additional dis­ HIV-positive mothers are given free programme hospitals, 48 health staff at tricts were added. The Harvard Aids Insti­ formula for 6 months (recently ex­ non-programme sites, and 90 health staff tute and GOB are testing the efficacy of tended to 12 months), but no feeding at programme sites. ZDV (zidovudine) in combination with NVP equipment. (nevirapine). CDC and GOB are developing Data were analysed by the HIV status of the voluntary counselling and testing (VCT) Methodology the mothers, the age of the child, and ru- component of the programme. The ral/urban. All mothers in the programme programme included counselling on infant The study was directed by the pMTCT Ad­ group were identified as either HIV-posi- feeding options, and developed Infant visory Group, a committee of persons from tive or HIV-negative. The HIV-status of all Feeding Guidelines for the Health Worker key Botswana agencies, with technical as­ mothers in the non-programme group was (revised July 2000) and two information sistance from two international consultants. “unknown”, meaning unknown to the booklets: Infant Formula Feeding Guide for Data on feeding practice were obtained study. The mothers in the non-programme the Mother and Questions and Answers from mothers and other caretakers of in­

26 HIV and Infant Feeding group may or may not have known or few breastfeeding HIV-positive mothers ing were asked if they had ever run out of thought they knew their HIV status, but were doing so exclusively at the time of formula, 32% (47 of 153) with children 0­ the study had no information about this. the interview, resulting in a pooled EBF rate 6 months old said yes, and 47% (27 of 63) HIV-positive mothers in the programme of 21% for all programme mothers com­ with children 7-12 months old said yes. group were further divided into mothers pared with 37% in the non-programme who chose to formula feed and those who group. Generally mothers introduced for­ Cessation of breastfeeding not a success chose to exclusively breastfeed. The analy­ mula at a very early age rather than other story: Most HIV-positive mothers who sis assumed that the ratio of HIV-positive milks (Row 6, Table 1). Thus, the breastfed did not recall receiving advice mothers to HIV-negative mothers was the programme’s successful efforts to increase about feeding after 6 months (23/35 = same in the programme and non- formula feeding among HIV-positive moth­ 66%). Most who had stopped by the time programme groups. ers apparently had a spillover effect on the of the interview had done so by gradually HIV-negative mothers (and possibly on HIV- changing to other milks (7/13 = 54%). Results positive mothers who decided to Compared to mothers of older children (7­ breastfeed), causing them to fail to 12 months), mothers of younger children (0-6 months) who stopped breastfeeding This study produced a mountain of data; breastfeed exclusively. This was true for its report presents the results in 33 tables both urban and rural mothers, although no were more likely to have suffered engorge­ ment (4/8=50% versus 1/5=20%), breast and three graphs. There are many insights HIV-positive urban mothers decided to inflammation (3/8=38% versus none), and in these results; we summarise the impor­ breastfeed. tant ones here. criticism from own mother for stopping (1/ The programme appears to reduce the 8=13% versus 1/5=20%). The programme appears to increase for­ number of children aged 7-12 months fed Poor staff knowledge and counselling: The mula feeding among HIV-positive moth­ only home-made porridge: 52% of non- ers: Most HIV-positive mothers in the programme mothers fed their 7-12 month report says there was poor knowledge of HIV and MTCT among trained and untrained programme decided to formula feed (Row olds only home-made porridge (nothing staff at both programme and non- 1, Table 1), and nearly all the children (90% else) the day before the interview, com­ in urban areas and 87% in rural areas) were pared to 27% in the programme group programme sites. Many did not feel confi­ dent in counselling on infant feeding prac­ exclusively formula feeding at the time of (Row 13, Table 1). The mothers in the tices. the interview if they were 0-6 months of programme group used more commercial age (Row 5, Table 1), or were given for­ infant food. mula as the main milk at interview if they Conclusions and were 7-12 months of age (Row 10, Table Most mothers use a bottle to feed formula: recommendations of authors 1). The data indicate that this was a result Over 90% of mothers who used formula of the programme because the rates of for­ gave it to their 0-6 month olds using a The report includes numerous recommen­ mula feeding in the pooled (HIV-positive bottle. This is true in both programme and dations of relevance to pMTCT-related and HIV-negative) programme group were non-programme groups (row 7, Table 1). training, programme support, monitoring, much higher than in the non-programme policy, and community awareness: group. More rural than urban “formula” mothers cleaned the bottle by boiling: About half Training: 1) Training should include the role Most HIV-negative women in the of all mothers who formula fed cleaned the of pMTCT programme beyond the mother’s programme decided to breastfeed: 92% bottle by boiling (row 8, Table 1). In the choice of infant feeding method, to sup­ decided to breastfeed (Row 3, Table 1). non-programme group, 58% of rural port her infant feeding practices and moni­ mothers and 42% of urban mothers said tor these in order to manage difficulties. Spillover of formula feeding among HIV- they regularly use this method, and in the 2) Training on (and demonstration of) negative mothers: For children aged 0-6 programme group the figure is 68% in ru­ preparation, storage and giving of formula months, only 20% of the HIV-negative ral mothers and 49% in urban mothers. feeds and continuing support for mother breastfeeding mothers in the programme should be strengthened. 3) Support struc­ were doing so exclusively at the time of Formula not always available: When HIV- tures need to be devised with extra care the interview. Similarly, only 30% of the positive mothers who were formula feed­ paid to intervention messages to protect

A Compilation of Programmatic Evidence 27 HIV-negative mothers and mothers of un- Table 1. A Few Key Results known status from “spillover” of formula feeding. 4) Staff skills to promote and sup- Non Programme Programme port exclusive breastfeeding (including HIV Status Unknown HIV – HIV + Pooled avoidance of pre-lacteal feeds), for HIV- Children 0-6 months positive women who choose to breastfeed 1. Sample size 186 157 158 315 and for HIV-negative mothers and moth­ 2. Decided to formula feed 16 (9%) 12 (8%) 141 (89%) 153 (49%) ers of unknown status should be developed. 3. Decided to breast feed 169 (91%) 144 (92%) 15 (9%) 159 (50%) 5) Training programme for infant feeding practices should be revised and developed, 4. Received BF within 1 hour 63 (34%) 49 (31%) 25 (16%) 74 (23%) and include training for all health workers 5. EFF of those choosing FF2 14 (88%) 9 (6%) 139 (99%) 148 (97%) on optimal complementary feeding. 6) Ap- 6. EBF of those choosing BF2 60 (37%)3 27 (20%)3 3 (30%)3 30 (21%)3 propriate strategies and training for health 7. Use bottle to give formula 2 56 (93%)3 45 (88%)3 129 (91%)3 174 (91%)3 workers to support HIV-positive mothers 8. Clean bottle by boiling 29 (48%)3 34 (67%)3 78 (55%)3 112(58%)3 in the early cessation of breastfeeding Children 7-12 months should be devised and developed. 7) Nu­ 9. Sample size 97 90 68 158 trition training should be integrated with 1 other programmes (IMCI, BFHI), in the con­ 10. Main milk formula 9 (9%) 10 (11%) 29 (43%) 39 (25%) text of HIV, to optimise child survival (avoid 11. Main milk breast1 65 (67%) 69 (77%) 7 (10%) 78 (49%) MTCT, malnutrition and diarrhoeal illness 12. Use bottle to give formula1 56 (93%)3 45 (88%)3 129 (91%)3 174 (91%)3 and optimise development). 8) Staff knowl­ 13. Home-made porridge only1 47 (52%)3 21 (25%)3 19 (66%)3 40 (27%)3 edge of HIV, MTCT and counselling skills in order to effectively support mothers need Notes: 1. Feeding practice yesterday. 2. Feeding practice continuously between birth and interview date in 0-6 month olds. 3. Denominator less than sample due to missing data. to be improved.

General programme support: 1) Support of for health workers from district manage­ needs to be reviewed and disseminated. 3) all infant feeding practices, antenatally and ment team should be instituted. Cessation of breastfeeding should not be in the early postnatal period (BFHI) should recommended for an infant already in­ be strengthened. 2) Formula feeding prac­ Monitoring: 1) The tracking of “spillover’ fected with HIV. The (decreasing) risks of tices should be optimised. 3) All infant feed­ by monitoring infant feeding practices on continued exposure and transmission ing practices, not just mothers’ initial choice a regular basis should be considered. 2) The through breastfeeding need to be weighed should be monitored. 4) Efforts need to be morbidity costs of formula feeding prac­ against the risks of diarrhoea and malnu­ made to increase EBF rates among moth­ tices need to be investigated. 3) A com- trition due to cessation of breastfeeding, if ers of unknown status and HIV-negative munity-based study of the mothers who safe replacement milks are not available, mothers. 5) Mothers access to skilled coun­ do not enroll or attend the pMTCT affordable and acceptable. 4) HIV-positive sellors, for follow-up support in addition programme should be conducted to estab­ women who have chosen to breastfeed to initial counselling sessions needs to be lish their reasons for this. 4) Clinic-based should be encouraged and supported to do improved. 6) The use of cup rather than surveys such as this should be repeated so exclusively for the first 6 months of life. bottle for feeding formula milk to infants every 1-2 years to monitor changes in in­ Mothers whose infant is thought to be should be promoted. 7) Consider provid­ fant feeding practices after measures to uninfected at the time she would like to ing mothers with larger tins of formula, improve the programme have been imple­ introduce other fluids or foods should be possibly branded, although the latter must mented. 5) Data collection methods at clin­ advised on the best way to make a safe be given careful consideration given the ics need to be standardised to facilitate transition from breast milk to replacement already considerable “spillover” of formula auditing of programme. milk feeding (formula or modified animal feeding to uninfected mothers. 8) Means milks). to identify mothers on pMTCT programme, Policy: 1) A review infant feeding policy so that they may access help at alternative and approach to breastfeeding should be Community awareness/communication: clinics if they move area, need to be devel­ conducted. 2) Policy on abrupt cessation 1) Community awareness of programme oped. 9) Supervision and support structures of breastfeeding by HIV-positive mothers and components needs to be increased. 2)

28 HIV and Infant Feeding Assistance should be offered to mothers ous levels) in the pMTCT programme in one Community Responses to with disclosure of status and involvement of the targeted communities near Gaborone of family members in infant feeding sup- pMTCT in Botswana from November 1999 to May 2000. Due to (Thou et al, 2000) port. difficulties in locating women willing to be interviewed, the recruitment area for in- Document title Methodological considerations/ depth interviews was expanded to include Working report on community responses the central maternity hospital in Gaborone reviewer’s comment to initiatives to prevent mother-to-child transmission of HIV in Botswana (Princess Marina). Unfortunately, this re­ Strengths: This large and well-done study port neither identifies which comments Authors has several important advantages: compari­ were provided by programme participants Tlou S, Nyblade L, Kidd R, Field ML son group (programme versus non- nor specifies the number of FGD partici­ programme); large sample size; knowledge­ Institution pants from each of the community group­ able, external evaluation team; pre-tested University of Botswana; International ings. In addition, details are not provided data collection instruments; trained data Center for Research on Women, Wash­ on the three health provider interviews that ington; PEER Consultants, Botswana; were planned/conducted. collectors; many different variables mea­ Society for Women and AIDS, Botswana; sured and reported; and explicit discussion Youth Matters, Botswana in the report of methodological limitations. Results Date June 2000

Limitations: There are also some important Country Botswana A large amount of information on com­ limitations to the study and report, includ­ Document type Report munity and mothers’ beliefs and knowledge ing: mother recall data only, which is sub­ of HIV and MTCT was reported. For the ject to recall bias (no direct observation); Source ESARO CD purpose of this summary, the focus is lim­ assumption of equal prevalence of HIV- ited to information relating to infant feed­ positive and HIV-negative in programme Background ing and MTCT. and non-programme groups; statistical sig­ nificance of differences between groups not In response to the high seroprevalence of Confusion as to modes of transmission was reported; and sample of mothers from HIV infection (43% in urban and 30% in evident from many FGD participants, and programme sites selected by health work­ rural antenatal clinics in 1998), the Gov­ there was an assumption that all infants ers with a bias towards mothers who en­ ernment of Botswana in collaboration with would be infected by their mother, espe­ rolled in programme and who were actively the Harvard AIDS Institute and UNAIDS cially during pregnancy and delivery, due participating. initiated a MTCT programme to provide to shared blood supply, which also cast mothers with: a short-course AZT (from 34 doubt on the effectiveness of AZT. weeks and during labour, plus for 4 weeks to infant), information on alternatives to Awareness of MTCT programme was lim­ breastfeeding, and free formula for those ited among fathers and community elders, choosing not to breastfeed. Due to time although there was some awareness of a constraints, however, there was little con­ drug to prevent MTCT, but not that it was sultation or feedback with targeted com­ available in Botswana. Most mothers had munities, so this formative research was limited knowledge of specific components conducted to obtain information that could of MTCT programmes, other than availabil­ be used to improve the effectiveness and ity of the drug. Infant feeding counselling acceptability of messages and services. was less frequently mentioned (report gives no figures). Methodology Fear of disclosure of positive test results Focus group discussions (FGD) were held was great, with mothers being the only with mothers (of unknown HIV status) and person consistently cited as being the one diverse residents, and in-depth interviews people would disclose to and frequent were conducted with participants (at vari­

A Compilation of Programmatic Evidence 29 mention of partner disapproval, denial, The underlying concern was the infant’s Adherence to Recommended IF blame, discrimination and violence in re­ health, and this overrode any traditional sponse to a positive result. Many were con­ norms. Strategies in Botswana (Shapiro et al, 2003) cerned about lack of confidentiality, from service providers, friends and family mem­ Conclusions and Document bers. recommendations of authors Concerns regarding adherence to recommended infant feeding strategies Influence of male partners in decision mak­ Knowledge of pMTCT programme: Knowl­ among HIV-infected women: results from ing was evidenced by mothers’ concerns edge was limited among community mem­ the pilot phase of a randomized trial to prevent mother-to-child transmission in regarding VCT, programme participation bers and males, and therefore education Botswana and taking AZT tablets without partner directed toward community members and approval. males on various components needs to be Authors improved, as others greatly influence a Shapiro R, Lockman S, Thior I, Stocking L, Kebaabetswe P, Wester C, Peter T, Breastfeeding was regarded as norm and mother’s participation in the programme. Marlink R, Essex M, Heymann S tradition, and part of being “a real woman”. Community members should be involved There was recognition of the benefits of in designing the communication strategy. Institution breastfeeding in terms of protection from The Botswana-Harvard AIDS Institute disease and the dangers and difficulties of Partnership, The Harvard School of HIV/AIDS stigma and discrimination: There Public Health, Department of Immunol­ bottle-feeding, in addition to the financial is great stigma and discrimination associ­ ogy and Infectious Diseases, and burden. In particular, more male partici­ ated with testing and positive HIV status. Department of Health and Social pants commented that bottle-fed children Participatory education strategies are Behavior are more prone to illness. needed to dispel incorrect beliefs. Date 2003

Country Botswana Non-breastfeeding mothers were regarded HIV and breastfeeding: Breastfeeding is a as uncaring and more concerned with their cultural norm. Acceptance of free infant Document type appearance and sexuality. Tradition main­ formula from the clinic is seen as a clear In press (AIDS Education and tains that a breastfeeding mother should indication of a woman’s HIV-positive sta­ Prevention) not have sex with a man who is not the tus, which leads to discrimination. Hus­ baby’s father while lactating, as this would bands and partners have great influence Background harm the child: breastfeeding assures her on a woman’s decision to test for HIV and partner of her faithfulness. have some influence on treatment and in­ Botswana MoH recommends formula feed­ fant feeding decisions. ing (FF) for HIV-positive mothers and pro­ Some legitimate reasons for not breast- vides it for free in government clinics. FF is feeding was stated (such as cancer, breast Methodological considerations/ exclusivity recommended for mothers problems, returning to work, pregnancy reviewer’s comment choosing breastfeeding. Both FF and ex­ and HIV), but these would need to be ex­ clusive breastfeeding (EBF) are tradition­ ally uncommon in Botswana. plained to a wide range of people. Not Weakness: The report does not clearly iden­ breastfeeding is becoming associated with tify which comments were attributable to HIV infection. which group and no information is given The purpose of this research was to study of the health worker interviews. the adherence to these 2 feeding practices Infant feeding decisions need to be taken in rural Botswana. in consultation, especially with the child’s father and the maternal grandmother (who Methodology cares for the mother during the traditional post-delivery confinement and ensures she This was part of the pilot phase of a ran­ adheres to cultural rules). However, a few domised control trial of EBF plus the ad­ women asserted that they would make ministration of AZT while breastfeeding feeding decisions alone, as the child “was versus FF. All women received AZT from 34 theirs”.

30 HIV and Infant Feeding weeks gestation and infants for 1 month. from one to 9 months of age). Some loss been an overestimate. However, increasing Between April 2000 and March 2001, 75 to follow up may have been due to moth­ acceptance of the pMTCT programme and women were randomised to EBF plus daily ers’ dissatisfaction with their assigned feed­ a reduction in the stigma associated with AZT to uninfected babies for 6 months, or ing mode. Age, parity, marital status (most FF may be leading to greater adherence to FF (AZT to babies for 1 month). Formula were unmarried), viral load and CD4 counts over time. Low adherence to exclusivity has was provided for free. All women had ac­ were similar in both groups. been reported from many different settings. cess to safe water from standpipes in the The fact that several FF women reported village. Recruitment was at 34 weeks ges­ Three out of 31 EBF women did so exclu­ breastfeeding for the first time after 6 tation, post-partum follow up monthly to sively for 3 months, none for 5 months. months may reflect an increasing willing­ 9 months with counselling to encourage Giving of water was reported at 72% of ness to “admit” to it, and perhaps that exclusivity at each visit. Those breastfeeding visits in the first 5 months, cereal or por­ women do not want to and do not know were encouraged to begin weaning from 5 ridge at 27%, juice at 20%, fruits or veg­ how to wean early. Evidence of expressible months. Detailed feeding history was ob­ etables at 18%. milk after 2 months may be an indicator tained at each visit. Maternal breast ex­ of breastfeeding in the early postpartum amination was performed at each visit to Two FF women were encouraged to period. evaluate breast health and evidence of breastfeed after their babies were found breast milk production (= at least one drop to be HIV-infected at age one month. Be­ Conclusions and of milk expressed after 3 squeezes, modi­ tween 5 and 7 out of the remaining 32 recommendations of authors fied halfway through the study to “flow of (16-22%) FF women reported or were wit­ more than a drop of expressible milk”) at nessed to be breastfeeding at some time The authors present the following conclu­ visits later than 1 month. Informed con­ during the first 9 months (often for the sions: 1) the use of breast examination as a sent from all mothers and IRB approvals first time after several months of follow determination of breastfeeding needs vali­ (Botswana and Harvard) were obtained. up). From 2-9 months 16/32 (50%) of FF dation; 2) consideration (expectation) needs women had evidence of breast milk pro­ to be given to poor adherence when rec­ Reviewer’s Comment: The determination duction on at least 2 visits. The FF women ommending feeding strategies different that a mother is breastfeeding on this ba­ who had or gave evidence of breastfeeding from local customs; and 3) strategies that sis (at least a drop of milk expressed by 3 were not different from those who did not allow women to feed their babies as they squeezes) is not an established methodol­ in terms of most variables, although higher please (e.g., prophylactic ARVs for ogy. There was some discussion of this in viral loads were significantly associated breastfeeding babies or therapeutic ARVs the e-mail forum hosted by UNAIDS (13 with having breast milk on fewer than 2 for mothers) need to be evaluated. Aug – 13 Sept 2002) with questions raised examinations (compared to at least 2). about the specificity of the method. The Methodological considerations/ authors acknowledge the need for valida­ Seventeen women refused to be ran­ reviewer’s comment tion of the technique. No alternative meth­ domised because they wanted to FF; they ods have been established. were older, more likely to be married and Limitations: There was no assessment of had had more children than those who counselling quality, and breast examination Results agreed to randomisation. Three in 17 technique may have varied between ob­ (18%) reported breastfeeding at some servers. EBF women may have thought that Less than 20% of all pregnant women of­ time, and 9/17 (53%) had evidence of the AZT they and their babies took would fered HIV testing during the period of this breast milk production (similar to the group make breastfeeding safe. Small sample size. pilot study agreed to testing and then to randomised to FF). participation in the study. After loss to fol- This was a small (albeit carefully conducted) low-up (6) and deaths (4), 31 mothers who Authors’ discussion: Adherence to EBF or study that raises serious concerns about were practicing EBF and 34 who were prac­ exclusive FF was poor in spite of the inten­ expecting (rural) women to conform to ticing FF had at least 3 follow up visits (7.2 sity of follow up involved in a clinical trial, advice on how to feed their babies. visits per infant [90% of those scheduled] and the recorded adherence may itself have

A Compilation of Programmatic Evidence 31 CÔTE D’IVOIRE

longed and predominant breastfeeding in Nutritional counselling was provided by nu­ Uptake of IF Intervention in HIV-infected women enrolled in the tritionists: pre-partum – explanations of the Côte d’Ivoire DITRAME PLUS project, in Abidjan, Côte proposed interventions; at follow up – in­ (Leroy et al, 2002) d’Ivoire. formation on benefits of BF, risks of mixed feeding, specific counselling during wean­ Document title Methodology ing, regular “workshops” to learn how to Uptake of infant feeding interventions to cook baby food. reduce postnatal transmission of HIV-1 in Abidjan, Côte d’Ivoire This non-randomised therapeutic cohort (This summary is also derived from (n=1500) study was initiated in Abidjan in Follow up occurred at birth, second day of “Exclusive breastfeeding and early March 2001. The study included consent­ life (D2), weekly to 6 weeks, monthly to cessation of breastfeeding to prevent one year, quarterly to 2 years; documenta­ HIV-1 transmission through breast milk”, ing pregnant women, age 18 years or more, presented at the Ghent Workshop on who were HIV-positive and informed of tion of clinical events and actual IF prac­ Prevention of HIV Transmission through their serostatus. tices (data collected by independent coun­ Breast-milk, December 12-13 2002, sellors to minimise bias, 7-day recall, in which was based on the same material.) Peri-partum ARV intervention: Pregnant detail). Authors women from 36 weeks gestation to deliv­ Leroy V, Becquet L, Ekouevi D, Viho I, ery: 300 mg ZDV bid orally and multivita­ Results Castetbon K, Sakarovitch C, Elenga N, Dabis F, Timité-Konan M min supplementation, iron and folate, and malaria chemoprophylaxis. Intra-partum: From March 6–May 31, 2001: 323 HIV- Institution 600 mg ZDV and 200 mg NVP once orally, positive pregnant women were enrolled, The DITRAME PLUS ANRS 1202 Project self-administered at home; Children: ZDV 266 of whom delivered: 252 singletons (1 Date 2002 syrup 2 mg/kg 6 hourly for seven days and stillbirth), 12 pairs of twins; 2 triplets (1 NVP: single dose 2 mg/kg on Day 2. stillbirth). All but one (0.4%) expressed their Country Cote d’Ivoire infant feeding intention before delivery: Document type Post-partum intervention: Systematic 151 (59%) chose FF from birth and 104 Poster MoPeD3677 at Barcelona proposition from 36 weeks of gestation of (41%) planned to breastfed. Conference two alternatives to prolonged breast- Source feeding (the common practice in Côte Those who did not choose FF before deliv­ Barcelona Abstract CD and co-author d’Ivoire): formula feeding (FF) from birth ery were more likely to be living with their (with a drug inhibiting lactation) or exclu­ partner or a co-spouse (ORs [CIs]] 2.4 [1.3- Background sive breastfeeding (EBF) with early cessa­ 4.5] and 2.1 [1.1-3.9], respectively), and tion from three months of age; vitamin A have no schooling (OR 3.8 [1.7-8.6]. supplementation; postnatal contraception The primary objective was to evaluate the efficacy of a package of interventions tar­ systematically proposed; assessment of HIV Only one of 229 women made no pre-de- infection in children performed until two geted at HIV-positive pregnant women and livery IF choice: 134 (59%) chose FF and months after complete cessation of their children, combining 1) a peri-partum breastfeeding. HIV-infected ARV intervention: ZDV plus NVP and 2) a Prenatal choice children received cotrimoxazole post-partum intervention. The post-partum from six weeks until at least one IF practice at D2 post-partum FF, n (%) BF, n (%) intervention was the systematic proposal Formula feeding (FF) 123 (82) 3 (3) of safe and appropriate infant feeding year. All services were provided free, including formula from methods and proper case management of Exclusive breastfeeding (EBF) 8 (5) 54 (52) birth or time of weaning to nine infected children born to HIV-positive Predominant Breastfeeding (PBF) 14 (9) 46 (44) mothers. The long-term objective was to months; follow-up was for 2 Mixed feeding (MF=breast+formula) 6 (4) 1 (1) years. describe the uptake of alternatives to pro­ TOTAL 151 104

32 HIV and Infant Feeding 94 (41%) BF. Of those who, before deliv­ high; 2) nearly all women expressed their tal HIV transmission according to feeding ery, had said they would FF, 82% were do­ choice before delivery; 3) FF was better practice, and incidence of severe morbid- ing so on Day 2. accepted than anticipated (about 60%); 4) ity/mortality according to feeding practice women living with their partner or a co- (including time of weaning). The authors Of those who said they would BF, 57% were spouse or who had had no education were stress that there is an urgent need to find EBF on D2 and 39% predominantly less likely to choose FF; 5) for women who innovative approaches to involve fathers breastfeeding (PBF). Including deaths and chose FF, postnatal compliance with their in pMTCT interventions and to reduce loss to follow up, of those who were FF on prenatal choice was high, and failures were stigmatisation of people living with HIV/ D2, 80% were still doing so after 1 month mainly related to their partner or family AIDS. and 69% after 3 months. Of those who environment; 6) for women who chose BF, were EBF on D2, 50% were still doing so EBF seemed to be difficult to achieve be­ Methodological considerations/ after 1 month and 22% after 3 months. Of yond the first weeks of life, with more than reviewer’s comment those who were PBF on D2, 62% were do­ one-third of the breastfeeding mothers ing so after 1 month and 32% after 3 practicing PBF, or some degree of mixed Assessment of feeding practices was thor­ months. feeding, as early as D2; 7) weaning as early ough, although 7-day recall may overesti­ as 3 months is probably not acceptable that mate EBF rates; little evidence has yet been Conclusions and early, possibly because of stigma, but there presented in relation to early weaning; rea­ recommendations of authors is no evidence given for this conclusion; sons for changing feeding practice were and 8) completion of follow-up will allow not well documented. The authors present the following conclu­ assessment of: acceptability of the nutri­ sions: 1) uptake of the intervention was tional interventions, incidence of postna­

A Compilation of Programmatic Evidence 33 HONDURAS

program experience, managed by the Popu­ sults and conclusions are limited to assess­ Rapid Assessment of pMTCT in lation Council. The assessment was con­ ment findings relevant to infant feeding Honduras (Baek et al, 2002) ducted in order to contribute to the prepa­ counselling. ration of a practical programming frame­ work, including scaling up strategies. Les­ Document title Results sons learned and best practices derived Report on the Qualitative Rapid Assess­ from the evaluation will help form the ba­ ment of the UN-Supported PMTCT Pilot The Honduran pMTCT Program promotes Program in Honduras sis for the large-scale expansion in Hon­ formula feeding. A decision was made early duras. The goal is to have a national pro­ Authors in the implementation to simplify the coun­ gram by the end of 2003. Baek C, Rodriguez MX, Escoto LR selling component for both providers and clients, apparently reducing difficulties ex­ Institution Methodology perienced in other pilot programs. Although Population Council/HORIZONS Project the program protocol outlines several op­ Date December 2002 Several factors resulted in the rapid assess­ tions (exclusive breastfeeding, heat-treated ment being reduced to the use of only milk, wet nurse, and breast milk substitutes), Country Honduras qualitative methods. It was conducted over and indicates that the individual woman Document type a one-week period, between August 26­ should make the decision regarding infant Program evaluation (under review, not for 30, 2002. Meetings and interviews were feeding without any pressure (following circulation) held with national stakeholders, regional WHO recommendations of informed Source UNICEF Headquarters managers, site managers, providers, and choice), in practice, there is a bias toward clients. Most of these interactions were in­ promoting formula feeding for HIV-posi- Background formal and without the use of formal ques­ tive clients. Informants state that this is due tionnaires. The type of information acquired to program preference as well as some pro­ is similar, however, to that collected in Zam­ viders’ lack of knowledge regarding the This report summarizes a rapid assessment bia and Rwanda, since the questions were probability of transmission through of UNICEF’s pMTCT pilot project in Hondu­ based on the evaluation instruments used breastfeeding. ras, the second poorest country in Central in those countries. The evaluation team vis­ American, with a population of 6.5 mil­ ited sites where pMTCT programs had been Breastfeeding is discouraged and the safety lion. Honduras has 17,199 registered HIV/ established for the longest period of time, and feasibility of formula use are assessed AIDS cases, predominantly in urban areas, a total of 6 sites in 3 areas of the country. with a prevalence rate of less than 1% to 5 during the counselling session. Currently, A site questionnaire was carried out to as­ the pilot program distributes formula free %. Additionally, 690 children under 5 have certain services provided and referrals avail­ for 6 months. These factors are thought to AIDS, which is 5% of the total cases. Ap­ able at five out of the six sites. Other in­ proximately 95% of these children have contribute to the high percentage of HIV- formation collected ranged from provider positive patients choosing formula. From acquired AIDS through vertical transmis­ commitment and motivation to issues of November 2000 to June 2002, 30 out of sion. The Honduran Ministry of Health and confidentiality and training. Issues related UNICEF began implementing a pMTCT pi­ 30 HIV-positive women chose formula to the integration of VCT in ANC/MCH pro­ feeding. lot project in 1999, becoming the first grams and infant feeding counselling were country in Latin America and the Carib­ also examined. Family planning, care and bean to implement such a project. In less Bottle feeding is widely accepted cultur­ support, supplies, monitoring and evalua­ than 2 years, 40 sites were established. This ally. There is no stigma attached to a woman tion, communication strategies, male in­ rapid assessment is the first in Honduras, who has decided to use formula. Conse­ volvement and transitioning from a pilot and was undertaken as part of a global quently, providers reported that HIV-posi- to national programs were explored. Re­ evaluation of UN-supported pMTCT pilot tive clients are using formula without prob-

34 HIV and Infant Feeding lems, and there were no reports or suspi­ the introduction of free formula in ANC/ feeding options are not discussed prior to cions of mixed feeding due to cultural pres­ MCH settings and could undermine HIV testing. Only women who are HIV-posi- sures or fear of stigma. The program seems breastfeeding in the general population. tive are counselled to formula feed their to have introduced infant formula for HIV- infants. All HIV-negative women and those positive women without adversely affect­ Providers and stakeholders view infant for­ of unknown status are encouraged to ing other women’s potential to breastfeed mula as an important part of the pMTCT breastfeed exclusively. This approach is exclusively. HIV-negative women and those program. A consensus among all the pro­ thought to decrease potential spillover of of unknown status are encouraged to viders and stakeholders was that infant infant formula uptake by the general pub­ breastfeed throughout the country. formula should continue to be provided. lic and has been recommended by the pi­ The change in UNICEF’s policy to no longer lot programs as part of the national pMTCT Obvious spillover was not reported to be a procure and donate formula (to be imple­ scaling up strategy. problem. Providers indicated that they were mented February 2003) presents a chal­ concerned about this at the outset of the lenge. The inter-institutional committee is Methodological considerations/ project but have not witnessed women who requesting that the government take re­ reviewer’s comment are HIV-negative or of unknown status re­ sponsibility for the free provision of for­ questing formula. Some sites have reported mula. Providers at one site expressed seri­ Authors note that the report comes out of that infant formula is never mentioned ous concern that if formula cannot be pro­ an informal, one-week assessment, consist­ during HIV pre-test counselling sessions, vided, they will not be seen as credible, and ing of very brief site visits. Information but only mentioned to HIV-positive women their motivation to support this program collected on infant feeding provides very during post-test counselling. HIV-negative will decrease sharply. useful insights and should help program women are encouraged to breastfeed ex­ planners improve training related to infant clusively, and are not told of the distribu­ Conclusions and feeding options and anticipate potential tion of formula. This strategy was devel­ recommendations of authors problems related to the supply of free or oped in consultation with members of La subsidized formula when the program is Leche League, who were concerned that Authors conclude that at some sites infant expanded.

A Compilation of Programmatic Evidence 35 INDIA

Methodology counsellors interviewed believed that EBF Rapid Assessment of pMTCT in was the best choice for both HIV-positive India (Sarna, 2002) Informal visits to a non-representative and HIV-negative women. sample of sites (two out of eleven) and very Document title few interviews were used to collect infor­ Socioeconomic factors affect IF decisions. Report on Discussions with National mation. All key informant, health provider Several clients indicated that they choose AIDS Control Organization and Visits to Two Pilot Program Sites and client interviews were informal and to breastfeed because they did not have without questionnaires, meant to collect means to boil or sterilise utensils or afford Author Sarna A qualitative information on actual experi­ cows’ milk. Clients appeared to be aware Institution ences and lessons learned. Questions were of the importance of EBF. Population Council/HORIZONS Project based on evaluation instruments created for the global evaluation so that the infor­ Modified cow or buffalos’ milk is the only Date December 2002 mation acquired is similar to that from the replacement feed being offered as an al­ Country India other three countries (Honduras, Rwanda ternative to breastfeeding. Mothers in one and Zambia). Document type site receive a demonstration on how to Program Report (under review, not for prepare the feed (sterilisation, dilutions, circulation) Results etc.) and use a bowl and spoon instead of a bottle. No nutritional supplement is added Source UNICEF Headquarters Infant feeding counselling forms an impor­ to the milk. tant part of the pMTCT program in India. Background The official NACO policy is to promote in­ There is a general reluctance by providers formed choice by the mother. The message to promote or offer formula as a choice, India is still considered to be a low-preva- on infant feeding is initiated early, during given the low levels of education and low lence country (0.7%), estimated to have pregnancy itself and at the time of pre- socio-economic status of women using around 3.8 to 4 million persons infected and post-test counselling. All members of public sector facilities. Formula is only of­ with HIV, the second largest number of the participating AZT research team rein­ fered as a choice to women who ask for it people living with HIV/AIDS (PLHA) in the force the same message at the time of de­ or appear to be able to afford it. world after South Africa. In these high- livery. prevalence states, the epidemic is already Other choices such as milk banks, heat- showing signs of spreading into the gen­ Mothers are informed about the risk of treated breast milk and wet nursing are not eral population, with prevalence among the MTCT through breast milk, the benefits of discussed at all. antenatal clinic attendees ranging between breast milk, and the risks and benefits of two and 2.5% in five states. The pMTCT replacement feeding. program, in the form of feasibility studies Conclusions and with AZT and then NVP, has been ongoing recommendations of authors IF counselling emphasizes exclusive in India since April 2000. This summary re­ ports on the findings of a rapid assessment breastfeeding with early weaning between Success reported by the two AZT and then 4-6 months to be done as quickly as pos­ of UNICEF-supported pMTCT pilot projects NVP studies in India indicates that the pi­ sible, when breastfeeding is the IF method around the world, conducted by Horizons/ lot pMTCT program is ready for scale-up to Population Council in July 2002. In India, chosen by a mother. the district level in the high-prevalence this assessment is meant to complement a states. Prevention of MTCT services, includ­ quantitative feasibility study on the short Given higher mortality documented among ing VCT, has been integrated into the an­ course AZT intervention for pMTCT, con­ babies who receive replacement feeds in tenatal care program quite successfully, ducted by The National AIDS Control Or­ the AZT feasibility study, emphasis is placed despite several resource constraints at these ganization (NACO). on promoting exclusive breastfeeding. All sites. A rapid scale-up, however, has sev-

36 HIV and Infant Feeding eral challenges and the program will need three pilot studies in pubic hospital set- HIV Child Survival Project to establish monitoring and supervision tings. These interventions raised important (South India AIDS Action systems, upgrade MCH facilities and ensure questions concerning issues of informed the adequate training of human resources. Programme et al, 2001) consent, confidentiality, stigma, and ad- There are no specific conclusions drawn or equate alternatives to breastfeeding. Most recommendations made by the authors Document infected women do not know their status concerning infant feeding counselling or Karu: Chennai HIV child survival and many prefer not to be tested. This project—Report of a situational analysis follow-up, although general scale-up is­ project aimed to address the needs and sues apply to this component of the pMTCT Authors concerns of women in relation to preg­ program as well. South India AIDS Action Programme, nancy and breastfeeding, and to contrib­ Community Health Education Society, ute to the development of strategies to care Tamil Nadu Dr MGR Medical University, Methodological considerations/ Macfarlane Burnet Institute for Medical for and support women and families with reviewer’s comment Research and Public Health, Interna­ infected babies. tional Health Unit

Authors note that the report comes out of Institution Methodology an informal assessment, consisting of key South India AIDS Action Programme; informant interview and 2 very brief site Community Health Education Society; This collaborative project, which ran be­ Tamil Nadu Dr MGR Medical University; visits. Information collected on infant feed­ and the Macfarlane Burnet Institute for tween January and August, 2001, was con­ ing provides very useful insights, however, Medical Research and Public Health, sidered a situational analysis focused on and should help NACO and other program International Health Unit knowledge, attitudes, and practices (KAP). planners in designing the scale-up strat­ Date August 2001 Qualitative research methods were used, egy, especially the training and counsel­ including 22 in-depth interviews and 36 ling components. Country India focus group discussions (FGDs) involving Document type eight to twenty participants. Urban, semi- Report, Funded by the Australian-India urban, and rural settings in the districts Council contiguous to Chennai were included, as well as Chennai City. Staff and volunteers Background familiar with the communities facilitated the group discussions. Participants in­ With a population of over 60 million, Tamil cluded: women in prostitution, unmarried Nadu, India, has been identified as a state girls between 16 and 22 years, married with significant levels of HIV infection. women, pregnant and lactating women liv­ Recent studies indicate a rapid spread of ing with HIV, couples between 25 and 35, HIV among women of reproductive age. mothers-in-law, nurse trainees, dai (rural There are some areas in Tamil Nadu where traditional midwives), female health work­ prevalence is up to 3%, representing ers (VHNs), mail volunteers, pharmacists, 400,000 to 500,000 women. Pioneering youth and student groups, husbands of interventions, such as voluntary counsel­ women living with HIV, truck drivers, and ling and testing and antiretroviral prophy­ doctors. Consultations were held with of­ laxis with avoidance of breastfeeding for ficials and community leaders. KAP issues those women found to be positive, have included: pregnancy and antenatal care, been established in the Tamil Nadu Dr MGR breastfeeding and replacement feeding, Medical University. The government of In­ sexually transmitted infections, HIV/AIDS, dia, with support from UNICEF, established safer sex practices including condom use,

A Compilation of Programmatic Evidence 37 mother and child health, expectations in an important factor. Both men and women the need to address messages and infor­ marriage and pregnancy, care of sick ba­ are discriminated against when they are mation about parent to child transmission bies, and discrimination against people in- known to be HIV-positive, but women more (PTCT) to older women as well as younger fected/affected with HIV/AIDS. so from their families. Also, becoming a women. Participants indicated that many widow causes discrimination given their men do try to help in domestic chores and Results low status. Relatives often take belongings a few accompany their pregnant wives to following a husband’s death. the clinics and inquire about their health. Knowledge, attitude, beliefs about HIV/ The great majority of pregnant women at­ AIDS: Knowledge of HIV among health care Sexual health and relationships: The expec­ tend antenatal care and also receive home workers varied greatly (sexual transmission, tations of women from marriage were af­ visits. The majority of women deliver in MTCT, prevention, and condom use). Rural fection, sex, income, respect, security, to be hospitals or health centres. Induced abor­ health workers, including pharmacists and understood, and to love and be loved. When tion is legal in India, and the possibility of dai, lacked clarity and place more stress on asked about testing for HIV before mar­ terminating a pregnancy because of HIV blood as a source of transmission. Urban riage, many women expressed agreement, has begun to be considered in these com­ nurses expressed fear of handling HIV-posi- but said it was a difficult issue requiring munities. The decision to terminate is usu­ tive patients who were sick, a potent indi­ community consensus. There is great soci­ ally made by the husband or mother-in- cator of stigma. Community knowledge of etal pressure to conceive soon after mar­ law. HIV transmission was better in urban set­ riage, with rural women stating that it was tings. Rural people had less general knowl­ best to conceive even if they were HIV- Infant Feeding: In general, participants be­ edge and more difficulty in understanding positive or had a congenital illness. For men, lieved that breastfeeding is necessary and the difference between HIV and AIDS. Many sex outside of marriage is common. Women beneficial. The hazards of not breastfeeding believed that HIV can be transmitted casu­ feel both angry and resigned about this were also recognised. It was expected that ally. behavior. Couples have sex throughout mothers will breastfeed unless she they are pregnancy, up to 4 or 5 days before deliv­ sick or have no milk. Those who do not Discrimination: Urban participants ex­ ery. Most participants were uncomfortable breastfeed are likely to receive some pres­ pressed a range of factors associated with talking about safe sex, which was gener­ sure to do so. Breastfeeding practices are discrimination and prejudice, with distress­ ally only associated with using condoms not optimal given prelacteal feeds, early ing reports from people infected with HIV and being faithful. If other birth control introduction of foods and other liquids, and concerning stigma. Transmission was of­ methods were being used, then condoms the early cessation of breastfeeding. Ba­ ten equated with misbehaviour and im­ were associated with mistrust. Rural par­ bies are put to the breast soon after deliv­ moral behaviour, leading to a lack of rec­ ticipants said that condoms were never ery and colostrum are generally given. ognition that faithful married women may used when a wife was pregnant. Married Those who mentioned duration of be at risk of HIV from their husbands. Dis­ urban women felt that it is a man’s duty to breastfeeding indicated one to two years. crimination of people with HIV at the family wear a condom but they could not ask him Many women introduce cow’s milk, given level ranges from ostracizing PLWHs by giv­ to use one. by bottle, in the early months as a supple­ ing them separate plates and tumblers to ment. Many thought infant formula to be total rejection and failure to participate in Pregnancy: Most of the women expressed too expensive and would give diluted fresh the rituals of dying and death. Urban par­ a desire to stay in their own mother’s house liquid cow’s milk or diluted dried milk pow­ ticipants explained that discrimination only during pregnancy, depending on such fac­ der. Weaning foods unsuitable for an in­ occurs when confidentiality is breached, tors as the order of pregnancy, socioeco­ fant were also mentioned and included stressing that it was common among health nomic level, and the relationship between Cerelac, Nestum, and millet porridge. Some­ care providers. Doctors revealed that it was the woman and her mother-in-law. Since times milks were over- or under-diluted. based on fear of becoming infected mothers-in-law and mothers have great Sugar and micronutrient supplements were through occupational exposure. Gender is influence on decisions during pregnancy, not added. The idea of expressing and boil-

38 HIV and Infant Feeding ing breast milk was completely unfamiliar need to encourage empathy and support the level of the family and community to or considered not practical. Participants for mothers rather than blame. address issues of safe sex within arranged mentioned the need to clean bottles but marriages, including condom use. There is not sterilise them. Conclusions and an urgent need to provide training about recommendations of authors the true risks of exposure to HIV and how Impact of HIV and infant feeding counsel­ to minimise them. Medical providers, who ling: According to health professionals and This study provided a wealth of informa­ continue to be potent generators of stigma, HIV-positive women respondents, HIV- tion that can be used to inform the design need access to post-exposure prophylaxis positive women are currently being advised and implementation of prevention and care so that their fears are addressed. Exclusive not to breastfeed. All participants talked strategies in relation to pMTCT. The results breastfeeding is rare and both prelacteal about the difficulties involved if women are relevant to other areas of India. The feeds, which have spiritual or symbolic are told not to breastfeed, including the authors conclude that promoting a “child meaning, and the early introduction of rice practical (cost and time), social, and emo­ survival” approach—rather than the current feeds for fear of insufficient milk produc­ tional reasons. Most women felt that it was focus on counselling and testing during tion, must be addressed in order to make dangerous to not breastfeed and worried pregnancy, provision of anti-retroviral pro­ breastfeeding safer. that if they followed the doctor’s advice phylaxis and infant feeding counselling— that the baby would become ill with fever will lead to a broader response to the epi­ Methodological considerations/ or diarrhoea, or die. Women mentioned the demic and greater impact on mothers and reviewer’s comment social difficulties and discrimination they children. A “child survival” approach would face if they did not breastfeed. emphasises the need for balance in coun­ Strengths: Training of collaborating insti­ selling women about infant feeding so that tution researchers and use of participatory Childhood illnesses: Rural groups view the they can make the safest choice for their methods appear to have strengthened the mother as the primary caregiver when a own circumstances. The study highlights response of participants and analysis of child is sick. Urban women mentioned other the need to provide follow-up care and FGDs. The inclusion of both younger and family members that might care for a sick support for HIV-positive mothers, and ad­ older women provided an historic perspec­ baby if the mother was unable to. Mothers vocate for these women to receive tive on key issues. usually try home remedies and prayer be­ antiretroviral therapy, rather than just pro­ fore seeking medical attention. For preven­ phylaxis. Informed consent and confiden­ Limitations: Description of the research tion of childhood illnesses, many women tiality need to be addressed in the context process is limited. In-depth interview ques­ mentioned nutrition, immunisation, medi­ of antenatal HIV counselling and testing. tionnaires, FDG guides, and instructions to cal check ups, and child spacing. When a Involvement of husbands in counselling interviewers and facilitators are not pro­ child is ill, the mother is often blamed by before testing for HIV needs to be explored, vided for review. Consequently, little com­ her husband and mother-in-law. Respon­ along with the concept of “couple visits” ment can be made concerning the quality dents indicated that care and support to as a routine part of ante-natal care. Other of the instruments and methodology. mothers of sick babies is needed. Messages recommendations include interventions at

A Compilation of Programmatic Evidence 39 KENYA

Methodology All except two of the HIV-positive mothers Maternal Knowledge of MTCT were breastfeeding “because they did not and Infant Feeding Practices This was a cross-sectional exploratory study know their status early enough”. Of the (Oguta et al, 2001; Oguta, of women of unknown HIV status with mothers of unknown HIV status, 98% were 2001) babies aged 0-12 months and a sub-group breastfeeding, none exclusively. Median of HIV-positive women with children up duration of breastfeeding was 23 months. Document title to two years. The area for the study was 1) Maternal knowledge of MTCT of HIV chosen because of its high HIV prevalence and breast-milk alternatives for HIV Alternatives to breastfeeding: Cow’s milk positive mothers in South-Western Kenya and infant mortality rate and for being a was most acceptable (mentioned by 85%), 2) Infant feeding practices and breast pilot site for the national pMTCT but (if have no cow) expensive (up to 45% milk alternatives for infants born to HIV- programme. Villages (25) were randomly of income); very few mothers knew of the infected mothers in Homa Bay District selected and mothers recruited consecu­ need for modification of whole cow’s milk; Authors tively. wet nursing was acceptable for older but 1) Oguta TJ, Omwega AM, Sehmi JK. not younger women (common for orphans, 2) Oguta TJ Data collection consisting of semi-struc- not for babies of healthy mothers); formula Institution tured questionnaires were administered to was considered “good” but unaffordable; Applied Nutrition Programme, Dept of 112 women; also held were 4 focus group goat’s milk/expression of breast milk/milk Food Technology & Nutrition, University discussions (two with eight women age 18­ powder were rarely mentioned; expression of Nairobi 45 and two with eight men age 20-54); of breast milk was considered unaccept­ Date 1) 2001. 2) 2001 key informant interviews with 5 experi­ able. enced women; observation (using obser­ Country Kenya vation study guide) of IF practices of 11 Knowledge about MTCT: More knowledge Document type HIV-positive women; and four case stud­ about MTCT 1) had no effect on initiation, 1) Unpublished report. 2) MSc Thesis ies: two HIV-positive women (one formula frequency or duration of breastfeeding; 2) feeding, one breastfeeding), and two Source ESARO CD was associated with earlier introduction of women of unknown status (one using cow’s complementary feeds (author’s suggestion: milk, one using a wet nurse). A scoring sys­ because more knowledge was also associ­ Background tem was developed for knowledge of MTCT. ated with more education, higher income, and the likelihood of the mother doing More than 300,000 babies are at risk of “business”); 3) was associated with more HIV infection per year in Kenya. The aim of Results consideration of alternatives to breast milk; the study was to assess 1) maternal knowl­ and 4) was linked to less social rejection of edge of MTCT, 2) infant feeding practices, Only 9% of women answered all six ques­ non-breastfeeding mothers. and 3) the viable alternatives to breast milk tions on MTCT correctly; 46% had “aver­ and conditions surrounding the choice of age” knowledge. It was thought that all infant feeding methods in rural South- babies of HIV-positive women are infected Western Kenya. and that this is not preventable. HIV-posi- tive women were more knowledgeable.

40 HIV and Infant Feeding Conclusions and cess to cow’s milk and knowledge about This study was largely of intentions. The recommendations of authors modifications required; 5) encourage com- author considers unmodified cow’s milk a munity-based care and feeding of orphans; potential infant feeding option. The poten­ The level of knowledge about MTCT is very 6) incorporate infant feeding counselling tial for increasing (or changing attitudes low. Cow’s milk is the most viable alterna­ into all HIV/AIDS counselling and BFHI of mothers towards) exclusivity of tive to breast milk. Wet nursing is viable at programmes; and 7) reduce stigma. breastfeeding was not explored. The de­ the family level according to mother of gree of support for wet-nursing is inter­ unknown status (not among HIV-positive Methodological considerations/ esting, perhaps important, but the consid­ mothers). reviewer’s comment eration of (possibly repeated) HIV testing of the wet nurse to confirm HIV negativity Recommendations include: 1) intensify A study guide and scoring system were de­ was not explored, though it was recom­ educational efforts about MTCT in general veloped to standardise the research tech­ mended. and exclusive feeding in particular; 2) im­ nique. The observational study methodol­ prove primary health care coverage; 3) im­ ogy was not reported. prove water and sanitation, 4) improve ac­

A Compilation of Programmatic Evidence 41 MYANMAR

key informants, including mothers in Country Adaptation of Global but still often not the case in private hos­ Yangon. HIV/ IF Guidelines: Stage I pitals or in all parts of the country). EBF (Williams, 2001) rates were very low (16% of mothers prac­ Results tised EBF at 0–3 months) because of giv­ Document title ing water (seen as necessary for thirst and Country Adaptation of Global HIV and Current policies: The National Breastfeeding cooling). However, BF is prolonged: 89% Infant Feeding Guidelines and Develop­ Policy adopted in 1993 approximates the were breastfeeding at 12 months and 67% ment of Replacement Feeding Guidelines Baby Friendly Hospital Initiative’s (BFHI) 10 at 20 months. Reasons for early cessation for Myanmar, 2001-2002. Stage I: Review steps, but additionally prohibits advertise­ of currently used infant feeding guidelines (which is uncommon) include pregnancy, and information on infant feeding ments for and free gifts of breast milk sub­ work and refusal of breast. practices in Myanmar stitutes (BMS), and recommends that the duration of exclusive breastfeeding be for Authors Williams C Complementary food: Timing of introduc­ four months and encourages breastfeeding tion of complementary food (CF) is poor at Institution up to at least two years of age. At 4–6 both ends of the age spectrum: 40–50% National Nutrition Centre and National months rice, banana and papaya are to be of infants are given CF too early (at less Aids Programme, Myanmar, UNICEF; introduced; at seven months meat, fish, Centre for International Child Health, than 4 months), and 15% start CF too late: Institute of Child Health, London beans and vegetables; at 10–11 months at over 9 months. Early introduction is re­ egg; and at 12 months family pot. A 1998 lated to traditional beliefs in the impor­ Date December 13, 2001 national consensus meeting endorsed the tance of rice as protection and as being Country Myanmar 4-month EBF goal (rather than 6) for sev­ good for health and growth. Rice (meshed eral reasons, including the capacity of un­ Document type through cloth or pre-chewed) is always dernourished mothers and maternity leave UNICEF Consultant Report given first, sometimes salt is added but sel­ constraints. The “Code” has not yet been dom oil (as recommended). No clear pat­ Source UNICEF Myanmar incorporated into national law; formula is tern was seen thereafter. Malnourished rarely labelled in local languages, and pri­ children (compared to well nourished) are Background vate and children’s hospitals accept dona­ fed rice at less than 4 months, given insuf­ tions of BMS. Other breaches of the Code ficient food of no variety infrequently, in a The 1998 WHO/UNAIDS/UNICEF Guidelines are also common: HIV-positive mothers context of poor hygiene practices. The liq­ on HIV and Infant Feeding need country near Thailand are believed to cross the bor­ uid portion of soup (low nutrient density) adaptation to the food items and feeding der to obtain free supplies of BMS from is commonly given to babies. Milk of any practices that are locally available, afford­ Thai PMCT programmes. kind is rarely mentioned as an adjunct to able and acceptable in Myanmar and that complementary feeding. Stunting preva­ can be prepared safely in the typical do­ Other factors that may affect policy: The lence was 22% at 6–11 months and 37% mestic environment. This review is the first Baby Friendly Hospital Initiative (BFHI) has at 12–23 months. stage in a project to develop replacement been extended to home deliveries and pri­ feeding guidelines for Myanmar. vate clinics through the Baby Friendly Clinic In Yangon, 70% of mothers work, mostly Initiatives. away from home and the baby; in rural Methodology areas mothers are more involved in feed­ Breastfeeding: Most women feed colos­ ing and caring for children. Domestic hy­ Methods used to conduct this study in­ trum; prelacteal feeding is unusual and giene (e.g., hand washing) is often poor, cluded the review of published studies and demand feeding normal—all a big change and rice is often left for up to 4 hours be­ internal field reports, and meetings with from earlier (probably a result of the BFHI fore feeding.

42 HIV and Infant Feeding Conclusions and Breastfeeding had been explored during recommendations of author Country Adaptation of Global stage 1, and this was used to develop guide­ HIV/IF Guidelines: Stage II lines that were consumer-tested in stage (Williams, 2003) The BFHI has improved breastfeeding ini­ two. TIPS were conducted with women of tiation practices, but EBF is rare due to the unknown HIV status only to avoid disclos­ very early giving of water. Complementary Document title ing the status of infected mothers. foods are often of low quality (energy and Country Adaptation of Global HIV and Infant Feeding Guidelines and Develop­ other nutrients) and given infrequently. ment of Replacement Feeding Guidelines Results Prolonged breastfeeding substantially for Myanmar, 2001-2003. Stage II: makes up for this. Feeding babies without Formative research and development of Exclusive breastfeeding (EBF) was uncom­ breast milk and with limited access to in­ replacement feeding guidelines for site 1: Monywa mon, with two-thirds of the infants receiv­ fant formula or animal milks will be very ing water (to quench thirst) by 2-3 months difficult. Authors Williams C, Zin MM, Mon AA of age. Current feeding recommendations Institution advise that infants begin complementary Methodological considerations/ National Nutrition Centre and National foods at 4-6 months, but there is tradi­ reviewer’s comment Aids Programme, Myanmar,UNICEF; tional use of pre-lacteal feeds and a Centre for International Child Health, Institute of Child Health, London celebratory rice meal is given during first 7 This was preliminary work before a quali­ days of life. Many mothers introduce rice tative field assessment of infant feeding Date January 2003 between 2-3 months to make baby strong practices. Country Myanmar and resistant to mosquito bites.

Document type Majority of mothers found the idea of EBF UNICEF Consultant Report (under review, not for circulation) acceptable and commented that it was convenient, less time-consuming and saved Source UNICEF Myanmar money. However, a minority were unconvinced and worried that infant Background needed water and breast milk would not satisfy their hunger. Health workers had The 1998 WHO/UNAIDS/UNICEF Guidelines good knowledge of EBF but believed EBF on HIV and Infant Feeding need adapta­ rates were higher than they actually were. tion to reflect country conditions and the food items and feeding practices which are Most mothers breastfed for at least two locally available, affordable and acceptable years, with most common reason for stop­ and which can be prepared safely in the ping being subsequent pregnancy. Many typical domestic environment. This paper mothers applied bitter leaves to dissuade presents results form formative research of child, moved child out of their bed or sepa­ infant feeding options for HIV-positive rate from child. Most managed to stop mothers at one pMTCT site in 2002. breastfeeding over 3 days, but many com­ plained that breasts became engorged Methodology when stopping. Mothers and health pro­ fessionals reluctant to consider early ces­ Rapid appraisal techniques, dietary recall sation of breastfeeding, when child about and household trials of improved practices 6 months of age, as this was considered (TIPS) were used. Attitudes towards Safer cruel.

A Compilation of Programmatic Evidence 43 Although knowledge of expression to re­ Modified cow or other animal milks were lies regarded this as expensive and are likely lieve distension was considerable, little considered too complicated to prepare sev­ to use it in combination with heat-treated community experience of expressed breast eral times a day and no household was us­ breast milk. milk for storage to feed child later due to ing powdered milk. The trial of cup feed­ concerns about cleanliness. However, TIPS ing was successful, but many mothers were Local powdered milk is not thought to be proved successful and mothers were already using soup spoons to feed infants suitable for infant feeding, but more de­ amazed and delighted that there was a free water anyway. Trial of boiling water for tails of nutrient composition are needed. way to feed their infant if they had to be infants met with resistance. Mothers were separated. not boiling water and reported no prob­ Wet-nursing is complicated by the need to lems associated with this and therefore are test wet-nurse and ensure she remains Heat treatment of breast milk was possible reluctant to invest time and fuel. uninfected. and many homes had suitable pots. How­ ever, the fuel cost was an issue. Mothers Heat-treated expressed breast milk is con­ Conditions are favourable for introduction suggested placing milk in cup in the middle sidered feasible and acceptable, possibly in of EBF as an option, since there is already of rice pot while cooking rice twice a day combination with other milks, or during some community experience. EBF practice to conserve fuel. cessation, mostly because of low cost and needs to be strengthened and a mass out­ fulfilling desire to breastfeed. However, reach campaign may be required. Wet-nursing is common between house­ health professionals lack confidence in ex­ hold members, but concerns were expressed pression as an option and may require fur­ Little community experience of early ces­ about wet-nursing in case of HIV infection. ther training and support. sation of breastfeeding, but some experi­ ence of managing cessation at later stage. If an infant could not be breastfed, moth­ Replacing breast milk is potentially prob­ HIV-positive mothers who are considering ers suggested using formula, rice, con­ lematic and considerable confusion be­ this option will need adequate support and densed milk, wet-nursing, cow’s milk and tween powdered milk and formula is con­ counselling. tea, although many were aware of the siderable. Reluctance to boil water for in­ health risks these carried. Health profes­ fants is also considerable. Many are aware Conclusions and sionals suggested formula feeding by of the health risk of feeding non-human recommendations of authors bottle, or powdered milk, cow’s milk or wet- milks. Infant formula is very expensive, but nursing, but many considered financial con­ is considered by senior staff to be the pre­ The global guidelines for HIV/IF should be ferred option of HIV-positive women, with straints, followed by access to clean water modified for Myanmar to reflect the find­ cost the main barrier. and fuel as major obstacles. Senior profes­ ings of this formative research, which was sionals felt mother could only safely re­ designed to explore infant feeding options. placement feed if they could afford to buy Staff believe mothers can be taught how formula. to prepare formula safely and feel it should Methodological considerations/ be provided free as part of pMTCT reviewer’s comment Rice was the most frequently suggested programme. (Please note that there is no alternative food after cessation of breast- local infant formula, and imported brands This was a detailed study of current prac­ feeding, since infant formula is considered are labelled in English, Chinese, Malay or tices and attitudes, plus trials of improved too expensive. Less than half of the health Thai, not Burmese.) (alternative) practices, which greatly in­ professionals were aware that a child from formed the development of guidelines for 6-12 months who is not breastfed still Few have experience feeding infants ani­ use in this area. Great detail is also pro­ needs milk/milk products in addition to mal milks but TIP suggested that cow and vided on improved complementary feed­ complementary foods. goat milk may be an acceptable option for ing, which has not been included in this some mothers and very likely to be an op­ summary. tion after cessation. However, many fami­

44 HIV and Infant Feeding NIGERIA

cations ranged from 6-16 years (mean Weaning practices: 81% had weaned at 12­ Early and Abrupt Cessation of 10.6). KIs (18) were held with health work­ 18 months (mean 16 months); 38% BF in Nigeria (Isiramen, 2002) ers. The site was the Departments of Pae­ achieved weaning within one day; 20% diatrics and Obstetrics, Ahmadu Bello Uni­ within 2-3 days; and 26% within 7-14 days. Document title versity Teaching Hospital, Kaduna, Nigeria, Early and Abrupt Cessation of designated as one of three proposed na­ How weaning was achieved: Weaning was Breastfeeding In The Nigerian Context: Is This An Option For HIV Positive Women? tional pMTCT sites. achieved by applying something to the breasts, taking the child to a relative, giv­ Author Isiramen V Subjects were health workers (all HIV/AIDS ing other food or milk (41%), decreasing Institution counsellors or lactation managers: five the number of breastfeeds (26%), or ‘noth­ Institute of Child Health, University paediatricians, four obstetricians, two nu­ ing special’ (22%). College, London; Ahmadu Bello Univer­ tritionists, two midwives, two paediatric sity Teaching Hospital, Kaduna, Nigeria nurses, one research/community nurse, two Reasons for weaning: Babies were weaned Date August 2002 community health workers) and women because they were considered old enough who attended paediatric outpatient clinics (51%), to encourage the infant to eat and Country Nigeria at the teaching hospital and have one other to eat other foods, refusing the breast, Document type MSc dissertation child that they had breastfed. mother going to work, and advice from Source Author others. No mother mentioned worry about Questionnaires were administered in English HIV infection as a reason for weaning. Only Background and FGDs were conducted mostly in En­ two women re-lactated after weaning. glish. Problems weaning: 56% had no problems; The Nigerian national HIV seroprevalence 30% had pain; 17% had engorgement; and rate is 5.8%, and that of Kaduna, Nigeria is Results 8.1%. 19% reported infant crying excessively. Quantitative Study: 60 participants were Knowledge of MTCT: 14% had some knowl­ The aim of the study was to: 1) define and aged 18-42 (52% 24-30, mean 31); 85% edge of MTCT; 5% knew of MTCT through explore the process of early and abrupt had 4-19 years of education and 15% had cessation of breastfeeding in the Nigerian no education; Islamic and Christian; Age breastfeeding; and 91% knew of transmis­ sion by sexual intercourse. context; 2) find out how HIV-positive of weaning (meaning no breastfeeding): 3­ mothers can be supported by health work­ 24 months (mean 15-16); Age of this child: ers in this practice; and 3) use the infor­ 2 weeks to 2.5 years (mean 9.1 months); Themes: Breastfeeding is “normal”, impor­ mation gathered to improve the effective­ Age of previous child: 9 months to 10 years tant, nutritionally adequate. Other fluids ness and acceptability of messages and ser­ (mean 4 years). are given because of thirst, “cleaning out vices for MTCT prevention in Nigeria. the gut”, abdominal pain, skin conditions. Feeding practices: Predominant breast- EBF is thought to cause thirst, is difficult and stressful. Mothers seemed very respon­ Methodology feeding (PBF, defined as introduction of other liquids at less than 1 month) was sive to educational messages given by Baby Friendly Hospital-designated institutions. This was a cross-sectional qualitative (us­ 48%; exclusive breastfeeding (EBF) was Mothers suggest that three months EBF is ing focus group discussions [FGD] and key 33% at 4-6 months; mixed feeding more practicable than six. Relatives make informant [KI] interviews) and quantitative (breastfeeding plus introduction of other EBF difficult. Time for stopping (structured directed questionnaires) study. milks or cereal) was 19% at 4-6 months. breastfeeding coincides with the child Qualitative study: Two FGDs were held with More education was associated with more walking and eating other foods (for boys eight women in each, age 18-38. Their edu­ EBF.

A Compilation of Programmatic Evidence 45 18 months [otherwise they will be “dull”], about cost of replacement food, and did frequently used), and donated infant for­ for girls 21 months). not mention stigma. Health workers con­ mula. sidered abrupt cessation to be unethical and Early weaning (generally defined as under unacceptable; they would rather recom- Conclusions and 10 months) is unusual. Accepted reasons mend/supply replacement feeds from the recommendations of authors included pregnancy, refusal of breast milk start. How to do it - many health workers and mother’s ill health. Unacceptable rea­ do not even want to discuss early abrupt There were low rates of EBF; abrupt early sons included mother’s career and fashion cessation, but suggestions related to ces­ weaning occurs, is acceptable (if for the consciousness. sation of breastfeeding included the need “right” reasons), affordable and feasible, but for: 1) good preparation – train health health workers do not accept it. Abrupt weaning (generally defined as oc­ workers in infant feeding counselling, team curring over 1-3 days) is preferred and most work between physicians and nutritionists, Author recommends: 1) training/research common. Abrupt weaning is achieved by free VCT, support groups, infant feeding on infant feeding counselling, 2) more VCT sending the baby to a relative, mother stay­ counselling during pregnancy and infant availability, 3) anti-retroviral drugs, 4) HIV ing out all day, giving the baby snacks and feeding clinics; 2) support during EBF – positive mother-friendly services, 5) pro­ drinks, covering the breasts or putting bit­ make lactation managers available at ini­ vision of replacement food, and 6) research ter tasting substances on them, wearing a tiation of breastfeeding, regular follow-up, on the use of soya as replacement feed. firm brassiere, mother decreasing fluid in­ breastfeed to the clock (not on demand), gradually increase the time between feeds, take, expressing breast milk, using analge­ Methodological considerations/ express breast milk into a cup (to get the sics, balm, and having a “strong will”. Health reviewer’s comment workers recommended weaning over 1-2 baby accustomed to using a cup), pacify weeks. the baby with massage, rocking, talking, Study strengths: This was a careful explo­ need to commit to a family planning ration of practices and opinions regarding method; 3) support during transition – Weaning foods: From 4 months babies re­ early abrupt cessation of breastfeeding. someone else to care for the baby, hospital ceived pap (porridge, various sorts) with or There was considerable experience of admission, and introduce replacement without soya beans, groundnuts, palm oil, abrupt cessation. crayfish, bananas, eggs, with or without foods stepwise and in small quantities. sugar, commercially prepared cereals. By six Health workers recommended supportive Study weaknesses: The only mothers stud­ months babies received adult diet of rice, brassiere, analgesics, diuretics, lactation ied were those attending a teaching hos­ suppressants and family planning. Moth­ beans, potatoes, yams but not milk. pital. Mothers had little knowledge of MTCT. ers suggested psychological support, wet- Early abrupt cessation: Mothers wanted nursing (how common this practice is not advice from health workers, were worried discussed), cow or goat milk (although in­

46 HIV and Infant Feeding RWANDA

gress, experience, and lessons learned in the lenges. Because the Rwandan government Rapid Assessment of pMTCT in pMTCT pilot sites and identify key issues wanted to put an HIV/AIDS initiative in Rwanda (Pham et al, 2002) and challenges to scaling-up; 2) examine place, the program has focused on rapidly the mechanisms of collaboration, coordi­ rolling out pMTCT services so that there will Document title nation, and linkage with bilateral and NGO be sites that offer pMTCT in each of the Report on the Rapid Assessment of the partners; and 3) contribute to the prepa­ health districts. The program was launched, UN-Supported PMCT Initiative in Rwanda: Pilot interventions at Kicukiro, ration of a practical programming frame­ however, before national protocols and Muhura, and Gisenyi Health Centers work, including scaling up strategies and guidelines for voluntary counselling and requirements for technical and resource testing (VCT), infant feeding counselling Authors supports. Lessons learned and best prac­ and other pMTCT services could be final­ Pham P, Musemakweri A, Stewart H tices derived from the evaluation will help ized and disseminated. basic support sys­ Institution form the basis for the large-scale expan­ tems need to be strengthened, including Population Council/HORIZONS Project sion in Rwanda. The research was under­ training, communication (advocacy, BCC

Date December 2002 taken by the National University of Rwanda and community mobilization), and moni­ with financial and technical support form toring and evaluation of all pMTCT services. Country Rwanda the Population Council and UNICEF- Document type Rwanda. Selected findings related to IF included 1) Program evaluation clients, in general, did not receive adequate (under review, not for circulation) Methodology information on danger signs during preg­ Source UNICEF Headquarters nancy, breastfeeding and replacement Six standard instruments were used to col­ feeding; 2) pretest counselling and health Background lect information from clients, providers, site talks were found by clients to be useful in managers and other pMTCT stakeholders determining how to discuss HIV/AIDS-re- lated issues with their partner; 3) confi­ This report summarizes a rapid assessment at the three clinics from May 27 to June dentiality was maintained, but privacy and of UNICEF’s pMTCT pilot project in Rwanda, 11, 2002. Quantitative and qualitative shortage of staff in this service were seen where approximately 13.7 % of Rwandans methods were used to collect facility-based as constraints; 4) infant feeding counsel­ aged 15-49 are HIV-positive (a conserva­ data on the quantity and quality of ser­ ling (IFC) is the weakest service in the tive estimate) and where about 430,000 vices; and qualitative information was col­ pMTCT package because of the lack of clear adults and 65,000 children were infected lected from providers and clients related protocols of guidelines that providers can by the end of 2001. UNICEF began piloting to program implementation, the supply refer to. Since the government cannot sus­ PMTCT programs in April 1999 at the situation, community reactions to the tain artificial milk as an infant feeding Kicukiro Health Center (KHC) and later pMTCT program, and lessons learned on the choice at this time, exclusive breastfeeding launched two additional programs in successes and challenges. Two days were with early weaning after 4-6 months is the Muhura (Byumba province) and in Gisenyi allocated at each site. A total of 30 clients most affordable and accessible infant feed­ (Gisenyi province). UNICEF plans to expand and 34 providers were interviewed; 106 ing choice for new mothers; 5) providers to 40 sites by 2006. The Interagency Task observations of 5 pMTCT services were held usually recommend replacement feeding or Team on Prevention of HIV in Pregnant (ANC, VCT, IFC, GM and FP); and four focus formula feeding to their clients, even Women, Mothers, and their Children (IATT), groups were conducted. though these choices are not financially which includes UNICEF, UNFPA, WHO, sustainable. (There was frustration with not UNAIDS and the World Bank, are prepar­ Results being able to offer artificial milk to clients ing to scale up pilot intervention and ini­ who could not afford it and who could not tiate other pMTCT interventions in Rwanda. The rapid assessment determined that, al­ safely breastfeed given low CD4 counts [less This rapid assessment was conducted in though the three pilot sites differ, they than 100].); 6) administrators and provid- order to 1) examine and document pro­ share some common successes and chal­

A Compilation of Programmatic Evidence 47 ers at two sites did not know how their ANC session observations at the third site Under general lessons learned, site man­ clients were educated about infant feed­ revealed that IFC was discussed in only 1of agers and the evaluation team noted that ing choices because counselling on this 13 sessions. Providers reported that artifi­ the pMTCT program would benefit by 1) topic was done off-site; 7) women admit­ cial milk was available in limited quantities developing a system for postnatal follow- ted being fearful of telling partner that they and was reserved, at the discretion of the up of clients and newborns; 2) adequately were HIV-positive. Few males are involved administration, for “exceptionally poor cli­ training providers and offering periodic in the pMTCT program. ents.” upgrading training on pMTCT services; 3) developing strategies to increase and main­ Observations of IFC in one of the three sites Conclusions and tain staff motivation; 4) increasing com­ revealed that no provider gave client in­ recommendations of authors munity awareness of and participation in formation leaflets on infant feeding op­ the pMTCT program; 5) increasing male in­ tions. Counsellors were inconsistent in the Information and IF counselling: pMTCT volvement in the pMTCT program; 6) in­ way they presented information on EBF, counselling on IF needs to be strengthened. volving the community in pMTCT in order early cessation, advantages and disadvan­ Providers need to be given information on to follow up pMTCT clients, support HIV- tages of infant formula and modified ani­ how their clients will be counselled off- positive mothers, and reduce stigma; and mal milk. Clients were not taught about site and what the content of that counsel­ 7) integrating pMTCT services into main­ optimal methods of breastfeeding, but ling will be. stream ANC, maternity and nutritional ser­ those clients who opted for artificial feed­ vice, and into the purview of health dis­ ing were informed about safety issues con­ Care and support: Support for HIV-nega- trict management. cerning formula preparation. tive and HIV-positive clients needs to be strengthened; no pro forma follow-up care Methodological considerations/ The focus group discussion on the topic of is provided to help HIV-negative women reviewer’s comment breastfeeding at another site reflected the stay negative and HIV-positive clients find dilemma of counsellors’ discussing IF op­ resources to help them take care of them­ This rapid assessment appears to have been tions that are not actually feasible for cli­ selves and their babies. extremely well organized, generating a ents being counselled. Since replacement great deal of valuable information in a rela­ feeding is no longer provided at this site, Male involvement: Men need to be encour­ tively short period of time using 6 struc­ only exclusive breastfeeding is promoted. aged to participate in the pMTCT program tured instruments appropriate for the col­ All FGD participants, however, believed that and should be provided with information lection of relevant quantitative and quali­ the pMTCT program actually recommended about pMTCT at VCT centres. tative data concerning pMTCT operational replacement feeding over breastfeeding for issues, health care providers and clients. The babies of HIV-positive mothers, but the Client-provider relationships: Good rela­ results are presented systematically, and problem was the poverty of the popula­ tionships between clients and providers are organized by program site and key issues tion. One participant said that women were key to the clients’ success in following in a way that is useful to the reader. forced to switch to breastfeeding when the through with the pMTCT package, and pro­ health centre stopped providing free arti­ gram success depends on a high level of ficial milk. dedication of health care providers.

48 HIV and Infant Feeding SOUTH AFRICA

Methodology Breastfeeding Promotion and of mothers introduced formula because IF Practices in South Africa they felt they had insufficient milk or were Focus group discussions were held with lay returning to work. The view that formula (Bentley et al, 2002) counsellors and mothers to guide the de­ was good for babies increased at both sites, velopment of the intervention. The inter­ and there was a significant increase in the Document title vention consisted of 12 lay counsellors, use of formula in the previous 24 hours at Breastfeeding promotion and infant feeding practices in South African women selected from the community and trained the control site (45.8% to 56.9%), where living in an area of high HIV prevalence in breastfeeding counselling, promotion free formula was given during the last seven and support, who worked at the clinic and months of the intervention period. Authors local delivery facility (tertiary hospital) and Bentley J, Coutsoudis A, Kagoro H, Newell HL visited mothers in their homes. Posters and Widespread use of over-the-counter medi­ educational pamphlets were also distrib­ cation (44.8%) and water (31%) was found. Institution uted and four articles placed in the local Water use was significantly reduced in the University of Natal, South Africa; Medical newspaper. Baseline and evaluation (17 intervention area (32.7% to 20.6% of in­ Research Council, South Africa; Univer­ sity College, London months later) questionnaires on infant fants) and increased (30.1% to 40.7%) in feeding practices were administered to the control area. In the intervention area, Date 2002 mothers attending the clinic in the inter­ there was a significant reduction in the use Country South Africa vention (n=214 baseline and 209 evalua­ of traditional medicines (10.3% to 3.3%), tion) and a control (n=217 and 209, re­ but no comment is made on commercial Document type spectively) area, with infants aged 0-26 over-the-counter medicines (such as gripe Manuscript submitted for publication (not weeks. The control site was a pMTCT pilot for distribution) water, etc.). site where free formula was given during Source Authors the last seven months of the intervention There was a significant reduction in the period. early (14-26 weeks) introduction of solids Background among infants at the intervention site Results (89.9% to 73.5%) and no change at the Results from a study of HIV transmission in control site (about 85%). Durban suggest that exclusively breastfed Formula use within first 24 hours decreased infants are less likely to become infected significantly (30% to 0%) at the interven­ An increase occurred in the number of than those who are mixed fed. Exclusive tion site and increased significantly at the mothers leaving expressed breast milk when breastfeeding (EBF) in the first 6 months control site (4.8% to 15.4%), even though separated. This activity rose from 5.8 to has been shown to be beneficial in terms initiation of breastfeeding within the first 25% (significant) in the intervention area of health in both developing and devel­ hour was lower at the intervention site (due and from 6.7 to 11.4% (not significant) in oped countries. The 1998 DHS survey in to tertiary hospital practices). the control area. These increases may have South Africa showed an EBF rate of 10.4% been due to the distribution during the in­ in infants under four months. Bentley et al Most (over 80%) mothers breastfed dur­ tervention period of a provincial govern­ aimed to assess the EBF rate in an area of ing the previous 24 hours: the rate was ment pamphlet about expressing breast high HIV prevalence where free infant for­ similar at both sites, before and after the milk. mula was being provided to HIV-positive intervention. mothers, in combination with an extensive EBF was significantly protective for diar­ breastfeeding promotion and support strat­ The exclusive breastfeeding rate increased rhoea compared with non-exclusive egy. significantly from 13.9% to 21.5% in the breastfeeding (4.8% versus 18.7% reported intervention area but did not change sig­ diarrhoea episodes in the previous two nificantly in the control area. Nearly 60% weeks).

A Compilation of Programmatic Evidence 49 Breastfeeding advice was received from HIV-positive mothers (seven part of pMTCT Khayelitsha, South Africa various sources, including health staff, programme, remainder did not receive AZT breastfeeding talks at clinic and home vis- MTCT Programme but were receiving free formula) and 11 (Chopra et al, 2000) its from breastfeeding counsellors. Some health workers (mainly the nutrition coun­ suggestion was made that health staff at sellors for the pMTCT programme); and the intervention site had shifted the re­ Document title household interviews and Trial of Improved sponsibility of providing infant-feeding Summary of the findings and recommen­ Practices (TIPS) in 17 homes. The house­ dations from a formative research study advice to breastfeeding counsellors, as more from the Khayelitsha MTCT Programme, hold interviews systematically overrepre­ mothers at the control site had received South Africa sented better-off households. such advice from health workers than at Authors the intervention site. Chopra M, Shaay N, Sanders D, Results Sengwana J, Puoane T, Piwoz E, Conclusions and Dunnett L From interviews with caregivers (unknown recommendations of authors Institution HIV status; n = 70): University of the Western Cape Public It is possible to improve exclusive Health Programme; USAID (SARA Caregivers had poor knowledge about MTCT breastfeeding rates at a population level, Project); DoH Provincial Authority of risk: 40% stated that transmission occurred Western Cape even in an informal (and likely transient) primarily during pregnancy, 27% men­ community. Date May 2000 tioned breastfeeding as a mode of trans­

Country South Africa mission, while only 7% mentioned deliv­ Exposure to conflicting advice and infor­ ery. When probed, 62% affirmed that they mation (perceived health worker endorse­ Document type Research report had heard of transmission through ment of formula through free provision as Source Author breastfeeding: 30% believed all HIV-posi- part of pMTCT programme, media cover­ tive mothers who breastfeed transmit the age of MTCT risk through breastfeeding, Background virus to their infant, and 45% said they little support for EBF in tertiary hospital didn’t know what percentage of HIV-posi- and then promotion by breastfeeding tive mothers would transmit the virus if In 1998 the Provincial Authority of the counsellors) highlights the need for com­ Western Cape decided to provide a free they breastfed. prehensive, coordinated and specific mes­ short course of antenatal and intrapartum sages regarding exclusive breastfeeding. AZT to HIV-positive women in Khayelitsha, Caretakers believed knowledge of MTCT risk an urban township near Cape Town with a would have little impact: 90% of respon­ Methodological considerations/ seroprevalence of 15%. Women were told dents said they would not change their in­ reviewer’s comment not to breastfeed and were given a pre­ fant feeding practice as a result of know­ scription for free formula, which could be ing the risk of transmission via This was a small but carefully implemented obtained at local clinics. This report pre­ breastfeeding, but 68% stated that an HIV- study, conducted at baseline and follow- sents the findings of a formative research positive woman should not breastfeed her up in both the intervention and control study of infant feeding practices and the baby. clinic areas. influence of the pMTCT programme on in­ fant feeding in the Khayelitsha area. Many (80%) knew a woman who did not Weakness. Only mothers attending clinic breastfeed: One-third thought this was because she was HIV-positive. Family, com­ were interviewed. Methodology munity and health worker reactions to women who did not breastfeed were re­ This study involved structured interviews ported to be very negative, as they will as­ with 70 caregivers randomly selected from sume infidelity, a desire to become preg­ clinics; semi-structured interviews with 11 nant again or negligence of the baby.

50 HIV and Infant Feeding Numerous advantages of breastfeeding Infant-feeding counselling was poor: No Formula preparation inadequate: Although were reported by “nearly all” caregivers, mother reported discussion of options or water was boiled (not for more than 1 including protection against disease and risk of each choice, and mothers were only minute) and scoop used, the number of bonding, with an optimum duration of two told about infant feeding during pre-test scoops varied enormously (one-to-seven). years. Only one woman reported that counselling. Limited information had been Caregivers reported not saving unfinished breastfeeding protected against HIV. given on how to correctly formula feed. feeds, although household income suggests They reported receiving one kg of formula that formula cannot be easily afforded and So-called “exclusive breastfeeding”18 was per month, which would be supplemented “most” reported running out of formula practised for a very short time, with half of with sugar water or juice between milk during the month. caregivers reporting the introduction of feeds (only given three-to-four times a day formula (mostly Nan or Pelargon) before to conserve milk). Solids were introduced Cup feeding during the day was readily one month and most before three months. by four months of age. taken up, but no mothers of infant under Such EBF was practised by default by those four months were willing to try EBF. Some unable to afford other milks or if baby re­ From interviews with health workers mothers (one third) succeeded in express­ jects the bottle. (n = 11): ing milk, but the idea of boiling breast milk was alien and dismissed. Early introduction of commercial comple­ Poor counselling: Health workers (HWs) had mentary feeds occurs before four months, limited knowledge of optimal infant feed­ Maize meal porridge was widely fed to on advice of health workers, or purchase ing and were unclear about MTCT risks; they young babies, but rarely enriched, despite by family members. Cues for introduction were increasingly confused as a result of on-site availability of oil, margarine, pea­ of solid food include crying after breast or the pMTCT programme. nut butter and eggs. bottle feed, reaching for food and teeth­ ing. All reported telling HIV-infected mothers True EBF was rare and formula feeding is not to breastfeed, and no HW accepted becoming the norm, among all mothers. From interviews with HIV-positive moth expressing and heat-treating breast milk. Health workers often recommend early ers (n = 11): None had seen national or provincial guide­ supplementation with formula and/or sol­ lines for MTCT. ids. Commercial weaning foods and un- None reported discrimination for not enriched porridge are introduced very early, breastfeeding: These mothers told people HWs gave mixed responses to a study re­ but mothers are willing to accept and adopt a variety of explanations: have TB, breast porting reduced risk of MTCT with EBF. Four enriched porridge and cup feeding. sores, “have poison in breasts”, told not to said they did not believe the results and breastfeed by health worker. would not change their advice; seven said Conclusions and they would. recommendations of authors All said they were advised (during pre-test counselling) not to breastfeed if they were From household observations and TIPS Strengths of pMTCT programme: Mothers found to be HIV-positive: “Most” found it (n = 17): in the programme have benefited from fac­ difficult not to breastfeed, but all reported ing up to their diagnoses. Support groups that they had never done so due to the Households had basic sanitation and food: facilitated this progress. Programme tools risk of transmission. When told of the study “Nearly all” had on-site soap, water, sani­ for formative research are very useful. reporting reduced risk of MTCT with ex­ tary facilities, formula tins, and bottles that clusive breastfeeding, ten HIV-positive appeared clean, some graduated for vol­ Weaknesses of pMTCT programme: The mothers did not believe the results, and all ume. Most had vegetables, fruits, commer­ quality of counselling provided by health 11 said they would not breastfeed exclu­ cial cereals, and facilities for storing for­ workers is generally poor. The pMTCT sively in the future. No mother reported mula. Ten had a refrigerator or cooling cup­ programme has further confused them being informed about the risks of not board. about appropriate messages. breastfeeding.

A Compilation of Programmatic Evidence 51 Stigma related to HIV/AIDS: Despite high taken during labour, NVP for their babies, South Africa National pMTCT public awareness of HIV/AIDS, it elicits fear as well as free formula for six months. This and stigmatisation in the community. In Pilot Sites (McCoy et al, 2002) report presents data from an evaluation of contrast, many HIV-positive mothers said the pilot sites carried out at the end of 2001. they coped well with public disclosure. Document title Interim findings on the National PMTCT pilot sites: Lessons and recommenda­ Methodology HIV and breastfeeding: Widespread misun­ tions derstanding among health workers and Data collection included key informant in­ Authors caretakers about the risk of spreading HIV terviews, site visits and document reviews McCoy D, Besser M, Visser R, Doherty T via breastfeeding. As a result, health work­ of routinely collected and programme-spe- ers advise all HIV-positive mothers to for­ Institution cific registers. Data on infant feeding (IF) mula feed regardless of risk, resulting in Health Systems Trust, for National reflects reported practices and reported IF Department of Health, South Africa no informed choice. All HIV-positive moth­ intentions, as stated by the mothers soon ers interviewed were formula feeding ex­ Date February 2002 after delivery. (Researchers recognize that clusively and struggling financially; some mothers may report what they believe the Country South Africa gave insufficient or over-diluted formula. nurse/counsellor collecting the information Some might have chosen to breastfeed had Document type Published report wishes to hear.) There was no data on trans­ they been given all information. There is Source Author mission, since the pilot programme had not an urgent need to train health workers to been implemented for a long enough pe­ appropriately inform mothers. riod of time. Background

Infant Caring Practices: Feeding practices Results should be monitored to inform on-going At the end of 2000, the South African gov­ ernment decided to implement a pilot advice and support for mothers, and HIV- programme for pMTCT at two sites in each Most women choose to replacement feed negative mothers should be assessed to (RF) using infant formula, although there determine whether they/their children are of the nine provinces. This programme pro­ vided women who requested appointments is considerable variation across sites. being adversely affected. for antenatal care with VCT and counsel­ Breastfeeding was more prevalent in rural ling on infant feeding. Women identified areas and in Durban. Methodological considerations/ as being HIV-positive are given NVP, to be reviewer’s comment

This was a large and carefully conducted Programme description study, but there was systematic Number of sites 193 health facilities overrepresentation of better-off house- (21 hospitals, 12 MOU/CHC/day hospitals and poly clinics, 160 clinics) holds in the household observations. Coverage Approximately 6090 antenatal appointments per month (about 9% of national antenatal appointments per month) Uptake Only about 51% of women agree to test for HIV, with wide range of uptake figures across sites. Seroprevalence Ranges from 8.7% to 36.2% across provinces ARV intervention NVP was provided to mother at 28 weeks with instructions to take it at onset of labour. Baby is given NVP 24-72 hours post-delivery, unless mother took a dose less than two hours before delivery, in which case baby is given an additional dose immediately after birth. IF counselling An assessment is made of mother’s ability to provide safe formula feeding; she is then advised on which feeding option may be most appropriate. Breastfeeding Women choosing to breastfeed were advised to do so exclusively. No information was given on recommended duration of exclusive breastfeeding (EBF).

52 HIV and Infant Feeding Rural Mpumalanga: It was difficult to get Conclusions and On-going research in South Africa includes: data on breastfeeding, as mothers do not recommendations of authors ■ attend hospital for follow-up. Study of change in IF practices in 1800 ■ The authors recommend employing and mothers attending immunisation clin­ equitably remunerating more lay coun- ics Rural KZN: Hospital does not encourage sellors (but the reviewer found no link formula feeding, as counsellors “do not between this recommendation and the ■ Qualitative research into IFP in N. Prov­ consider mothers educated enough to cor- results). ince, North West and KZN (by HSRC) rectly mix feeds” and community associ­ to describe determinants ated formula feeding with being HIV-posi- ■ Complement VCT training with train­ tive. Retraining of health care workers was ing on infant feeding and child health. ■ Cohort of mothers at three pilot sites recommended to prevent coercion. (W. Cape, E. Cape, KZN) investigating ■ Reconsider providing free infant for- IF practices and transmission over first mula, as current policy may contribute Spillover of formula feeding was suspected, nine months of life. but no data on this was collected. Infant to increased mortality and morbidity, and may encourage mixed feeding. Free formula may also be shared with other chil- Methodological considerations/ infant formula may entice mothers who dren. reviewer’s comment could not safely replacement feed to opt for this IF method. This is an interim report, detailing the Province Rural/Urban RF EBF ■ A national commission of experts progress made by provinces in the imple- Gauteng Urban/Peri-urban 96% 3% mentation of the pMTCT pilot programme. Rural/Peri-urban 85% 15% should consider possible options: rec- ommend using infant formula only to Relatively little information is given on in- W Cape Urban/Peri-urban 95% 4% fant feeding practices. Rural/Peri-urban 73% 27% those who could afford to safely re- N Province Urban/Peri-urban 73% 7% placement feed; develop support and Rural N/A N/A strategy to enable women to exclu- Weakness: Data relate to IF practices col- Mpumalanga Urban 89% 11% sively breastfeed; target free infant for- lected by nurse/counsellor soon after de- Rural 74% 26% mula only to communities/households livery and reflect intention (and also bias Free State Urban 77% 23% that could safely replacement feed; and related to the mother having to report to Rural 68% 32% provide ARV to mother and infant for those who counselled them), rather than KwaZulu-Natal Urban 40% 42% duration of breastfeeding. actual practice after discharge from hos- Rural 65% 35% pital. E Cape Urban 69% 31% ■ If free infant formula is provided, con- Rural 54% 46% tinued access must be ensured. N Cape Urban 82% 8% Rural 100% 0% North West Urban 81% 19% Rural 79% 0%

A Compilation of Programmatic Evidence 53 modified HIFC Course, and the appropri­ If the intention seems appropriate, the Counselling Options for ateness of their choice and actual feeding counsellor affirms it and also gives infor­ HIV-Infected Women in Rural practice during the first week of life were mation that there are other options (e.g., SA (Rollins et al, 2002) compared. An ethnographic study was also heat-treating breast milk, alternative re­ conducted to describe the perceptions of placement feeds) that women may choose. Document title the trained counsellors with respect to their If circumstances do not favour the intended Counselling HIV-infected women on infant training and the task of counselling using feeding method or a better practice could feeding choices in rural South Africa the modified approach. be feasible, the counsellor discusses other Authors options in detail. Counselling takes place Rollins NC, Bland RM, Thairu L, Results over a number of sessions. Coovadia HM (for the Child Health Group) HIFC presents the advantages and disad­ If the mother is unsure about how she in­ Institution vantages of five or six options, and coun­ tends to feed, the counsellor starts by giv­ Africa Centre for Health and Population sellors found women were overwhelmed ing information on various options and Studies, South Africa; Dept Paeds and relative risks of transmission, before explor­ Child Health, University of Natal, South and still asked for explicit advice on how Africa; Centre for HIV/AIDS Networking, to feed their child. ing mother’s home and personal circum­ University of Natal, South Africa; Dept stances. Nutritional Anthropology, Cornell University, USA Counselling was modified to first consider woman’s feeding intention and then con­ Out of 189, 171 (91%) of women intended Date October 2002 sider appropriateness of the intended feed­ to exclusively breastfeed (EBF), while only Country South Africa ing practise based on circumstances, using 18 (9%) intended to replacement feed (RF: a visual tool where appropriate. The coun­ 17 formula, one modified cow’s milk). There Document type Draft manuscript selling session first starts with a discussion was no correlation between intention and Source Author of infant feeding over the first 12 months socio-economic variables, but if the mother of life and recommends that mothers ei­ was the main income provider, this was sig­ Background ther exclusively breastfeed (according to nificantly associated with the intention to WHO definitions) or exclusively replace­ give commercial formula. UNAIDS guidelines promote the informed ment feed for the first four-to-six months. free choice by mothers with respect to in­ The mother is then asked what her inten­ Most women did not have the four neces­ fant feeding (IF), but also recommend that tion is in light of her HIV status, and this sary conditions for safe RF (access to clean mothers be given “specific guidance in se­ intention is explored in terms of previous water, refrigerator, fuel for boiling water, lecting the option most likely to be suit­ experience, whether feedings would be regular source of income), but of the 28 able for her situation”. Understanding feed­ mixed or exclusive, plans to return to work, (15%) women who did meet these condi­ ing choices is complicated and making etc. tions, only three planned to RF. The others modifications to the WHO/UNICEF HIV and chose to breastfeed due to concerns with Infant Feeding Counselling (HIFC) Course Stating aim of a healthy child by two years stigma and practicalities of avoiding seemed necessary. At the time of this study, of age (HIV free and avoiding serious ill­ breastfeeding altogether. If a regular source free infant formula was not available at ness such as pneumonia or diarrhoea), this of income were removed from conditions, clinics in the area. method highlights the need for exclusivity another 11 women would have all three and the counsellor then explores the feasi­ remaining conditions available: none of them would have chosen exclusive RF. Methodology bility of the intention using a simple chart to focus discussion on home, personal cir­ cumstances (including prospect of disclo­ Fifteen women planned to replacement Pregnant women attending antenatal clin­ feed (RF) even though they had less than ics (n=189) were counselled using the sure and support) and family expectations.

54 HIV and Infant Feeding ideal conditions for safe RF: 10 in 15 had women who did have all four conditions two or fewer conditions for safe RF. Anec­ available still chose to EBF (due to family Experiences of Breastfeeding dotal evidence suggest that the plan to RF expectations, stigma, concerns about dis­ and Vulnerability was due to fear of transmitting HIV and closure and beliefs regarding benefits of (Seidel et al, 2000) the desire to completely avoid breastfeeding). breastfeeding. Document title Experiences of breastfeeding and A regular source of income is a major fac­ vulnerability among a group of HIV Intended RF was not necessarily initiated: tor in deciding to RF, but even if no regu­ positive women – discussions with a peer 12 out of 18 mothers initiated and contin­ lar income is available in household, most support group of HIV positive mothers at ued breastfeeding during the first week; mothers still chose to EBF, suggesting that King Edward Hospital, Durban, KwaZulu- Natal, South Africa 100% of mothers intending to breastfed a steady income is not a major influence initiated and continued EBF during the first on the decision. Authors Seidel G, Sewpaul V, Dano B week. Anecdotal evidence suggests this was Institution due to “baby friendly” environment in hos­ Most mothers who intended to RF initi­ Sante et Development, Universite de pital, mother’s reluctance to disclose sta­ ated and continued EBF in first week, sug­ Bordeaux, France; Department of Social tus, and family expectation to breastfeed. gesting that external pressures and com­ Work, University of Natal, Durban, South munity perceptions are very important. Africa Mothers seemed satisfied with counselling Date 2000 approach and counsellors believed their job Modified counselling approach seems to be Country South Africa involved helping women to make informed effective and focuses on woman’s view­ choices and that the training was relevant. point and insight into the feasibility of Document type feeding options. Journal article: Health Policy and Planning 2000, 15(1):24-33 Conclusions and recommendations of authors Methodological considerations/ Source SAFAIDS reviewer’s comment Criteria previously considered to be deter­ Background minants of feeding choice were not neces­ There was a potential bias in that women sarily the basis for intended practice. who were very dissatisfied with the coun­ There have been few studies that elicit selling they received may not return to or HIV-positive mothers’ experiences in Availability of safe RF conditions were lim­ be available or willing to participate at fol- breastfeeding and paediatric infection. ited in rural KwaZulu-Natal, but most low-up. There is an urgent need to document this knowledge and use the data to inform policy development and for advocacy and counselling purposes.

Methodology

Two in-depth discussions were held with a group of 13 HIV-positive mothers, using facilitators well known to the mothers. Dis­ cussions included further dialog to clarify ambiguous terms in Zulu and clarify mean­ ings.

A Compilation of Programmatic Evidence 55 Results abuse for not breastfeeding. One mother Methodological considerations/ reported that not breastfeeding had given reviewer’s comment Seven out of 13 HIV-positive mothers had her increased freedoms, but others felt that not breastfed because they had been “told” it broke the bond between mother and The methodological weaknesses in this not to breastfeed (although not initially); baby. study include: one had read about HIV transmission and ■ Use of group facilitators to conduct decided against breastfeeding, one had Women were not financially able to pur­ discussions, may have lead to bias, de­ overheard a nurse talking and acted on this chase infant formula and there seemed to pending on the skill of the facilitator information, and four had chosen not to be some confusion as to the formula milk and previous group dynamics. breastfeed because they were working or prescribed for their child while in hospital. seeking work. No formula is prescribed for use after dis­ ■ There was no discussion of how knowl­ charge, unless a child is on special feeds, edge of HIV status during pregnancy Only two of the 13 knew they were HIV- but this distinction did not seem to have influenced decision making. All moth­ positive during pregnancy, but all claimed been clearly explained to the group. ers were “lumped” together and there not to have been told anything about HIV is considerable bias in the reporting of transmission through breastfeeding, either Women who do not breastfeed are blamed results, such that they are occasionally during their pregnancy or immediately af­ and abused by male family members. contradictory and often initially rep­ ter. Those who had been advised to stop resent only one side of the data col­ breastfeeding had been told to do so only Women were “told” what to do in terms of lected. once their infant became sick. They ex­ infant feeding and not helped in decision- ■ pressed considerable regret and anger that making. Mothers’ opinions were retrospective this information had not been made avail­ and given in the light of their subse­ quent discovery of their HIV status. able to them. Conclusions and Their responses and recollection of in­ recommendations of authors The association between breastfeeding and formation regarding HIV and infant feeding may be biased by length of bouts of diarrhoea in their children caused The authors concluded that: 1) There is a recall and nature of the questioning. a number of participants to stop lack of information given to HIV-positive breastfeeding of their own account. mothers and pregnant women in general Although this paper highlights issues of about the risks of breastfeeding. 2) There inequality and hierarchy within the health Many mothers reported stopping breast- are different understandings of formula provider-client relationship that contrib­ feeding once their child was admitted and milk (including special lactose-free milks). ute to inadequate support for infant feed­ found to be HIV-positive: There was no 3) Although confirmatory data are lacking ing decision-making, some inconsistencies mention in the report of the potential ad­ as to whether nurses counselling women and misrepresentations of the data make vantages of continued breastfeeding for in infant feeding and the importance of it difficult to draw conclusions. The infected children. When one participant breastfeeding knew the women’s status, the women’s experiences and feelings about asked the others about the link between study highlights a form of denial of HIV infant feeding, after they had discovered breastfeeding and diarrhoea, there was and its transmission of HIV by nurses trained both their child’s and their own HIV status consensus that stopping breastfeeding did to support breastfeeding. 4) Women’s could have been explored in greater depth. not stop the diarrhoea. Even the child of knowledge and experience gained by the It was not clear at what age the data on the mother who chose not to breastfeed observation of a relationship between feeding practices presented was reported, from birth suffered prolonged diarrhoea. breastfeeding and diarrhoea were appar­ and this caused confusion, as feeding prac­ ently disregarded, thus humiliating moth­ tices had changed after diagnosis. Women’s Breastfeeding was seen as the norm and ers. discussions of infant feeding were quoted some women suffered verbal and physical as if all had known their status during preg­ nancy and had been denied information deliberately.

56 HIV and Infant Feeding SWAZILAND

Methodology Rapid Situational Analysis of BFHI has slowed down; and 5) formula BFHI in Swaziland (Vilakati feeding has “brought back malnutrition”. Checklist-guided interviews were con­ and Shongwe, 2001) ducted with health workers (doctors, nurses, Conclusions and counsellors) in six referral hospitals and five Document title recommendations of authors health centres. Rapid situational analysis of the BFHI in Swaziland Authors concluded that Swaziland should: Results 1) Re-launch the BFHI; 2) train more Authors Vilakati D, Shongwe N breastfeeding counsellors, and incorporate Institution 1) Promotion of breastfeeding still occurred, HIV/AIDS into the training; 3) effectively BFHI Taskforce, Swaziland Infant in principle, in all centres; 2) breastfeeding legislate and disseminate the ‘Code of Mar­ Nutrition Action Network (SINAN); policy was usually not displayed or known keting of Breast-milk Substitutes” to health National Nutrition Council of; 3) availability of VCT was very irregular; workers; 4) develop policy and guidelines Date May 2001 4) majority of health workers discouraged on HIV and IF; 5) establish a nutrition re­ habilitation centre; 6) consider providing Country Swaziland breastfeeding by HIV-positive mothers, but opinions disparate; 5) most health workers locally available and acceptable replace­ Document type did not know of the ‘Code’ or what it en­ ment foods; and 7) develop counselling Report of a “Rapid Assessment” tails; and 6) very little training had been materials and the educational capacity of Source UNICEF ESARO CD provided in infant feeding counselling. the public and health workers on MTCT and IF. Background Observations (no data was given in sup­ port): 1) Commercial infant formula and Methodological considerations/ The National Baby Friendly Hospital Initia­ feeding bottles (with teats) were seen in reviewer’s comment tive (BFHI) Taskforce was established in duty rooms and wards; 2) there were few 1992 and was challenged by aggressive breastfeeding counsellors; 3) communities This obviously rapid and cursory survey does marketing of breast milk substitutes and were still in denial, and people who were not provide substantiated data but does the emergence of HIV/AIDS. This study tested (VCT) usually did not return for re­ demonstrate confusion among health aimed to 1) establish the BFHI status in sults; those who did return are discouraged workers, significant problems with appli­ health facilities, 2) establish the impact of by delayed return of results; testing was cation of the “Code”, and a need for in­ MTCT on breastfeeding practices, and 3) mostly carried out in the central hospital creased capacity and effectiveness of VCT identify information gaps among health (lab capacity of peripheral units was inad­ and infant feeding counselling. care providers. equate); 4) the promotion and support for

A Compilation of Programmatic Evidence 57 TANZANIA

Results Counsellors expressed disbelief in the ef­ Counsellors’ Perspectives in N. fectiveness of heat-treating breast milk to Tanzania (de Paoli et al, 2002) Counselling appeared to have a coercive destroy HIV and counsellors felt it would element, and counsellors themselves re­ be very difficult to explain this to mothers Document title ported that their role included convincing (as they themselves were not convinced and Counsellors perspectives on antenatal pregnant women to take the HIV test and found it difficult concept to understand). HIV testing and infant feeding dilemmas facing women with HIV in northern regarded it a failure if they were could not Tanzania do this. Some counsellors (and educators) were

Authors unclear about the meaning of EBF and did de Paoli M, Manongi R, Klepp K-I Most counsellors believed that a women not believe it was possible. choosing not to breastfeed risked Institution stigmatisation of being identified as HIV- Incorrect advice was given about abrupt Institute of Nutrition Research, University positive and that this contributed to cessation of breastfeeding, counsellors of Oslo, Norway; Community Health Dept, Kilimanjaro Christian Medical College, women’s decision to breastfeed. The finan­ lacked knowledge of how to advise moth­ Tanzania cial burden of replacement feeding (free ers to feed an infant after cessation, and formula was not supplied) was also a bar­ advice on modifying cow’s milk was con­ Date 2002 rier, especially when the woman did not fused and incorrect. Country Tanzania disclose status to husband, who controlled the money. Source Author Counsellors knowledge of MTCT risk was inadequate, and risk of transmission Document type Replacement feeding was seen as an op­ through breastfeeding was regarded as Article in press (Reproductive Health tion only for educated women with eco­ much greater than risk of diarrhoea or Matters, 2002) nomic means, who were the minority. They malnutrition if not breastfed. were also assumed to have all the neces­ Background sary knowledge and skills to safely carry Counsellors emphasised that counselling out their infant feeding choice. was time-consuming and should include Studies in resource-poor settings have iden­ follow-up, but no facilities were available tified constraints and barriers—in terms of Counsellors realised that an infant feeding for this. Lack of follow-up contributed to infant feeding choices—for pregnant choice was difficult to implement in rural their feeling of lack of control and was women who are offered VCT antenatally. It areas and that EBF would be the best op­ viewed as major weakness of the trial. has been suggested that many weaknesses tion for HIV-positive mothers, although exist in the counselling currently provided most would only partially breastfeed, in Conclusions and by pMTCT programmes and that these must part because of the common belief that recommendations of authors be significantly strengthened. infants need additional water. However, knowing her HIV status may motivate some ■ The IF choice was seriously compro­ Methodology mothers to practise EBF. mised by the advice given, directive counselling and lack of time to cope In-depth interviews were held with all 16 None of the counsellors had breastfed ex­ with results and follow-up support. HIV/AIDS counsellors for a pMTCT trial in clusively themselves, questioned the safety ■ IF options were not always clearly ex­ Moshi, five local HIV/AIDS counsellors and of EBF and thought it would not be viable. plained, and counsellors believed two medical doctors who had been work­ If HIV-positive themselves, they would women had little choice but to ing in VCT for many years. chose replacement feeding breastfeed and were unlikely to EBF.

58 HIV and Infant Feeding ■ Risks and benefits of feeding options ing histories were obtained from the 309 were too complicated for counsellors Exclusive Breastfeeding in Era who had previous breastfeeding experi­ of AIDS (de Paoli et al, 2001) to understand. ence; a structured questionnaire was ad- ministered to them during a cross-sectional ■ Further training in feeding options, Document title interview by trained nurses from the refer­ counselling skills and cessation is Exclusive breastfeeding in the era of ral hospital. Six focus group discussions AIDS needed. (FGDs) were conducted with 46 pregnant Authors ■ Follow up is needed with mother to women attending the same clinics; about de Paoli M, Manongi R, Helsing E, enable counsellors to see to impact of half had participated in the interview sur­ Klepp K-I their advice. vey. A FGD was also held with 10 active Institution female members of the Kilimanjaro Institute of Nutrition Research, University Women’s Group against AIDS; information Methodological considerations/ of Oslo, Norway; Community Health Dept, from the FGDs was used to validate the data reviewer’s comment Kilimanjaro Christian Medical College, from the interviews. Tanzania ■ All counsellors were included and are believed to be representative. Date July 2001 Results Country Tanzania ■ Responses were perceived by inter­ High rates of initiation of breastfeeding viewer to be honest and credible, show­ Document type were found, with 85% initiating breast- ing no signs of wanting to impress. Journal article (J Hum Lact 2001, 17 (4); 313-320) feeding within the first few hours of birth and 91% reporting using colostrums. Re­ This study shows clearly how counsellors’ ported duration averaged 23.7 months and personal experience, lack of knowledge and Background did not vary by socio-demographic factors. skills and bias in favour of one feeding Mothers intended to breastfeed their cur­ option influence (and undermine) their Breastfeeding is widely practiced in Tanza­ rently expected child for 32.3 months on ability to provide adequate counselling that nia, where rates of initiation are high and average; shorter intended duration was is non-directive and supportive to HIV- prolonged duration (22 months) occurs. associated with factors including younger positive women. In addition, health worker However, median duration of EBF is only maternal age, lowest parity, unmarried sta­ knowledge and attitudes regarding the fea­ one month. Knowing more about the fac­ tus and urban residence. sibility of EBF was a major barrier to the tors that discourage or encourage EBF promotion of this feeding option. would help to assess its feasibility and iden­ The study found that 18% of newborns tify effective interventions to increase EBF rates. were given prelacteal feeds (usually water or sugar water) and the remaining 82% were given breast milk as first feed. Methodology

Exclusivity of breastfeeding was broken This study aimed to describe breastfeeding within the first few days by 46% with the practices and what pregnant women know introduction of water, sugar water or cow’s about MTCT, as well as explore socio-de- milk because child was believed to be mographic factors that are associated with thirsty, as breast milk did not quench thirst. current breastfeeding practices. Five hun­ Complementary foods were introduced on dred pregnant women (regardless of HIV average by 3.4 months of age. status) were enrolled at four urban and five rural clinics in the Kilimanjaro area. Feed-

A Compilation of Programmatic Evidence 59 Poor knowledge of MTCT risk was found, ■ Information about EBF and risk of MTCT Breastfeeding Promotion with only 37% correctly identifying pos­ were received with skepticism, particu­ sible routes of transmission. FGDs revealed larly due to strong belief that infants Dilemma in Tanzania (de Paoli et al, 2000) strong, widespread belief that all infants are already born infected. born to infected mothers are already in­ ■ fected in utero. Early introduction of fluids needs to be Document title challenged. Breastfeeding promotion and the dilemma posed by AIDS in Tanzania Breastfeeding was highly valued, but only 17% of women (mostly urban) knew that Methodological considerations/ Authors it was not necessary to offer infants addi­ reviewer’s comment de Paoli M, Manongi R, Klepp K-I tional fluids in the first four months of life. Institution Retrospective data on breastfeeding prac­ Institute for Nutrition Research, Oslo, Associations with longer EBF: Being mar­ tices is subject to recall bias and digit pref­ Norway; Kilimanjaro Christian Medical ried and knowing that additional fluids are erence. The study had high participation, College, Moshi, Tanzania but mothers were selected by clinic staff not needed before 4 months were the only Date 2000 factors associated with longer EBF. and not randomly Country Tanzania This research collected data that correspond Conclusions and Document type recommendations of authors with other known and documented find­ Report in MCH News 2000 (15) ings; the vast majority of African women ■ Some findings are consistent with other initiate and continue breastfeeding into the Source UNICEF ESARO CD studies in Tanzania: that while partial 2nd year of life. The study also tried to elu­ breastfeeding endures for long periods, cidate when EBF stopped and the factors Background EBF is rare and other fluids are often that may predict this. However, the sam­ given from a very early age. pling method chosen (women pregnant Transmission of HIV through breast milk has again) introduced further recall bias and complicated the advice on infant feeding ■ Young, unmarried, non-farming urban could have been reduced somewhat by se­ (IF) in resource-poor settings. This study women reported shortest intended lecting new mothers instead, in order to evaluated pregnant women’s perceived fea­ duration of breastfeeding, possibly due focus on early feeding practices and fac­ sibility of the Revised Guidelines on to perception that breastfeeding leads tors associated with EBF failure. Women’s Breastfeeding and HIV from June to Sep­ to less attractive breasts. knowledge of EBF seemed to be an impor­ tember 1999. ■ Attendance at urban clinic was associ­ tant factor in maintenance of EBF, although ated with greater knowledge of EBF, no details are provided as to the duration Methodology indicating that health worker knowl­ of this. Poor knowledge of MTCT risk fac­ edge, skills and motivation are influ­ tors was widespread, and in one FDG was This was a structured cross-sectional inter­ ential. shown to be an important barrier to ac­ view survey of systematically selected preg­ ceptance of EBF as a means to reduce MTCT nant women (n=500) attending one of nine ■ Knowledge of EBF was a strong pre­ risk. selected antenatal clinics in urban and ru­ dictor for not terminating EBF within ral settings. Focus group discussions (FGDs) the first few days. were also held.

60 HIV and Infant Feeding Results Cow’s milk was regarded as the most fea­ Rapid Assessment of pMTCT in sible IF alternative for HIV-positive moth­ All respondents had a strong intention to ers (other feeding methods, formula and Tanzania (Swartzendruber et al, 2002) breastfeed, and those with previous expe­ expressed heated-treated milk received low rience recalled a median duration of 2 years. scores). Thirty-seven percent strongly be­ lieved that advice to HIV-positive mothers Document Evaluation of the UNICEF-Sponsored These women largely believed that all in­ not to breastfeed would cause them wor­ Prevention of Mother-to-Child HIV fants of HIV-positive mothers were infected ries. The major obstacle to replacement Transmission (pMTCT) Pilot Sites in in utero, although a majority knew the vi­ feeding was financial resources for obtain­ Tanzania rus could be transmitted during pregnancy, ing and preparing it. However, if offered Authors birth and breastfeeding. Awareness of MTCT free or subsidised, it achieved highest scores Swartzendruber A, Msamanga G, was high and did not vary by demographic as a choice for HIV-positive mothers. PMTCT Evaluation Team factors. Institution The idea that EBF might be “protective” (this Centers for Disease Control and Preven­ was how concept was incorporated into One-third strongly believed pregnant tion; Tanzania Ministry of Health; Institute women should be offered VCT; depending FGD) was not easily understood, seen as of Public Health, Muhimbili University on motivation, 29% said they would contradictory and received with scepticism. College of Health Sciences strongly agree to VCT to help them make Date December 2002 IF decisions; and 39% would want to be Conclusions and able to receive medication to reduce the recommendations of authors Country Tanzania risk of MTCT. Document type Programme Report The authors concluded the following: Not Source USAID/Tanzania Only 7% had been tested themselves and to breastfeed was seen as a complicated 39% noted the importance of testing fa­ choice, and mothers would likely be labelled Background thers, too; however, half believed HIV sta­ as HIV infected and face a high risk of tus should be kept a secret in the family, stigmatisation. Efforts to involve husbands The population of Tanzania is currently es­ for fear of social ostracism. Many had wit­ should be considered as a way to reduce nessed ostracisms of people living with HIV/ this. There are still many dilemmas to in­ timated at 34.5 million, with a population growth of 2.9% per annum. Approximately AIDS (PLWHA). vestigate and MTCT efforts will face edu­ 2.2 million people aged 15 years and above cational challenges related to misconcep­ Seventy-one percent (71%) would lie about tions, stigma and how to advise mothers are HIV-positive. Among blood donors, the overall prevalence of HIV infection in 2001 their HIV status if they chose not to on infant feeding. was 11.01%. Estimated median HIV preva­ breastfeed, and two-thirds would not pub­ lence among women attending ANC clin­ licly show they were replacement feeding. Methodological considerations/ ics in 2002 was 9.6%, ranging from 5.6% They clearly believed breastfeeding was reviewer’s comment in Kagera to 16.0% in Mbeya. While 95.6% superior and the preferred IF method. of pregnant women in Tanzania register for This was a carefully conducted study, with ANC, less than half (43.5%) of women de­ strict random selection criteria. liver in health facilities (34.5% in rural ar­ eas and 82.8% in urban areas). Assuming 1.5 million annual live births, 12% HIV prevalence among pregnant women, and 40% risk of HIV transmission from mother to child with no pMTCT services and one- to-two years breastfeeding, an estimated

A Compilation of Programmatic Evidence 61 180,000 infants in Tanzania are exposed achievements and challenges; and to de­ and low short-course AZT uptake and ad­ to the risk of HIV infections each year, with scribe the progress and impact to date, as herence (8-20%). Infant follow-up was lim­ 72,000 becoming infected. In 1999, the well as the potential for expansion of ited and potentially biased, so effective­ under-five mortality rate was estimated to pMTCT services to other regions and health ness of the pilot project could not be de­ be 147 per 1,000 live births, and the infant facilities. termined. mortality rate was estimated to be 99 per 1,000 live births. Despite high HIV The evaluation of the five pMTCT program Training and human resource development: seroprevalence rates, the total fertility rate sites included: discussions with MOH and There was no clear training plan or train­ is 5.6 births per woman and only 15.6% of collaborating partners to understand the ing strategy, which resulted in a lack of all women aged 15-49 years currently use roles of stakeholders, as well as goals, ac­ standardization of training methods and any method of modern contraceptive. tivities and future directions; discussions content across sites. Training manuals, es­ with site coordinators and local pMTCT Task pecially the counselling and infant feed­ With support from UNICEF, planning for Forces to identify key activities as well as ing sections, need to be updated and sub­ the pMTCT pilot project in Tanzania began capacity, strengths and challenges; discus­ stantially improved. Staff at all sites re­ in 1998, and implementation of services sions with site implementers to understand ported feeling inadequately trained on in­ began in at five sites in 2000, four referral daily implementation of pMTCT services, fant feeding, family planning and primary hospitals (two of which each supported staff needs and perspectives; site visits to prevention. The team noted a lack of train­ health center activities) and one regional observe and understand daily implemen­ ing on counselling for disclosure, psycho­ hospital. The pilot project included: VCT for tation procedures and set up; and docu­ social support and bereavement. There had new ANC attendees using rapid testing; ment reviews to supplement information been no evaluation of any of the trainings short-course AZT to HIV-positive pregnant gathered by other methods (the original to determine the quality of the training, women (starting at 36 weeks); infant feed­ proposal, existing written site descriptions, and whether staff adequately learned and ing counseling; modified obstetric care; and monitoring forms, reports [progress, meet­ could implement the content. There was monitoring and follow-up, including HIV ings and final donor report to UNFIP], clini­ no assessment of the need to conduct on­ testing of exposed children at 15 and 18 cal guidelines and training material). going trainings for new staff or refresher months of age. In 2002, the Tanzania Min­ trainings at any of the sites. Staff had lim­ istry of Health (MOH) requested the US Results ited access to project manuals and proto­ Centers for Disease Control and Prevention/ cols to review or refer to when new situa­ Global AIDS Program (CDC/GAP) and Tan­ This evaluation generated a large amount tions or questions arose. Supportive super­ zanian counterparts to conduct an evalu­ of relevant pMTCT program information. vision was limited, especially emotional and ation of the 5 UNICEF-sponsored national The following findings are of particular in­ technical support for counsellors. pMTCT pilot sites to inform planning of terest to the discussion of HIV and infant integrated national pMTCT services in Tan­ feeding. Implementation of counselling and test­ zania. Specifically, the terms of reference ing: The voluntary, “opt-in” strategy to called for review of pMTCT service provi­ Coverage and program performance: The counselling and testing impeded coverage. sion and utilization at the pilot sites, site three regional and district health facilities Significantly, all sites successfully imple­ management, coordination and logistics, implementing pMTCT as part of the pilot mented rapid HIV testing to give same-day and impact of the pilot project. project reported more new ANC clinic at­ results. Although counsellors were gener­ tendees than all four of the referral hospi­ ally well motivated and supportive of the Methodology tals. The vast majority of women deliver­ project, pMTCT-related infant feeding, pri­ ing at the pilot sites were of unknown HIV- mary prevention and family planning coun­ The main objectives of this rapid assess­ status (up to 99%). Across all sites, the selling was especially weak. Counsellors ment, conducted December 2-10, 2002, evaluation team noted large differences in independently reported lacking skills in were to provide an overview of the pilot counselling rates (9-56%), high acceptance these areas and there was little evidence program; summarize key pMTCT activities, and good use of HIV rapid testing (78-84%) of organized postpartum infant feeding

62 HIV and Infant Feeding counselling. Counselors reported that they Community awareness and IEC: Initial sites and expand pMTCT coverage to all 21 did not feel that they had clear and fea­ sensitisation seminars were held at each site regions in mainland Tanzania and to ef­ sible infant feeding messages to give to for community leaders as the pilot project fectively monitor the reduction of HIV mothers. Program materials, job aids and began, but the evaluation team found very MTCT. The high number of unknown status scripts for infant feeding and general HIV- few on-going IEC and outreach activities deliveries at all of the sites calls for ex­ related counselling were lacking. and little or no on-going input into the panded pMTCT services to benefit all preg­ project from the local communities. Com­ nant women in Tanzania and emphasizes Infant feeding recommendations: The munity awareness of pMTCT seemed low the need to 1) explore how pMTCT services original protocol called for infant feeding at all sites. There was a lack of both na­ can be delivered in the labor and delivery counseling on safe alternatives to pro­ tional and local IEC strategies and materi­ wards and 2) integrate and coordinate longed breastfeeding (replacement feed­ als. Some sites created their own commu­ pMTCT services in both ANC and maternity ing, early exclusive breastfeeding and early nication materials and pamphlets, but, in services, as well as across different levels weaning, avoiding early mixed feeding, general, there was a lack of posters, pam­ of healthcare. etc.), but this appeared to be a weak com­ phlets or other educational aids in ANC clin­ ponent at most sites. Although UNICEF ics, including counselling rooms, where sites To meet these objectives, the team recom­ planned support for replacement feeding, had direct control and participation in the mends to: this did not seem to have been provided. display of materials. ■ Establish strong national pMTCT coor­ Replacement formula was provided only at one site, where a French organization pro­ Stigma and discrimination: Staff reported dination and management, with regu­ lar interactions and standardized re­ vided up to 12 months of formula to HIV- fear of stigma and discrimination were porting positive women who decided not to prominent barriers to women’s uptake of breastfeed, handling both procurement and pMTCT services at all sites. Counsellors re­ ■ Implement simple, reliable monitoring distribution. Women who chose not to ported that the vast majority of women systems breastfeed could obtain tablets from the did not disclose their HIV serostatus to their company to stop lactation, were trained to partners for fear of abandonment and vio­ ■ Update and finalize pMTCT policies as prepare the formula, and given a thermos. lence. These fears and lack of disclosure well as technical and instruction guide­ (The report does not specify who provides prevented women from attending coun­ lines the training and thermos.) Uptake of re­ seling, being tested and adhering to the ■ Improve pMTCT training and skills of placement formula was low (specific data AZT regimen, and also limited their infant healthcare providers by developing a is not provided), reportedly because most feeding choices. Across all sites, male in­ standardized training strategy; updat­ women did not disclose their HIV status to volvement in pMTCT was low and was ing content, especially related to in­ their partners and feared disclosure and thought to greatly contribute to women’s fant feeding counselling on feeding discrimination related to replacement feed­ low uptake of and adherence to services. options; developing a comprehensive ing. training-of-trainers guide; conducting Conclusions and site-specific assessments and evalua­ Monitoring and follow-up: There was no recommendations of authors tions of trainings standardized pMTCT monitoring system. There were many data inconsistencies and Despite a number of significant challenges ■ Develop job aids, scripts and counsel­ staff reported that the collection forms identified in the pMTCT pilot project, the ling guides for pMTCT health providers were burdensome and redundant. In addi­ team concluded that the pilot project dem­ ■ Develop job descriptions for pMTCT tion, the data were not compiled locally or onstrated that it is feasible to implement staff, provide supportive supervision, as centrally in an accessible database and were and scale-up pMTCT services in Tanzania not available for local planning or evalua­ and recommends that the next steps should well as emotional and technical sup­ port through regular meetings tion or to provide feedback to the pilot be to improve pMTCT services at the pilot sites..

A Compilation of Programmatic Evidence 63 ■ Develop and implement IEC strategies Methodological considerations/ however, to provide an objective descrip­ to improve community awareness and reviewer’s comment tion of the achievements and challenges sensitisation of pMTCT in coordination and management, imple­ Various limitations of this rapid assessment mentation and utilization of pMTCT ser­ ■ Integrate routine counselling and test­ were noted by the evaluation team, includ­ vices at the pilot sites. Despite the stated ing and support services into MCH and ing: limited time at each site; limited num­ limitations, the evaluation generated a RCH services (routine, “opt-out” ap­ ber of interviews with staff and pMTCT great deal of valuable information to im­ proach) partners; few direct interviews with clients; prove pMTCT at the pilot sites in Tanzania and few interviews with community mem­ ■ Change to a simpler ARV regimen (NVP) and to expand national pMTCT services and to increase uptake and adherence (al­ bers or leaders. Copies of instruments used raises important questions about where in the evaluation are not included in the ready under discussion at the time of pMTCT services might be best focused in report and there if no discussion of their the review) the future. application. Although a secondary objec­ ■ Expand the number of sites offering tive was to inform the expansion of pMTCT pMTCT services (regions and districts), services, the team did not formally evalu­ with support from referral hospitals as ate the process or resources required for technical and training resources. expansion of activities. The report appears,

64 HIV and Infant Feeding THAILAND in Chiang Rai province, northern Thailand, (5% mixed, only 1 mother EBF); 87% had where antenatal seroprevalence was 10.8%. originally planned to breastfeed, but this Women were routinely offered counselling dropped to 6% after discovering their sta­ IF Practice and Attitudes in and HIV testing, with high acceptance rates. tus. Most women had worried they could Northern Thailand HIV-positive mothers were counselled not not afford infant formula and were afraid (Talawat et al, 2002) to breastfeed. that replacement feeding would disclose their status. Furthermore, 87% were asked Document title Structured, face-to-face interviews were by members of their community why they Infant feeding practices and attitudes conducted with 3 groups: 1) HIV-positive were formula feeding: 27% had responded among women with HIV infection in mothers (n=80, here ‘gp1’), 2) HIV-positive that they were HIV-positive and 73% had northern Thailand pregnant women (n=36, ‘gp2’) and 3) preg­ answered that their doctor had advised it Authors nant women of unknown status, after pre­ or they had insufficient breast milk. Lastly, Talawat S, Dore GJ, le Coeur S, test counselling and testing, but before they 83% of women of unknown status planned Lallemant M had received their results (n=86, ‘gp3’). Per­ to breastfeed, but only 25% of antenatal

Institution ceived advantages of breast and formula HIV-positive women planned to do so. National Centre in HIV Epidemiology and feeding were assessed using a 4-point scale Clinical Research, University of New for each category of convenience, cleanli­ Conclusions and South Wales, Australia; Institut National ness, low cost and safety. recommendations of authors d’Etudes Demographiques, Paris; Institut de Reserche pour le Developpement, Chiang Mai, Thailand; Harvard School of Results Breastfeeding was seen to be more advan­ Public Health, Boston tageous than formula feeding, yet there

Date 2002 Breastfeeding was considered more advan­ was a high level of compliance with the tageous than formula. Breastfeeding re­ advice to HIV-positive women to formula Country Thailand ceived near maximum scores in each cat­ feed. This may indicate high quality of in­ Document type egory, with similarly combined rates in each fant feeding counselling Journal article: AIDS Care (2002) 14 (5), of the 3 groups: (gp1=11.4; gp2=11.3; 625–31 gp3=11.4). In contrast, each characteristic Knowledge of HIV status had little impact on the perception of formula feeding Source Author of formula was rated much lower (between 2 and 0.5, highest for cleanliness and low­ (higher rating for “safety”). The relatively est for cost), and scores differed signifi­ low number of women of unknown status Background cantly between groups (gp1=6.8; gp2=5.9; reporting HIV as a reason for not gp3= 5.5; p=0.002). The HIV-positive moth­ breastfeeding would indicate that although Since 1993 the Ministry of Public Health ers rated formula significantly higher for there is potential for discrimination, the use in Thailand has recommended that infants safety compared with other groups. of infant formula is not exclusively associ­ born to HIV-infected mothers be formula ated with HIV with its inherent negative fed and has provided free formula to the Almost all women agreed that breast- connotations. poorest fraction of the population. How­ feeding was best for infants, but that HIV- ever, concern exists regarding spillover of positive women should not breastfeed. formula feeding into the general popula­ Methodological considerations/ HIV-positive women were more likely to reviewer’s comment tion and the risk of discrimination, since identify HIV infection as a reason why formula use may indicate a woman’s HIV women should not breastfeed. When Weakness: Although socioeconomic char­ status. The success of pMTCT interventions asked their opinion of mothers who re­ acteristics were similar between groups, such as AZT prophylaxis also will depend placement feed, 71% of all women said this there may have been some bias in the se­ on public knowledge and attitudes toward could indicate that mothers were working lection of postnatal mothers from the well- infant feeding. outside the home and 45% said this could baby clinic, as this was a distribution point indicate HIV infection. for formula. Also, there was potential in- Methodology terviewer/subject bias during face-to-face In addition, 94% of HIV-positive postnatal interviews, due to social norms and fear of This study involved two district hospitals mothers were exclusively formula feeding stigmatisation.

A Compilation of Programmatic Evidence 65 UGANDA

The purpose of this study was to evaluate Recordings and notes were reviewed by the Lessons from Early Cessation the experience of early, accelerated moderator and note-taker present at each of BF in Uganda breastfeeding cessation and the lessons discussion, transcribed and translated into (Bakaki, 2002) learned by health staff in order to improve English as necessary. Identified themes were the help given to HIV-positive women to coded and grouped. Document title exclusively breastfeed and accelerate the Lessons and experiences with early cessation of breastfeeding. abrupt cessation of breast feeding among Results HIV infected women in Kampala, Uganda Methodology Author Bakaki PM Mothers ages ranged from 19 to 37 (“most” were 20 to 29); “most” were married with Institution This was a qualitative study using focus 1-5 children (and “most” of them had 2­ Makerere University-Johns Hopkins group discussions (FGDs) and key informant 3); they were “mostly” housewives. University Research Collaboration (MU-JHURC) interviews (KIs) during December 2002. Re­ search assistants had two days of training Age at cessation of breastfeeding was 8 Date January 2002 by a social scientist and two social work­ days to 7 months (“most” 6 months; 7 Country Uganda ers. Questionnaire guides for the FGDs were months was an inclusion criterion); single pre-tested and changed accordingly. mothers, those employed, and those with Document type Research Report fewer than 3 children stopped soonest. Source Author Inclusion criteria for mothers were: all HIV- positive mothers participating in the infant Mixed feeding was practised by “most”, Background feeding clinic who had stopped especially nearing cessation. The duration breastfeeding by seven months and lived was one week to six months (half less than The HIVNET 012 trial, demonstrating a 47% within 15 km of Mulago Hospital. Totals: two months, one-fifth two weeks to one reduction in MTCT using single dose FGDs had 37 mothers in six groups. (The month, and three never). Those who nevirapine (NVP) to mother and baby, was number of mothers who refused to par­ stopped abruptly had introduced other conducted by Makere University – Johns ticipate or who were not available was not foods earlier. Others stopped gradually (e.g., Hopkins University Research Center (MU– stated.) Ten mothers who were active in breastfeeding only at night); some left the JHURC) and reported in 1999. HIVNET 012 the infant feeding clinic or who missed the baby with relatives. children are still under observation, and the FGDs participated in key informant inter­ Mulago Hospital site continues to offer views. Sessions were conducted in the lo­ Weaning foods included eggs, potatoes, pMTCT with NVP and support for replace­ cal dialect and tape recorded. cow’s milk, soya and millet porridges. ment feeding (RF) or exclusive breast- feeding (EBF) with accelerated early cessa­ Inclusion criteria for health workers (HWs) Replacement foods were cow’s milk, eggs, tion, according to MoH guidelines. An were: all involved in the research clinic or passion fruit juice, potatoes, groundnuts infant feeding clinic was set up and 012 in the NVP program. Totals: FGDs had 26 sauce, bananas, millet and maize porridges, trial mothers were invited to attend for health workers in four FGDs. (One refused meat and fish soups, etc. (wide variety), more information on infant feeding and and seven were not available.) Participants including a sieved mix of several different support for their infant feeding choice. included three physicians, seven nurse foods taught by the infant feeding clinic Most mothers received their baby’s HIV in­ counsellors, nine NVP counsellors, seven staff. fection status by 14 weeks. They were ad­ research counsellors and nine health visi­ vised to stop breastfeeding by six months tors. Sessions were conducted in English Health workers’ viewed early abrupt ces­ and to do it “abruptly”, defined as over two and tape recorded. sation of breastfeeding as: 1) a new idea, weeks. 2) difficult because of worries about the

66 HIV and Infant Feeding development of the babies, engorged Both mothers and health workers believed and/or that health worker advised stopping breasts, babies losing weight, crying, 3) the following would hinder early abrupt breastfeeding. sometimes resulting in resuming cessation: 1) stigma; 2) non-disclosure and breastfeeding (though this did not seem fear of husbands, relatives, general public; They believe the following would be to occur among the mothers in this study), 3) denial, e.g., of baby being uninfected, needed: income generation and education 4) requiring: knowledge, confidence, good and 4) poverty and lack of alternative feeds. through the infant feeding clinic. relationship with counsellor, 5) a good thing, because it reduces MTCT, 5) having Health workers also saw 1) less educated For crying babies they suggested frequent various characteristics: stop at 3 months, mothers, 2) lack of information (e.g., that feeds, toys, singing, and grandmother care. stop at 3-6 months, stop over 1-2 weeks, babies can survive without prolonged and 6) not being very successful. breastfeeding), 3) inconsistent advice from For sick babies they suggested going to the media (e.g., to breastfeed for as long as clinic to get treatment, counselling, food Mothers’ reasons for cessation of possible), and 4) cultural beliefs (e.g., supplements, referral to the nutrition unit, breastfeeding included 1) health education shouldn’t waste breast milk, or the child and advice on foods. from health workers and 2) being told the will hate the mother) as hindrances. baby was not HIV infected. Recommendations from mothers and Problems faced in attempting early abrupt health workers were: 1) to involve men, Mothers’ reasons for mixed feeding: 1) get­ cessation: Mothers and health workers con­ from the time of antenatal care; 2) con­ ting child used to other feeds and 2) not curred in identifying potential problems: duct peer and group counselling sessions; enough breast milk. 1) engorged breasts; 2) babies getting sick 3) ensure that health workers and mass (loss of weight, diarrhoea, vomiting, fever); media advice was consistent; 4) create po­ Factors leading to success of early abrupt 3) difficulties with husband, sometimes to litical will; 5) address income generation cessation: the point of breaking up, frequently to the and 6) promote nutrition education. point of domestic violence; 4) pressure from Mothers viewed the following as factors relatives, in-laws, neighbours; 5) unwanted Conclusions and facilitating early abrupt cessation: 1) edu­ early conceptions; 6) crying babies; 7) recommendations of author cation and counselling, 2) disclosure of HIV sleepless nights; 8) poor sex life; 9) intimi­ dation from health workers and 10) pov­ status to husbands and relatives (especially The author argues that the baby’s negative erty. early disclosure: after the antenatal test), PCR test (i.e., HIV test) at 14 weeks is not and 3) help from relatives and elderly com­ very influential because many (40-60%) munity women. Solutions to the problems: mothers at other centres (which do not offer PCR testing) also choose formula Health workers believed such facilitation Mothers and health workers suggested the feeding at delivery. He also argues that the would derive from 1) understanding HIV, following to address problems related to perception of “inadequate milk” can be related to education level of mother; 2) breasts: 1) painkillers (aspirin, paracetamol); used to advocate early cessation. Although supportive husbands and relatives, 3) single 2) cold drinks; 3) banana leaf veins tied mixed feeding was very common, he con­ mothers, because of having no one to around the breasts, and other cold com­ siders that it was not problematical because criticise them; 4) working mothers, because presses, firm brassieres and 4) coffee, only one of 49 babies born to the mothers of having independent financial means; 5) in the study “was thought” to have been disclosure; and 6) baby’s negative results. To address questions concerning cessation, HIV infected through breastfeeding. The it was suggested that mothers lie and say basis for this is not given. Hindrances to early abrupt cessation: that their baby was sick, the baby refuses milk, they have problems with the breasts,

A Compilation of Programmatic Evidence 67 The author recommends 1) uniformity of ties for education (in the antenatal clinic, Experience with Providing Free advice at all levels; 2) major public aware- labour ward, postnatal ward, postnatal Formula in Uganda ness campaign on early cessation; 3) in- clinic), discussion of options, and support (Matovu et al, 2002) volving men, with man-friendly hospital for the woman’s decision. An infant feed- services; 4) providing VCT for couples; 5) ing (IF) checklist has been established to Document title conducting family and marital counselling help in determining whether formula would Experience of providing free generic as part of pMTCT follow-up; and 6) close likely be a safe and successful choice. This infant formula to mothers in the follow-up (counselling, growth monitor­ nevirapine implementation program at includes: 1) socio-cultural (i.e., family, ing, nutrition education, food supplemen­ Mulago hospital in Kampala, Uganda. neighbour, community) acceptance; 2) eco­ tation, and curative services). nomic factors (cost of preparation, supplies, Authors replacement after the end of free supplies); Matovu JN, Bukenya R, Musoke PM, Methodological considerations/ Kikonyogo F, Guay L 3) logistics (fuel, supplies, time, night feeds) reviewer’s comment and 4) hygiene (water source, utensils, stor­ Institution age). Examples of questions include: What Mulago Hospital, Kampala; Makerere will you do when the baby wakes up in the Strengths: This was a very detailed explo­ University, Uganda; Johns Hopkins ration of the views and experiences of University, USA middle of night for food? How will you mothers and health workers trying to find prepare the formula and feed the baby Date 2002 ways to successfully achieve early abrupt when you have no electricity and the cry­ cessation of breastfeeding. Country Uganda ing baby is waking up the family? What will you do on a bus when the baby cries Document type and everyone tells you to put the baby to Weaknesses: The study was limited to an 1) Abstract MoPeE3748 from Barcelona urban setting with mothers (and babies) AIDS Conference 2) Presentation to the breast? What are you going to tell your receiving very intense input including re­ EGPAF Call to Action (CTA) meeting in husband whom you haven’t told your HIV Zambia, August 2002, and 3) Personal results to? How will you feed your baby search study-based curative services and communication from Laura Guay, when you have to go to the village for a the provision of infant HIV diagnosis. The January 2003 cost of the inputs was not assessed. burial? Source Barcelona Abstracts CD and authors Generic formula in cardboard boxes com­ plete with scoops (for powder and water), Background produced in France, was supplied by UNICEF. Problems related to the distribu­ The Mulago Hospital in Uganda did not, at tion of formula included: lack of storage first, provide free formula in its pMTCT pro­ space, difficulty in carrying cases of for­ gram. When it became a UNICEF/UNAIDS mula, expiration of formula, contamination, pilot site, however, a six-month supply of stealing, and supply interruptions. free generic formula was provided to women who decided not to breastfeed, In the pMTCT program, mothers are asked beginning in April 2000. As of September to return at six weeks for HIV PCR testing 2002, free formula is no longer offered. (HIV testing) of their babies and to obtain additional formula. With passive follow-up, Infant feeding counselling is offered to all only 50% (formula feeders and women, with HIV-positive women involved breastfeeders) returned, presumably mean­ in an ongoing counselling process with ing that many formula feeding women re­ trained counsellors assisted by midwives. verted to breastfeeding or mixed feeding. There are multiple counselling opportuni­ Active follow-up was initiated in August

68 HIV and Infant Feeding 2001 with the objectives of 1) improving reported what proportions were being “ac­ low-up, transmission rates seem to be the follow-up of infants receiving free formula tively” followed up. same or even higher in the replacement and 2) better assessing the impact of for­ feeding group than in the breastfeeding mula on MTCT. Personal communication: Women who suc­ group. ceeded with replacement feeding using Methodology infant formula were better educated and Personal communication: Provision of free had family support (no figures provided). infant formula cannot be done without All mothers leaving the hospital with for­ Those who went home breastfeeding, re­ active follow-up. Locally produced infant mula were asked to participate in the ac­ turned at six weeks for their scheduled fol­ formula is probably a better option than tive follow-up program. Women who ac­ low up, whose babies were tested and imported. There are significant numbers of cepted were visited every two weeks by a found to be HIV-negative, and subse­ women and infants who could benefit from health visitor who monitored progress and quently chose to switch to formula feed­ access to free infant formula and related offered advice and feeding support. ing were the most likely to return for their support. However, the majority of current supply of free formula. One possible ex­ health care systems and families are not planation is that, perhaps, it is easier to find ready for such programs in the absence of Results a reason to stop breastfeeding rather than significant investment in resources, train­ to never breastfeed. It should be noted, ing, manpower, etc. to handle infant for­ Barcelona abstract: From August 8, 2001 however, that these were particularly mo­ mula procurement, distribution and coun­ to December 31, 2001, 69 women (data on tivated women who had returned for fol- seling on its safe use. the total number of women is not included) low-up and wanted to know their babies’ chose to use infant formula. Twenty-one HIV test results. (30%) refused active follow up. Of these Methodological considerations/ refusers, eight (38%) did not return at 6 reviewer’s comment weeks. Out of the 13 (62%) who did re­ Conclusions and turn, one infant was HIV-infected. Forty- recommendations of authors This is a work-in-progress, rather than a eight (70%) women accepted active fol­ formal reporting of a research study. The low up. Nine (21% of the 43 due to return) Both women and staff lacked knowledge low rate of follow-up presents a signifi­ did not attend at six weeks; two infants and IEC (information, education and com­ cant methodological problem, which is in were HIV-positive. munication) materials to support counsel­ and of itself an important finding. ing about formula feeding. They might CTA presentation: Of the 870 HIV-positive know about hygiene but did not know These reports from the Mulago Hospital do about 1) how often to feed the baby, 2) women who delivered, 495 chose exclu­ not claim to be a formal assessment of the how much a baby should drink in a day, 3) sive breastfeeding (EBF) and 375 chose for­ effectiveness of provision of free formula mula. Of these 375 women, 279 were pro­ what formula-fed infant stools are like in terms of infant health or HIV transmis­ compared to a breastfed infant’s, etc. There vided with free formula from delivery. Of sion rates, or of other issues such as was low acceptance of formula among the 222 women scheduled for a 6-week “spillover” (although the impression was (or later) follow-up, 78 (35%) never re­ women, the community and health work­ that there was little sign of spillover). They ers. Providing free infant formula seems to turned, 49 (22%) completed 6 months of do, however, reflect considerable experi­ increase the opportunity for, or the likeli­ formula, 48 (22%) had not yet reached six ence, and the warnings about providing months but were up-to-date, and 47 (21%) hood of, mixed feeding. Although not for­ free formula are valid even without formal mally established because of the poor fol- had returned but then defaulted. It was not numerical corroboration.

A Compilation of Programmatic Evidence 69 ZAMBIA

focus group discussions (FGDs) with ser­ ity to refuse to help, especially since women Stigma, HIV/AIDS and pMTCT vice providers, as well as male and female were sometimes denied help in the clinics in Zambia (Bond et al, 2002) service users, and through key informant or were discharged from hospital while very interviews. This summary focuses only on ill and HIV-positive. Document title issues relating to MTCT and infant feeding. Breaking the silence, ending the stigma: stigma, HIV/AIDS and prevention of There were few incentives for pregnant mother-to-child transmission in Zambia Results women to test for HIV, unless they sus­ pected their partner, had a chronic illness Authors Bond V, Chase C, Aggleton P Uptake of the MTCT intervention (VCT, ARV or were following the doctor’s recommen­ Institution and pre- and postnatal counselling) was dation. The resulting likely stigmatisation ZAMBART Project, London School of low after nearly one year of service provi­ following a positive result was seen to out­ Hygiene and Tropical Medicine, Lusaka, weigh the advantages of testing and Zambia; Institute of Education, University sion at the local mission hospital. of London Stigmatisation and the fear it provokes can women often feared depression, had sui­ prevent women from participating effec­ cidal feelings, considered an abortion and Date 2002 tively in pMTCT programmes. Staff at two feared reaction of their partner and fam­ Country Zambia rural health centres were unaware of the ily, believing they will be abandoned and pMTCT programme at the hospital and said ignored, isolated and openly disgraced. It Document type that HIV was discussed at antenatal clinic is only considered safe to divulge status to Article in press one’s own mother, as she will always care (Evaluation and Program Planning) only if a mother presents with obvious symptoms. for her child. Source Author

Pregnant women with HIV have become Not breastfeeding is seen as an indication Background the main focus of HIV in this rural com­ of positive status and causes stigmatising, munity, with many respondents stating that yet women who continue to breastfeed are HIV/AIDS-related stigma and discrimination pregnant women falling sick and their ba­ accused of killing the child. In response, are known to negatively impact all efforts bies dying had made HIV/AIDS visible. Her­ women just pretend they are HIV-negative at prevention, diagnosis, treatment and pes zoster or emaciation in a pregnant and breastfeed as usual. care. This project assessed the complexities woman is considered diagnostic of HIV in­ of stigma across 4 countries and reports fection and enough reason to shun her. Recommendations around infant feeding on results from Zambia in particular. revealed mixed messages. Some women There was little sympathy for pregnant had heard from the local mission hospital Methodology women with HIV, who are assumed to be that HIV-positive mothers should not sex workers and/or promiscuous and there­ breastfeed, as their breast milk contained The project aimed to 1) assess both per­ fore deserving of blame and rejection. This “germs” and reduced the baby’s chance of ceived and enacted stigma among health is in sharp contrast with another rural com­ survival. However, a senior traditional healer care providers, those receiving care and munity with an established pMTCT inter­ and headman thought that babies should decision makers; 2) analyse the origins of vention, where health education and an be exclusively breastfed, because formula stigma, especially surrounding MTCT; and improved package of care had helped to is not good for babies. 3) inform the development of a wider in­ reduce community stigma. formation programme about stigma in or­ Conclusions and der to help alleviate it. The research was Midwives and traditional birth attendants recommendations of authors conducted in a rural community 170 km (TBAs) reported delivering infants of HIV- south of Lusaka, on the border with Zim­ positive women without minimum precau­ pMTCT programmes should take into ac­ babwe. Evidence was gathered through tions, due to lack of supplies and an inabil­ count the extent of fear, misconception and

70 HIV and Infant Feeding resulting stigma in the community, and after NDHMT) was conducted from Decem- they should be integrated into preventa- Formative Research on MTCT ber 1998 to February 1999, and the sec­ (NDHMT, 1999; Bond and tive, education, care and support initiatives ond (Bond and Ndubani) was conducted that address these fears. Communities need Ndubani, 1999) in November 1999. wider implementation of pMTCT and VCT Document titles services. NDHMT’s objective was to develop locally 1) Ndola Demonstration Project to appropriate and feasible infant feeding rec­ integrate infant feeding counselling and Methodological considerations/ HIV voluntary counselling and testing into ommendations for HIV-positive mothers reviewer’s comment health care and community services. A and families living with HIV in urban Zam­ summary of the findings and recommen­ bia. dations from the formative research This study conducted FGDs with a variety carried out in Lubuto, Main Masala, of service providers and users in one par­ Twapia and Kabushi Health Center areas, Bond and Ndubani conducted a pre- ticular area of Zambia, so findings may not Ndola, Zambia 2) Formative research on UNICEF pilot site feasibility assessment in mother to child transmission of HIV/AIDS a poor rural area. It sought to 1) better be applicable elsewhere. in Zambia understand women and community views Authors about MTCT of HIV; 2) assess local beliefs 1) Ndola District Health Management and perceptions about drug use during Team 2) Bond G and Ndubani P with pregnancy and breastfeeding; 3) determine Nyblade L potential social, cultural and economic fac­ Institution tors that would likely affect women’s par­ 1) National Food and Nutrition Commis­ ticipation in the MTCT program; 4) identify sion; Ndola District Health Management existing social and community networks Team; LINKAGES Project; SARA Project 2) ZAMBART Project, School of Medi­ relevant to the MTCT implementation; and cine, UTH, Zambia; Institute for Econom­ 5) recommend strategies to facilitate ef­ ics and Social Research (INESOR), fective implementation of the MTCT UNZA, Zambia; International Centre for Research on Women (ICRW), Washing­ programme. ton

Date Methodologies 1) April 1999. 2) November 1999 NDHMT conducted six focus group discus­ Country Zambia sions (FGDs): two each with mothers and Document type fathers of children under two years and one 1) Manuscript submitted for publication, each with HIV-positive women and HIV- 2) Working Report positive men. They also held semi-struc-

Source tured key informant interviews (KIs): 33 1) National Food and Nutrition Commis­ with mothers of children under two years, sion, Ndola District Health Management mothers support group members and mem­ Team, 2) UNICEF ESARO CD bers of the neighbourhood health commit­ tee, 22 with health workers, six with tradi­ Background tional birth attendants (TBAs), one with an HIV counsellor and one with a caregiver at These two reports provide information on an orphan transit home. Household inter­ two separate formative research projects views included observation and cooking to assess the readiness of Ndola, Zambia, demonstrations, and 28 household trials of for pMTCT programmes. The first (herein- improved feeding and caring practices in-

A Compilation of Programmatic Evidence 71 cluded trials of milk and replacement food or three months, and 4) the most feasible kapenta, vegetables, beans, beef); feedings preparation. aspects of infant feeding (IF), included cup 200-300 ml (increase with age); b) cow’s feeding, boiling water for mixing with for­ milk of at least 100 ml at least twice a day; Bond and Ndubani held nine FGDs of 6-14 mula and cleaning utensils, and the use of c) nshima with mashed solid foods (not just participants, as well as participatory re­ ‘long-life’ milk for babies over six months. soup); d) fruits, beef, fish if possible; and e) search and unstructured observations. Par­ continue feeding during illness. ticipants included pregnant women and Conclusions and breastfeeding mothers attending under- recommendations of authors Bond and Ndubani focused on program­ five or antenatal care clinics at a health ming issues and recommended that pro­ centre, men who were invited through lo­ NDHMT focused on clinical care and rec­ grams: 1) facilitate a successful MTCT in­ cal churches and community leaders. ommended: 1) IF advice and counselling tervention by simultaneously addressing for all women; 2) propagation of the BFHI; prevention, care, support and stigma; 2) Results 3) de-stigmatisation of HIV; 4) expansion enhance capacity to regain control in or­ and publicising of VCT; 5) assurance of con­ der to overcome feelings of hopelessness Both research teams found high levels of fidentiality; 6) expansion of support for (with appropriate outside organisations, HIV awareness and concern about stigma, HIV-positive people; 7) more information including existing local structures, helping recognition of health centres as sources of on living positively with HIV; 8) increased communities cope); 3) improve inadequate information, and valuing breastfeeding and information on MTCT; 9) consistent mes­ existing health services, especially through seeing it as the norm. NFNC reported that sages on breastfeeding; 10) IF counselling, health worker training (addressing the lack care-seeking starts at home, while Bond based on informed choice and support of confidence that is justified by breached and Ndubani noted that orphans are usu­ (considering the risk of transmission confidentiality; limited capacity of health ally cared for by the family despite through breastfeeding, of replacement workers; lack of equipment, supplies and affordability and feasibility challenges. feeding, of social stigma) for that choice, medicines; secrecy and innuendo that per­ to start in ANC; 11) more hand washing; petuate stigma; poor delivery care and poorly conceived communication strate­ NDHMT reported 1) problems with the 12) monitoring of “spillover”; 13) that HIV- health delivery system (fees, drug and staff positive women choosing to breastfeed: a) gies); 4) include households, since they play key roles in care seeking for serious illness, shortages, distances and lack of confiden­ exclusively breastfeed until 6 months, b) prevention, maternal health, VCT, etc., win­ tiality); 2) that good counselling is impor­ discontinue feeding from a breast affected tant and means nice, supportive, a private by mastitis or cracked nipples (express and ning their full (all members’) co-operation; 5) address the many sensitive issues related room, no public disclosure, and medicines; discard the milk); c) treat babies’ oral le­ to gender, which are not being handled and 3) very early (a few days after birth) sions immediately (express and heat-treat introduction of alternative foods, includ­ breast milk); and d) if mother gets sick, go correctly; 6) apply and exchange knowl­ edge so that program designs address the ing maize meal porridge, sweet beer, for treatment immediately; 14) HIV-posi- real barriers and fears (e.g., knowing one’s nshima mashed in soup/sauce, beans, beef, tive women choosing not to breastfeed cow and goat milk, eggs and fruits and that should: a) feed formula for first six months HIV status); 7) incorporate local discourse into communication strategies; 8) support concern about affordability of these foods (because, compared to cow’s milk, compa­ improved breastfeeding practices—chal- was substantial. rable cost, simpler, better known, more likely to be given to the baby only, storage lenging the early introduction of feeds other than breast milk is likely to be easier Bond and Ndubani’s found 1) that most better), but very expensive, likely to be than the introduction of infant formula; women do not work outside the home, 2) overdiluted, not always available; b) use and 9) promote the most feasible IF meth­ that people believed that HIV and AIDS cup; c) develop strategies for night feeds; ods, which probably include cup feeding, were equivalent and knew of MTCT, 3) that d) address the dangers of storage of for­ boiling water to make formula and clean breastfeeding is usually for 18 to 24 months mula; and e) monitor; 15) babies six months utensils, and using “long-life” milk for ba­ with water and porridge (usually in insuf­ and older not breastfeeding should receive: bies over six months. ficient amounts) being introduced at two a) vitamin supplement and porridge en­ riched with milk, oil, sugar, groundnuts,

72 HIV and Infant Feeding Methodological considerations/ onstration Project (NDP) was started in Ndola Demonstration Project reviewer’s comment 1999 in Ndola District by the Ndola Dis- (Hope Humana et al, 2002; trict Health Team under the auspices of the AED/Linkages Project 2002 These studies are dated but offer impor- NFNC and the Central Board of Health of a and b) tant insights relevant to the implementa- Zambia, with partial funding from USAID. tion of a pMTCT programme. Technical assistance contractors including Document titles AED (The Linkages and SARA Projects) and 1) Ndola Demonstration Project: A NDHMT Strengths: The study provides de­ the Population Council (Horizons). The NDP Midterm Analysis of Lessons Learned; 2) tailed exploration of prevailing attitudes Zambia Integrated PMTCT Program; 3) demonstration was successful and ex­ and practices around IF and HIV. LINKAGES/Zambia PMTCT Results panded to other parts of the Ndola District Reporting in 2000 and 2001. The NDP is listed as one NDHMT Weaknesses: The setting was ur­ Authors of five projects in UNAIDS Best Practices ban only. 1) Hope Humana, AED/LINKAGES Collection. Project, National Food and Nutrition Commission, Ndola District Health Bond and Ndubani Strengths: This well- Considerable data were collected about the Management Team, HORIZONS Project, written report contains a wealth of back­ Zambia Integrated Health Project (aka NDP, at baseline, midterm, and end-line. ground information. Economic and espe­ “Horizons”). 2) AED/LINKAGES Project. Although local conditions dictated differ­ cially anthropological detail frames the dis­ 3) AED/LINKAGES Project ent interventions at different sites, many cussions of community perceptions of HIV/ Institutions of the findings were similar. In this review AIDS and potential coping mechanisms. 1) The Population Council. 2) Academy we summarize three reports on the NDP: for Educational Development (AED). 3) 1) “Ndola Demonstration Project: A Mid­ Bond and Ndubani Weaknesses: This small, AED term Analysis of Lessons Learned,” Novem­ time-constrained study is limited in the Country Zambia ber 2002, by the Horizons Project (herein variety and quantity of data collected, the referred to as the Horizons’ midterm evalu­ Dates location for conducting interviews, the se­ ation); 2) “Zambia Integrated PMTCT Pro­ 1) November 2002. 2) September 2002. gram,” September 2002, World Linkages by lection of focus group participants, as well 3) December 2002 as the time available to find and train FGD AED (herein referred to as the AED/LINK- leaders. The findings and conclusions are Document types AGES Newletter); and 3) “LINKAGES/Zam- limited to the local community (Keemba), 1) Horizons Project - Midterm evaluation bia PMTCT Results Reporting,” December report. 2) AED/LINKAGES Project – 2002, by the AED/LINKAGES Project (herein which the authors note is a unique setting, Newsletter. 3) AED/LINKAGES Project ­ different in some respects from the rest of Memo reporting results referred to as the AED/LINKAGES Report). the province. The study was conducted in We refer to these documents as the “Hori­ order to inform the imminent introduction Background zons Midterm Evaluation,” the “WL News­ of pMTCT programs in Zambia and did not letter,” and the “AED Report,” respectively. (A preliminary unedited final report by address IF issues in detail. In 1997 the Zambian National Food and HORIZONS containing end-line data en Nutrition Commission (NFNC) initiated the titled: “Empowering Mothers to Respond development of a national program in to HIV: Ndola Demonstration Project Final MTCT. Its aim was to prevent MTCT in low- Report”, became available as this docu resource settings where MCH and ANC were ment went to press. It is referred to briefly carried out, especially through integrated here.) approaches that involved infant feeding. During 1998-99, formative research was While the three documents touch on over­ undertaken in four sites, and the method­ lapping aspects of the NDP, they also un­ ology and results of two of these are sum­ marized elsewhere in this compilation. As derscore different ones. The Horizons’ mid­ term evaluation identifies five key compo- a result of this research, the Ndola Dem-

A Compilation of Programmatic Evidence 73 nents: 1) strengthening routine services, 2) The AED/LINKAGES Newsletter stresses the The Horizons’ Midterm Evaluation describes introduction of VCT and pMTCT (including integrative nature of the Ndola interven- the types of statistical analysis used in the IF counselling) into ANC/MCH settings, 3) tion: IF is integrated with VCT, pMTCT, and report but not the method used to obtain promotion of EBF for HIV-negative and HIV testing in the ANC/MCH setting. It feeding practice. The AED/LINKAGES News- HIV-unknown status women, and informa­ states that behaviour change communica- letter gives an historical review of the tion about different feeding options and tion (BCC) and training are prominent com- project, but nothing on the methods used guidance through social/economic influ­ ponents of the NDP. BCC includes asser- in the evaluation. The AED/LINKAGES Re­ ences for HIV-positive women, 4) optimal tive, data-based approaches to behaviour port includes some data from the end-line obstetric practices, and 5) increased com­ change, ratio spots and print materials, and survey (January-November 2002) that is munity involvement including couple community “ambassadors against AIDS.” compared to baseline and midterm data. It counselling. It notes that IF was included The training described in the Horizons also gives updates on persons trained in ANC, in pre- and post-test counselling, Evaluation is noted, along with a six-day through 2002, various services provided in and after delivery. training of trainers (TOT). The AED/LINK- the clinics and districts, and sources of AGES Report notes that Nevirapine was funds. It notes that the home interview of The Horizons’ Midterm Evaluation states introduced in NDP in 2002. mothers (community survey) about infant that the centerpiece of the pMTCT program feeding 0-6 months is based on a 24-hour is IF counselling, the most innovative as­ Methodology recall (Editors note: 24-hour recall is known pect of the Ndola Demonstration Project. to over-estimate the rate of EBF). Both the Horizons’ and the AED Reports The Horizons’ Midterm Evaluation reports indicate that both HIV-negative and HIV- baseline (April-May 2000) and midterm Results unknown women are counselled to EBF for (April-May 2001) data in six sites that re­ six months and to continue breastfeeding ceived the NDP interventions. Household The Horizons’ Midterm Evaluation com- for two years; that HIV-positive women are KAP questionnaires provided information pares baseline to midterm results for many counselled to exclusively breast-milk feed on IF, MTCT, MCH, VCT, and HV from moth- variables. Community members’ knowledge for six months with heat treating and cup ers, other community members, and health of MTCT during pregnancy, delivery, and feeding; and that all women should avoid workers. The attached table gives sample breastfeeding increased significantly. mixed feeding, prevent HIV and unwanted sizes reported by the Horizons’ Midterm Awareness of free VCT services among all pregnancies, and introduce complementary Evaluation. community members increased from 45% feeds at six months. The Horizons’ Midterm to 75%, while HIV testing among all re- Evaluation says NDP interventions included enlargement of ANC space, plus adequate equipment and supplies, although short­ Sample Size ages of supplies continued. Staff and com­ Survey Baseline Midterm Selection Method munity health workers received substan­ Clinic survey: tial additional training: 99 health workers Mothers of infants 0-12m 460 185 Exit interview with every 4th woman who and their supervisors took a two-week Pregnant women 125 125 uses ANC or EPI in week 1. course that included HIV epidemiology, IF Community survey: and lactation management, pMTCT during Adult females 385 441 At baseline ask if the interviewee knows delivery, postnatal care, maternal health Adult males 251 232 a neighbor with baby; at midterm random and VCT; 104 community health workers Mothers of infants 0-6m 209 319 selection using census. (mothers, local committees, TBAs, promot­ Health worker (HW) interviews: 62 65 All staff at clinic and collaborating ers) took a modified course; and 47 of these # of interviews CBOs. took additional counselling training (an Client-HW observations: 469 392 (Selection method not clear.) # of observations eight-week course, according to the AED/ LINKAGES Newsletter). Qualitative cohort 59 mother-baby pairs Quarterly follow-up. Data not yet available.

74 HIV and Infant Feeding spondents increased from 5.2% to 9.8%, served in postnatal vitamin A (33% to 61%), and cost are responsible. 4) HIV-positive statistically significant for women with in­ use of sterile gloves (64% to 75%), and mothers are not changing from EBF to re­ fants 0-6 months but not for other women availability of piped water (67% to 100%), placement feeding at 6 months; they are or males. Proper breastfeeding increased: but hand washing by health workers de­ still breastfeeding at 12 months. More ef­ 58% of mothers initiated breastfeeding creased (26% to 15%). (The Horizons’ Mid fective counselling is needed about cessa­ early (within one hour of birth) at baseline term Evaluation notes that while substan tion of breastfeeding and replacement compared to 82% at midterm; EBF in the tial improvements were apparent in many feeding. 5) There is a need to develop a first 6 months rose from 71% to 85% indicators of performance between the tool to improve service delivery. 6) Efforts among HIV-unknown women and from baseline and midterm surveys, progress should continue to train health workers in 56% to 76% in HIV-known women. The seems to have plateaued for most indica IF counselling at ANC. 7) Comprehensive report does not distinguish between HIV- tors between the midterm and end-line systems for monitoring IF and counsellor positive and HIV-negative women. Al­ surveys. Exceptions may be knowledge of supervision should be organized. 8) Inno­ though knowledge of early weaning as a VCT scores and discussion of HIV risks, vative ways to reach men about HIV, in­ means of reducing the risk of MTCT had which continued to improve through the cluding couple counselling, should be ex­ increased, nearly all women (known and end-line.) plored. 9) Supply problems with VCT were unknown HIV status) with infants 6-12 overcome, but uptake remained low be­ months were still breastfeeding. Condom The AED/LINKAGES Newsletter reports that cause it is viewed as source of stress. The use among community members stayed the early initiation of breastfeeding rose to program should explore how the benefits same (13%), while women reporting 2 or 89% at end-line (compared to 53% and of VCT can be made relevant and how de­ more sexual partners in the last year de­ 85% at baseline and midterm), and that mand for it can be increased. 10) Disclo­ creased from 9% to 3%. Men reporting 2 EBF among 0-6 month olds rose to 85% in sure of HIV status remains low. Strategies or more partners increased insignificantly all women (compared to 73% and 84% at should be explored to increase disclosure, (69% to 72%). baseline and midterm), with HIV-known such as couple counselling and more skills women going to 90% and HIV-unknown for women. 11) Routine ANC must be Health worker training in HIV and STI in­ to 84% at end-line. Infants 0-5 months strengthened, including infrastructure, creased significantly, but not in lactation having diarrhea in the previous 2 weeks training, and logistics. 12) All ANC should management or family planning. Their dropped from 8.6% at midterm to 6.1% at provide anemia testing, iron and folic acid knowledge and practices related to pMTCT end-line. The AED/LINKAGES Report reit­ supplementation, malaria prophylaxis, and during breastfeeding showed little change erates the Horizons’ Midterm Evaluation syphilis testing and treatment. 13) NDP re­ in most ways. The exception was an increase about breastfeeding practices. It also notes quires community links. Referrals should be in post-test client sessions where MTCT and that the uptake of VCT had increased by given to community-based organizations IF were discussed with HIV-positive moth­ the end-line survey. (CBOs) as well as hospitals. The Horizons’ ers, rising from 33% to 100% , although Midterm Evaluation report hypothesizes the number of sessions observed was very Conclusions and that the initial improvement noted in its small (12 baseline, 5 midterm). The Hori­ recommendations of authors midterm report was due to the energy gen zons’ Midterm Evaluation reports that at­ erated in the staff by the training program; tendance at ANC during the current or pre­ The Horizons’ Midterm Evaluation con­ ways to maintain that enthusiasm should vious pregnancy rose from 91% to 96%, cludes that: 1) Although MTCT improved, be found. The Horizons’ Midterm Evalua­ but women reporting 4 or more visits re­ more is needed. Health workers and com­ tion notes some of the important limita­ mained at 71%. Hemoglobin tests offered, munity members should to be made more tions of the study, including: lack of a com­ syphilis tests given, and iron folate pre­ aware of ARVs. 2) Increasing knowledge of parison group, problems in measuring the scribed at ANC sessions did not increase MTCT did not erode good breastfeeding strength of the NDP intervention in rela­ significantly, possibly due to logistic prob­ practices. NDP increased early initiation and tionship to other related efforts in the study lems, but iron folate for all mothers and EBF. 3) The increased practice among HIV- area, and potential influences of other ef­ pregnant women in the community did positive mothers of choosing EBF over re­ forts in the study area. increase (15% to 38%). Increases were ob­ placement feeding suggests that stigma

A Compilation of Programmatic Evidence 75 The AED/LINKAGES Newsletter does not 8) Knowledge of EBF increased but remains Midterm Evaluation is comprehensive and provide conclusions or recommendations low, indicating a need for more EBF edu­ particularly well written. This careful study per se, but the following statements are cation. 9) Routine ANC requires more re­ overlaps with the other two documents, implied in their discussion: 1) The NDP has sources. ) Focusing on quality, integration which also present additional data and been successful in many ways. 2) The inte­ and informed choice will increase VCT up­ sometimes alternative views. The final re­ grated approach that NDP has used, incor­ take. Higher uptake of VCT requires dy­ port, when complete, should add to out porating ANC and MTCT, is a key factor in namic programs that allow for testing and/ understanding of the impact of this project. its success. 3) Some key factors contribut­ or opt-out models. 11) Community links It is clear that the authors of all three docu­ ing to its success include early formative need to be strengthened. ments consider the intervention a success, research, policy involving national infant although only the AED/LINKAGES Report feeding and the Code of Marketing Breast- Recommendations for scale-up of the NDP presents cost data and none formally ad­ milk Substitutes, assertive behavior change included: 1) explore ways to invest in health dress the problem of sustainability. strategies, training, and evaluation. workers and clinic infrastructure to pro­ vide routine and improved services; 2) find The Horizons’ Midterm Evaluation correctly Conclusions of the AED/LINKAGES Report innovative and effective ways to reach men identifies some of the important method­ include: 1) NDP depended on the owner­ and youth through community education ological limitations of their study: lack of ship of the program by the involved local and couple counselling; 3) develop consen­ comparison group, problems in measuring and national organizations of Zambia. 2) sus and partnerships with local stakehold­ the strength of the NDP intervention in Local situational analyses and formative ers in behaviour change communication relation to other related efforts in the study research are essential. 3) Follow-up to strategy based on formative research; 4) area, and the potential influences of other trainings, with on-the-job mentoring is address demand-side factors affecting VCT efforts in the study area. The lack of infor­ critical. 4) The integrated approach involv­ uptake; and 5) strengthen routine MCH mation given to mothers about replace­ ing partners from the very beginning is vi­ services as an integral component of pMTCT, ment feeding is of concern, especially be­ tal. 5) Gender inequality remains a major in addition to providing enhanced services cause a goal of the program was to enable issue: empower women and incorporate for programme components. women to make an informed choice. The men. 6) Focusing on quality, integration and expansion of the program to other areas informed choice will increase VCT uptake. Methodological considerations/ may provide additional insights about re­ Higher uptake of VCT requires dynamic pro­ reviewers comments placement feeding and other issues such grams that allow for testing and/or opt- as cost. The introduction of Nevirpine into out models. 7) Use research to test inter­ This complex intervention has been sub­ the program will likely alter the uptake of ventions and assess outcomes. pMTCT jected to a fairly extensive and detailed VCT and even choices of infant feeding, projects should appoint a staff person and before-and-after evaluation. The Horizons’ depending on the counsellor’s approach. plan evaluation indicators from the start.

76 HIV and Infant Feeding this study. Inclusion criteria were 1) known Feeding practices: 35% of mothers with Infant Feeding Practices in HIV status and 2) baby 12 months old or babies four months or less were exclusively Zambia (Omari et al, 2000) less. During those 3 months, 561 mothers breastfeeding (definition or methodology attended (177 [36%] were HIV-positive): not reported); ‘most’ planned to breastfeed Document title 152 were invited to participate; 140 were for two years (median 20.5 months); 12% Infant feeding practices of mothers of recruited: the selection was ‘opportunis­ of HIV-positive mothers (cf 2% of HIV- known HIV status in Lusaka, Zambia tic’. ‘One-on-one’ interviews were held in negative) planned to breastfeed for less Authors the vernacular using a structured question­ than 12 months; 31% of HIV-positive Omari AAA, Luo C, Kankasa C, Bhat G, naire. mothers (cf 8% of HIV-negative) planned Bunnr J to breastfeed for 18 months or less. Of ba­ Institution Results bies 4 months or more, 52% had started University Teaching Hospital, Lusaka, on other liquids by four months; 28% of Zambia; Liverpool School of Tropical Of 140 mothers, 121(86%) knew their sta­ babies of HIV-positive mothers (cf 11% of Medicine tus, 10 did not want to know and 9 were babies of HIV-negative) started other liq­ Date 2000 waiting to be told; 55 (39%) were HIV-posi- uids before two months (p=0.03). tive (HIV+) and 85 (60%) were HIV-nega- Country Zambia tive (HIV-). Water quality: 52% of households boiled Document type water, 38% added chlorine, and 27% did Report of research study neither. Mothers HIV+ HIV- p Source ESARO CD Average age 27 25 0.04 Introduction of complementary food Married 75% 86% 0.09 Background (mostly maize porridge) was as follows: Live children 2.4 2.3 15% by 2 months, 60% by 4 months (me- dian 4 months); introduction was earlier in Zambia’s national HIV prevalence is 12­ Education babies of HIV-positive mothers (p=0.002). 24%, and its peri-natal transmission rate is None 4% 3% 0.43 Reasons for introducing complementary 39%. Antenatal coverage in Lusaka is 96%, Primary 44% 39% food were 1) baby crying and 2) ‘insuffi­ but very few mothers are not breastfeeding. Secondary 49% 53% cient breast milk’. Tertiary 4% 6% The aims of the study included 1) compar­ Employed 26% 21% 0.55 Breast-milk substitutes (BMS): 36 (26%), ing the infant feeding (IF) practices of HIV- including 16 HIV-positive mothers, were positive mothers with those of HIV-nega- using or had used BMS. Median age at in­ tive mothers and 2) determining the pat­ Babies’ ages ranged from 2-12 months troduction was 2.5 months. Commercial tern of breastfeeding and the use and ap­ (median 6 months). The Weight for Age Z formula was used by 23 mothers (8 HIV- propriateness of breast-milk substitutes, score of babies of HIV-positive mothers was positive); 13 used fresh cow’s milk (two other liquids and complementary foods. -0.22 and of babies of HIV-negative moth­ added sugar, one added salt, none added ers was +0.41(p = 0.004). water). Of 29 mothers, 20 used a bottle and Methodology teat. MTCT knowledge: 85% of mothers knew Participants were recruited from the Fam­ of HIV transmission through breast milk; Conclusions and ily Support Unit at the University Teaching all (except one who stopped at eight recommendations of authors Hospital (UTH) where mothers are invited months when his HIV-positive mother to join ongoing research work. Mothers started anti-TB treatment) were breast- The authors conclude that 1) mothers were attending the follow-up clinic (which pro­ feeding; 25% of HIV-positive mothers had aware of the risk of HIV transmission vides free medical care) between April and been advised to stop breastfeeding. through breastfeeding, 2) breastfeeding June 2000 were invited to participate in

A Compilation of Programmatic Evidence 77 HIV-positive mothers intended to port for the monitoring and evaluation breastfeed for a shorter period than HIV- Rapid Assessment of pMTCT in component, dissemination, support for Zambia (Kankasa et al, 2002) negative mothers, but did not, 3) HIV-posi- some Secretariat personnel and data col­ tive mothers introduced other liquids and lection staff. The pMTCT Secretariat sup­ complementary foods earlier, often at less Document ports the day-to-day operations of the than 2 months; 4) no mother correctly Report on the Rapid Assessment of the pMTCT-WG and coordinates activities of all UN-supported PMTCT Pilot Program in modified cow’s milk; and 5) well babies of Zambia six pilot service delivery sites in three dis­ HIV-positive mothers showed poorer tricts, established to test and refine the growth than those of HIV- negative moth­ Authors delivery of a comprehensive package of ers (perhaps because of earlier introduc­ Kankasa C, Mshanga A, Baek C, Kalibala services. These pMTCT pilot sites, deliber­ S, Rutenberg N tion of other foods: author’s suggestion). ately selected in both urban and rural fa­ That is, HIV-positive mothers may be Institution cilities and in diverse geographic areas, are changing their infant feeding practices for Population Council/HORIZONS Project part of the national health facilities net­

the worse. Date December 2002 work, administered by local District Heath Management Teams (DHMT) in collabora­ Country Zambia Methodological considerations/ tion with bilateral and multilateral part­ reviewer’s comments Document type ners. The DHMT provides all health work­ Program Report ers, including counsellors, nurse/midwives Strengths: This study examined actual in­ (under review, not for circulation) and pharmacists, as well as health facilities and infrastructure. fant feeding practices of HIV-positive Source UNICEF Headquarters mothers (who had been counselled, tested and were receiving ongoing support). Background Methodology

Weaknesses: The report provides 1) no as­ Nearly one million adults and 150,000 chil­ A rapid assessment of the six National sessment of infant HIV status (to make dren were infected with HIV in Zambia by pMTCT pilot program sites in Zambia was sense of weight for age Z score), and 2) the the end of the 2001. MTCT of HIV is re­ undertaken as part of a global assessment reasons for infant-feeding decisions were sponsible for more than 90% of HIV infec­ of UN supported pilot pMTCT services, com­ not elicited in detail. tions in children. Each year, more than 20- prised of a desk review of 11 countries ini­ 30,000 HIV infected women give birth, tially supported by the UN and a rapid as­ without an intervention and over a third sessment in three countries: Zambia, of these women will pass on the infection Rwanda and Honduras. The pMTCT Secre­ to their infants. The Zambian MOH estab­ tariat, with extensive participation of local lished the pMTCT program in January 1999, organizations, carried out the assessment along with an interagency National pMTCT in all six pilot sites, with the technical and Working Group (pMTCT-WG), with repre­ financial support of Horizons/Population sentatives of the MOH, the National AIDS Council. Five evaluation instruments were Council, National Food and Nutrition Com­ employed, using both qualitative and quan­ mission, universities, NGOs, UN and donor titative methods (provider questionnaire agencies, the CDC and Linkages. The [46], FGD [6], service observations [254] and pMTCT-WG has standing subcommittees exit interviews) [163]), to examine and addressing training, IEC, program guide­ document progress, experience and lessons lines, research proposal reviews and dis­ learned to date, and to identify key issues semination. Coordination occurs through and challenges to scaling up of all compo­ monthly meetings. Horizons/Population nents of the pMTCT program; to examine Council provides funds and technical sup- mechanisms of collaboration and coordi-

78 HIV and Infant Feeding nation; and to contribute to the prepara­ ers interviewed, 21 said that formula was 69 women who had received IF counsel­ tion of a global generic programming the best option for HIV-positive women. ling indicated that the counsellors had ex­ framework. Providers’ opinions about EBF by HIV-posi- plained just one option (infant formula tive women and optimal choice of IF feeding was the most popular option, fol­ Results method were unrelated to having received lowed by breastfeeding). Of the 69 respon­ training on IF counselling, nor were there dents, 30 said that they had chosen for­ The pMTCT Secretariat offers 5 training and systematic differences among sites. mula feeding, while the rest had decided sensitisation programs, including an 8-day to breastfeed, with 11 opting to feed as course to update health workers on exclu­ Providers frequently steer women towards per norm. Despite most women indicating sive breastfeeding and HIV infant feeding an IF method based just on HIV status. that they did not receive more than one counselling, using the WHO modules. A Observations and exit interviews shed light infant feeding choice, only 15/69 reported total of 18 trainers of trainers and 96 health on the provider-client dynamic. During 42 that they felt a particular option was be­ workers. observations of IF counselling, providers ing promoted. almost always discussed the advantages All HIV-negative mothers and untested and disadvantages of EBF for three to six EBF followed by cessation of breastfeeding women are counselled in EBF for the first months then abrupt cessation and formula. and RF are contrary to community norms, six months. HIV-positive mothers make an Expressed heat treated milk was mentioned according to community FGD results. Both informed choice between EBF for 4-6 in one-third of sessions, and wet nursing options generate some level of derision that months or ERF, i.e. infant formula, after in five sessions. Most providers (41/42) children are being fed inadequately. These discussing the advantages and disadvan­ made suggestions rather than commands discussions underscored the need for fam­ tages of the available options. HIV-posi- about infant feeding. ily, and particularly partner support, for a tive who choose to feed their children with women to successfully manage infant for­ formula are taught how to do so correctly Counsellors did not ascertain the clients’ mula. by health workers. They are also monitored specific circumstances, necessary to help­ to try to ensure that the formula is pre­ ing women consider her ability to imple­ The community felt that HIV-positive pared properly and done under hygienic ment various feeding choices. Only 10/42 women should reveal their status and serve conditions. Formula is provided for 6-12 providers inquired whether the mother had as peer counsellors, stating that HIV-posi- months. In some sites, mothers can prac­ money to buy formula and only 6/42 asked tive women are preferred as a source of tice preparation under supervision. whether the client had access to adequate support for IF issues because they are like supplies of water and fuel. Just 7/42 asked the other women in the pMTCT program Providers demonstrated good knowledge whether the client had disclosed her HIV rather than health providers, who are old of advantages and disadvantages of EBF status to her partner, and 5/42 asked and long removed from their own experi­ for six months, EBF for three months, wet whether the client had disclosed her sta­ ence with IF. nursing, infant formula and expressed heat tus to other family members or close treated milk as the IF choice for HIV-posi- friends. In 26/42 sessions, the providers Reliable supply of infant formula and/or tive mothers. They were not familiar with adequately explored (and in 12 observa­ milk for babies is an issue for providers and milk banks or home prepared modified tions “somewhat” explored) the feasibility community. This is seen by both groups as animal milk. Providers saw their role as giv­ and acceptability of various feeding op­ important to maintaining the credibility of ing information, encouragement, support tions. the program. and assistance in making a decision about an IF option. Counsellors are seen as providing convinc­ Conclusions and ing, sound, comforting information about recommendations of authors Most providers showed a bias towards in­ the optimal choice and are helping women fant formula as the preferred IF method feel that they have made a good decision. As a result of various donors attracted by for HIV-positive women. Of the 32 provid­ In the exit interviews, the majority of the pMTCFT-Working Group, program inputs

A Compilation of Programmatic Evidence 79 and staff costs are currently met. The con­ ing counselling and support; and 3) If the cern now is whether these donors can pro­ pMTCT program takes the decision to no vide support for all of the country and what longer provide free formula, the impact on other sources of support can be secured program acceptability and uptake needs to for program expansion. be considered.

Specific infant feeding related conclusions Methodological considerations/ include: 1) providers demonstrated a bias reviewer’s comment towards infant formula as the IF method for HIV-positive women; 2) provision of This rapid assessment appears to have been infant formula by the pMTCT program is extremely well organized, generating a highly valued by the community; and 3) great deal of valuable information using safety of the use of infant formula in these five structured instruments appropriate for communities is unknown. the collection of relevant quantitative and qualitative data concerning pMTCT opera­ As part of the planning for replication and tional issues, health care providers, clients scale up of the pMTCT program, several IF- and communities. The results are presented related recommendations emerged, includ­ systematically, organized by key issues in a ing: 1) Safety data should be collected and way that is useful to the reader. Informa­ combined with the information provided tion collected on infant feeding provides by providers and the community about the very useful insights and should help pro­ role of formula in preventing MTCT; 2) These gram planners improve training and coun­ data, in combination with new data on selling related to infant feeding options and feeding patterns and link with MTCT which anticipate potential problems related to will be available in 2003, should guide the scaling up, including the supply of formula program in updating training materials and when the program is expanded. recommendations regarding infant feed­

80 HIV and Infant Feeding ZIMBABWE

Results Infant Feeding, which way? Recommendations: 1) Work on making Zimbabwe (Chitsike, 2000) breastfeeding safe and 2) HIV-negative Mean age of baby at interview seven mothers require attention. months, ranging from under one month Document title to 20 months; 35.7% reported having dis­ Infant feeding, which way? Methodological consideration/ closed HIV-positive status to partner. reviewer’s comment Authors Chitsike I

Institution Knowledge of HIV transmission through Weaknesses: The author concedes this to AIDS and TB Unit, MoH Zimbabwe breast milk: 88% of mothers knew there is have been a hurried survey of feeding prac­ a risk of transmission through breast milk. tice percentages of babies aged neonatal Date Undated, perhaps 2000 Asked whether one can reduce BMT, 52% to 20 months. Conclusion that mothers can Country Zimbabwe indicated no and 44% yes. To reduce BMT: make their own decisions is important but 33% said to avoid giving BM; 36% said to shaky if based on one statement by the Document type boil BM; 18.5% said to use BM exclusively; mothers. PowerPoint presentation 10% said they did not know; 1% said early Source ESARO CD cessation, and 1% said ARV drugs.

Background Infant feeding practices: Breastfeeding was cited by 84%, formula feeding by 16%, HIV seroprevalence in pregnant women in expressed BM by 5%, home-prepared milk Zimbabwe in 2000 was 35% (10-70%) as by 1%. EBF was practised by 84% at one compared to 29% in 1997. There is a 10.5% week; by 75% at one month; by 40% at 3 seroconversion in HIV negative pregnant months; and by 0% at 6 months women by the end of the second year post­ partum. There are 50-60 thousand babies Factors influencing mother’s decision: 70% infected with HIV annually, and 98% are of these mothers felt it was their decision. breastfeeding at one year. While policy rec­ If money were not an issue, 59% would ommends exclusive breastfeeding (EBF) for prefer formula and 39% breastfeeding. 6 months, EBF at 3 months is 16%. Cultural factors limiting breastfeeding in­ Prevention of MTCT pilot projects were at cluded suspicion of HIV infection by 30%; 3 urban clinics (10,000 ANC/year) in Harare, stolen baby by 16%; immorality by 13%; Chitungwiza and Bulawayo. Core interven­ witchcraft by 5%; others (medical reasons, tions were VCT, safe obstetric practices, work, etc.) were not quantified. short course AZT, and infant feeding coun­ selling. A survey was conducted (method Conclusions and ology not stated in the PowerPoint print recommendations of authors out) of 188 HIV-positive mothers inter­ viewed by counsellors in Zengeza and 1) Awareness of BM transmission was high; Chitungwiza, Zimbabwe. 2) mothers can be decision makers with regard to breastfeeding; 3) barriers include economic factors, stigma and cultural be­ liefs.

A Compilation of Programmatic Evidence 81 Feeding practices were defined as follows: Comparison of pre- and post-intervention Education and Counselling, exclusive breastfeeding (EBF) was nothing cohort showed an increase of condom use ZVITAMBO except breast milk, medicines and vaccines; (‘sometimes’ or ‘always’) from 5.3% to 9.7%. (Tavengwa et al, 2002) predominant breastfeeding (PBF) was breast milk and other non-milk-contain- The rate of EBF at 3 months, defined by Document title ing liquids; mixed feeding (MF) was breast 24-hour history, was 17%, by 7-day recall Education and counseling make a milk plus other animal milk including com­ was 12%, ‘ever’ was 5%, and ‘conditional difference to infant feeding practices and those feeding practices make a difference mercial infant formula, with or without ever’ was 4%. to infant mortality other liquids; and complementary feeding was breast milk and solid food with or with­ Authors The rate of EBF at 3 months (‘conditional out other liquids or other milk. Feeding Tavengwa N, Piwoz E, Gavin L, Zunguza ever’ definition) in the pre-intervention C, Marinda E, Iliff P, Humphrey J, practice category was defined by 1) 24­ cohort was 2%; in the post-intervention ZVITAMBO Study Group hour history, 2) seven-day history, 3) ‘ever’ (education but no individual counselling) (i.e., ‘Have you ever given your baby any­ Institution it was 9%; and in post-intervention (with thing other than breast milk?’), 4) ‘condi­ ZVITAMBO Project, University of education and individual counselling) it was Zimbabwe; Harare City Health Depart­ tional ever’ (previous data points available 19%. ment, Zimbabwe and consistent).

Date Sept 23–27, 2002 Counselling: 73% of the mothers attended Qualitative research consisted of focus one session only, with a duration of 30 to Country Zimbabwe group discussions (FGDs) and in-depth in­ 40 minutes. Document type terviews (IDIs), new research findings (es­ Power point presentation at WABA Global pecially on exclusive breastfeeding and The disclosure rate increased (pre- to post- Forum 2, Arusha, Tanzania mastitis) and recommendations from intervention) for HIV-positive mothers from UNAIDS (on empowerment of women to Source ZVITAMBO 52% to 64%, for HIV-negative mothers make informed decisions) and the Ministry from 80% to 89% (p<0.05). Rate of EBF at of Health were used to develop an educa­ Background 3 months (‘conditional ever’ definition) for tion and counselling intervention designed mothers who did not disclose 5%, for to assist mothers in reaching infant feed­ mothers who disclosed to their husbands This report is based on a placebo-controlled ing decisions. 9%, for those who disclosed to someone trial of postpartum vitamin A supplemen­ other than their husband 22%. tation of 14,110 mother-baby pairs in ur­ The intervention included 1) antenatal ban and peri-urban settings. sensitisation, 2) male outreach, 3) integra­ Unadjusted one-year mortality (per 1000) tion of infant feeding counselling into HIV of babies of HIV-positive mothers, by feed­ Methodology pre- and post-test counselling, 4) support­ ing practice (‘ever’ definition) at three ive counselling and 5) referral to other months: EBF 50, PBF 95, Comp 104, MMF Mothers were recruited within 96 hours of agencies as appropriate. 210. Hazard ratios (compared to EBF, ad­ delivery with written informed consent. justed for birth weight, maternal CD4 count They were tested for HIV (parallel ELISAs, if Results at recruitment and maternal arm circum­ positive confirmed on subsequent visit; if ference): PBF 2.5 (p=0.04), Comp 2.8 discordant, Western Blot). Mothers could HIV seroprevalence was 33% ; 43% of the (p=0.02), MMF 6.0 (p=0.001). Hazard ra­ choose to know status or not. Eligibility women were aged 25 to 34; incident HIV tios for babies of HIV-negative mothers: criteria required that neither mother nor infection in baseline seronegative mothers PBF 1.2, Comp 1.4, MMF 2.8 (not statisti­ baby was seriously ill, baby weighed at least was 4-5% per year; 94% of mothers were cally significant). 1500 g; and that they could be followed breastfeeding at 12 months and 63% were up at six weeks, three months and then still breastfeeding at 18 months. every three months to one-to-two years.

82 HIV and Infant Feeding Conclusions and Methodology recommendations of authors Feasibility of Heat-Treating Expressed Breast Milk Thirteen focus group discussions (FGDs), (Israel-Ballard et al, 2001) Authors concluded that: 1) the dilemma with four-to-seven participants each (to­ over breast or replacement feeding is dif­ tal 77), were held with four different tar­ ficult; 2) there is scope to substantially in­ Document title get populations (women of child bearing crease EBF rates; and 3) EBF is associated Zimbabwean Attitudes and Resource age who were breastfeeding at the time or Accessibility as a Measure of the with lower mortality than mixed feeding. Feasibility and Acceptability of Heat had previously breastfed a baby, grand­ Transmission rates have not yet been re­ Treating Expressed Breast-milk for mothers (over 45 years old), nurse midwives ported but it is likely that the reduction in Prevention of Mother to Child Transmis­ and traditional birth attendants (TBAs), sion of HIV mortality associated with EBF is primarily husbands who had fathered a child in the due to a reduction in breastfeeding MTCT Authors last five years), in three different sites of HIV. Israel-Ballard K; also Padian N, Chantry (Harare (upper socio-economic), Glenview C, Chipato T, Chirenje Z, Morrison P, a “high density” suburb of Harare (middle Chitibura L Methodological considerations/ socio-economic), and rural (commercial reviewer’s comment Institution farming estate). An extra FGD was held in University of California; University of “high density” Harare for women of child­ Strengths: This study offers a large sample Zimbabwe Collaborative Women’s Health bearing age who were members of an HIV Programme size and followed HIV-positive and HIV- support centre. negative mothers. Date 2002 Country Zimbabwe Informal discussions were first held with mothers who were expressing breast milk Weaknesses: This was not a randomised trial Document type for their premature babies, followed by a of either infant feeding practice or the edu­ MPH Thesis and Presentation (of same cation and counselling intervention. To name) at 130th Annual Meeting of the pilot FGD with HIV-positive peer counsel­ date, there is absence of HIV transmission American Public Health Association, lors in the high density suburb to develop November 10-13, 2002 data. the FGD Guide. The HIV status of partici­ Source Author pants was not asked or determined. This study was not in the setting of a ‘nor­ mal’ pMTCT program. It is likely that the Background Ten out of thirteen FGDs (nine of which effect on infant feeding practices of a simi­ were in Shona, one mixed, three in English) lar intervention, integrated into antenatal In Zimbabwe, little attention has been paid were facilitated by a Zimbabwean research and perinatal care, would be even greater. to heat-treating expressed breast milk assistant and co-facilitated by the first au­ (HEBM) as an infant feeding choice for HIV- thor, the other three were the other way positive mothers, although it is officially around. Written consent was obtained. listed as an option by the MoH. It is a good FGDs were audio-taped, transcribed ver­ potential candidate as an effective, simple, batim and translated. Questions addressed inexpensive and sustainable method. The included: knowledge of HEBM for pMTCT purpose of this study was to determine the or for other reasons, its practicality and likely feasibility of HEBM in different com­ acceptability, relevant cultural attitudes, munities in Zimbabwe. and the support and educational and coun­ selling inputs that would be required for it to be successful.

A Compilation of Programmatic Evidence 83 Findings/Results any case separate utensils are routinely used straints for HEBM are a) time, b) physical for infant feeding and these are normally constraints around manual expression and Age of participants: all mean of 42 years cleaned with boiling water. 5) HEBM was milk production, c) lack of support from (18-65); mothers 32, fathers 41, midwives/ considered affordable and therefore sus­ husband and family, and d) the influence TBAs 43, grandmothers 52. In Harare, 20 tainable. of traditional beliefs. 3) Benefits are the (91%) had had tertiary education, in the availability of breast milk at no cost with rural site, seven (20%) had had no formal Cultural beliefs: 1) Not breastfeeding is con­ its nutritional advantages but with protec­ education. Harare mothers had employ­ sidered to be an indicator of infidelity or tion against HIV transmission. 4) Partici­ ment, most rural mothers and those in other misdeeds, bewitchment or being pants from the (very superstitious) rural Glenview did not. Non-exclusive pregnant again. Breastfeeding means the area, who were of low educational level breastfeeding was the norm. baby belongs to the entire family. 2) Rural were quite negative about HEBM but even participants thought that expressed breast they thought that education would make Knowledge: 1) Most FGD participants knew milk might be used for witchcraft, is un­ a big difference. In this area it would be of breastfeeding transmission of HIV. 2) clean, comparable to human meat, indi­ difficult to attempt, especially because of Most, including most midwives, did not cates the HIV status of the mother. Some the mistrust of health workers. 5) Depen­ know of HEBM. 3) All knew of manual ex­ thought it was very dangerous. dence on the husband seemed to be in­ pression of breast milk (usually taught by versely proportional to the likelihood of the mother’s mother at the time of child­ Family perceptions: If consulted, the hus­ success with the method. 6) HEBM may be birth). The most common reason given for band would be supportive, if not he would more suited as an alternative to formula expression was the baby being unable to question the mother’s fidelity and perhaps feeding (rather than to breastfeeding). 7) suckle (eg because of prematurity or sick­ divorce her. Fathers, mothers-in-law and Resources (including breast pumps) were ness). Other reasons included feeding or­ perhaps other members of the family need not the perceived problem, rather the atti­ phans, sore nipples, and the use of breast to be involved and supportive. Some rural tudes of family and community. 8) Infor­ milk for various healing processes. Eigh­ TBAs and fathers thought that HEBM would mation is needed on a) denaturation of teen (30%) of the women had expressed never be acceptable. breast-milk constituents with flash boiling, at some time. and b) contamination of HEBM under dif­ Education and counselling should be con­ ferent storage conditions. Practicality: 1) Expression of breast milk was ducted by trained professionals or lay thought to be painful, but only at first; people. Rural participants wanted some­ Methodological considerations/ proper education and the use of vaseline one from outside the area because of con­ reviewers comment were said to be important. Rural grand­ cern that confidentiality would not be re­ mothers and TBAs thought that HEBM spected. Some participants from Harare felt This was a carefully conducted small study, should only be used in emergencies. Con­ strongly that information on all feeding with appropriate preparation and safe­ cerns expressed included diminished bond­ options (including HEBM) should be given guards. ing, reduction in milk production and time to all mothers, not just those found to be constraints. Several said it could be as quick HIV-positive. Education was considered the The study did not pretend to and did not as breastfeeding (<15 minutes). 2) Heat key to acceptance. test the feasibility or sustainability of HEBM treatment: “flash boiling” was considered as an infant feeding option but found a preferable to pasteurisation because of Conclusions and high degree of willingness to consider the being able to view the required heat point, recommendations of authors possibility. None of the participants had and because it is more efficient in time and expressed breast milk over a period of sev­ fuel. 3) Source of heat: electricity for Harare, 1) HEBM is an official feeding option in eral months. The statement that, as an ethi­ firewood for the rural area, though could Zimbabwe but few know about it. It is an cal imperative, it should be always included be paraffin. Nothing would have to be pur­ ethical right for an HIV-positive mother to when pMTCT issues are presented should chased specifically. 4) Using a cup was be properly informed about it. 2) Con­ be seriously considered. known to be safer than using a bottle. In

84 HIV and Infant Feeding MULTI-COUNTRY REPORTS

port breastfeeding in the previous two-to- method. The authors believe that the pre­ Status of Protection, Support three years (though how these observations sentation of this ‘choice’ is biased by a) and Promotion of BF and reviews were done is not explained in health workers believing that there is 100% (Latham and Kisanga, 2001) the report). HIV transmission through breastfeeding and being ignorant of the benefits of EBF Document title and the risks of not breastfeeding and b) Current status of protection, support and Results the economic advantage of free FF. Other promotion of breastfeeding in four African countries: Actions to protect, support and A major decline has occurred in support of concerns are that providing free FF results promote breastfeeding in Botswana, breastfeeding and consists of a) decreased in an increase in mixed feeding and that Kenya, Namibia, and Uganda support by UNICEF, b) weakened Nutrition AZT is shared with other family members. Authors Latham MC, Kisanga P Units in MoHs, c) BFHI action has almost At the time of the Latham/Kisanga report, there had been no independent evaluation Institution UNICEF ESARO stopped, d) little action/monitoring/en- forcement of the ‘Code’ in B, N and U, al­ of the Botswana pMTCT program; since Date January 2001 though there is some new interest in K, e) then see Willumsen and Rollins, 2001, summarised here under ‘Botswana’. Countries World Breastfeeding Week is still held but Botswana, Kenya, Namibia, Uganda with markedly reduced support, and f) breastfeeding NGOs are dead or dying, for Kenya had very disparate policies and ac­ Document type reasons including diminished support from tions. While high-level government state­ Report for UNICEF ESARO governments and UN agencies. ments have urged all HIV-positive mothers Source UNICEF ESARO CD not to breastfeed, many health workers are Breastfeeding is still the cultural norm, al­ advocating breastfeeding ‘as usual’ until Background though rates of exclusive breastfeeding more evidence is available. All evidence (EBF) at three and six months are very low. gathering relates to HIV transmission rates, not morbidity (including malnutrition), Government and UN agencies have been mortality, family economics, fertility, or reducing their support for breastfeeding in The decrease in support for breastfeeding exclusivity of feeding practice. There is (was) sub-Saharan Africa. This study was com­ (there is no evidence for a decline in no national pMTCT policy, and the authors missioned by the UNICEF Eastern and breastfeeding itself) is related to HIV/AIDS. are concerned about the balance (bias) of Southern Africa Regional Office to deter­ Concern about HIV has led to a) less activ­ the membership of committees advising the mine the extent of reduction in four coun­ ity in support of breastfeeding and b) the government on the development of policy. tries. belief that ‘all mothers will infect their chil­ dren through breastfeeding’. At the same Namibia: The government currently advises Methodology time there is a) inadequate recognition (by all, including professionals and lay people) 1) no change in the policy of promotion of the dangers of formula feeding and b) and support for breastfeeding and 2) in­ Data and other information for this study creased investment in family planning and were derived from 1) interviews with key inadequate knowledge of the Durban study (showing lower transmission of HIV to EBF control of STIs. (This policy clearly finds informants and organisations, including a babies than to those mixed fed). favour with the authors.) Minister of Health, Members of Parliament, senior officials in various Ministries (includ­ Uganda has a history of energetic advo­ ing Health), NGO leaders, UNICEF represen­ Policies on HIV/AIDS and pMTCT have in­ cacy for prevention. Advice on alternative tatives and program officers, WHO staff fluenced promotion of breastfeeding in feeding practices is well articulated in draft (though no specifics of these interviews, various ways in these countries: pMTCT policy, advocating either 1) EBF for numbers, etc. are given in the report) in three months (authors have recommended four countries: Kenya [K], Namibia [N], Botswana had undertaken a major expan­ this be changed to six months), 2) FF from Botswana [B] and Uganda [U] and 2) ob­ sion of VCT, provision of free AZT in late birth, or 3) animal milk from birth. servations and reviews of actions to sup­ pregnancy for those choosing formula feeding (FF), plus ‘choice’ of feeding

A Compilation of Programmatic Evidence 85 Conclusions and The authors recommend the following: 1) Prevention of MTCT in Asia recommendations of authors UNICEF, WHO, governments and NGOs (Preble and Piwoz, 2002) should increase support of breastfeeding; The authors’ comments on the approach 2) strengthen Nutrition Units; 3) create Document of the four countries to MTCT through national breastfeeding coordinating com­ Prevention of Mother-to-Child Transmis­ breastfeeding highlight the following: 1) mittees; 4) legislate, implement and moni­ sion of HIV in Asia: Practical Guidance family planning (to prevent conception of tor the ‘Code’; 5) increase support for the for Programs potentially HIV-infected babies) was not a BFHI, World Breastfeeding Week and Authors Preble AE, Piwoz EG high priority (except Uganda); 2) confu­ breastfeeding associations and NGOs; 6) sion caused by the linkage of intra-uter- promote EBF for 6 months; 7) submit Institution ine/-partum transmission and pMTCT activities to independent evaluation; Academy for Educational Development, breastfeeding transmission is expressed as 8) train VCT counsellors in infant feeding; Washington, DC ‘babies will only benefit from the ARV re­ and 9) UNICEF should appoint at least one Date June 2002 search study reductions in MTCT if they do nutrition program officer in each country. not breastfeed;’ 3) a compromise is tacitly They conclude that ‘going to scale’ with FF Country developing between advocates of exclu­ is currently insupportable. Cambodia, China, India, Myanmar, Thailand sive FF from birth and of ‘normal’ breastfeeding, i.e., short duration Methodological considerations/ Document type Report breastfeeding with abrupt cessation; 4) reviewer’s comment Source LINKAGES Project health workers and the general public lack knowledge of the relative risks of A blurring of the distinctions between data, Background breastfeeding and alternative feeding, ex­ interpretation of data, and recommenda­ pressed as an exaggeration of the risks of tions makes assessment of this report dif­ Many countries in Asia are experiencing a breastfeeding transmission and minimising ficult. The overall conclusions are, however, dramatic rise in both adult and pediatric the risks of FF; and 5) an urgent need for clear: that breastfeeding action has been AIDS. To date, there exists little documented research into alternate feeding methods. markedly reduced and that there is an ab­ experience related to the implementation The authors worry about potential result­ sence of coherent evidence-based policy of programs to prevent transmission. Two ant malnutrition and the absence of con­ on infant feeding. Some of the informa­ notable exceptions, Thailand and Cambo­ sideration of what to feed babies after ei­ tion presented is now outdated (at least dia, have taken deliberate actions to re­ ther EBF or exclusive FF. for Botswana). verse the trend. This review focuses on five core interventions to prevent maternal to child transmission (pMTCT) of HIV, one of which is specifically related to infant feed­ ing. Necessary medical care and social sup­ port for mothers and infants living with HIV/AIDS are also discussed. Annexes pro­ vide data on HIV/AIDS, infant feeding, and women’s health for all Asian countries; the bibliography is extensive.

Methodology

This systematic and well-written review compiles existing published and unpub­ lished data and other information related

86 HIV and Infant Feeding to the five countries most seriously affected duct vaginal deliveries on HIV-positive as the first month of life by grandmothers. by HIV/AIDS in the region: Cambodia, women. A 1997 study of Thai doctors found Early cessation conflicts directly with cur­ China, India, Myanmar, and Thailand. It also many were unwilling to perform vaginal rent infant feeding practices in many parts reviews the technical dimensions of MTCT exams (19%), vaginal deliveries (31%), or of Asia. of HIV in Asia, characterized by highly di­ C-sections (39%) on HIV-positive women. verse epidemiological patterns within and The replacement feeding option for HIV- among countries. Given the lack of pro­ Voluntary counselling and testing: Data on positive mothers: Although replacement gram experience specific to the region, the demand for VCT by antenatal women in feeding is recommended when safe, accept­ authors draw on considerable experience Asia are limited. Acceptance rates for VCT able, feasible, affordable, and sustainable, and lessons learned from Africa and else­ were high in pMTCT pilot projects in Thai­ the problem in Asia is that the majority of where in outlining core interventions to land (93%) and Cambodia (85%), but a re­ women do not know their HIV status. Thai­ reduce transmission: 1) comprehensive cent pMTCT site in Myanmar reported only land has decided to advise all HIV-positive maternal and child health services, 2) vol­ about 30% acceptance. Several Asian sites mothers not to breastfeed and to provide untary counselling and testing (VCT), 3) (Cambodia, India, Thailand) provided HIV them with free formula for 12 months, but antiretroviral (ARV) prophylaxis, 4) coun­ testing and VCT at the time of delivery to the increasing number of mothers who selling and support for safe infant feeding, reach women who have not received an­ qualify and government budget cuts are and 5) optimal obstetric practice. tenatal care. Two studies in India (one ur­ making it difficult to sustain this policy. In ban, one rural) concluded that a rapid test India, a National AIDS Control Organiza­ Results in the delivery room can increase VCT up­ tion (NACO) feasibility study on AZT found take significantly. that in infants of HIV-positive mothers, General findings of relevance to pMTCT mortality was higher (but not statistically programming, with direct or indirect im­ Use of ARV for pMTCT: Several studies in significant) among replacement-fed infants pact on counselling and support for safe Thailand demonstrated the feasibility, effi­ than among infants breastfed exclusively infant feeding, include the following: cacy, and safety (for infants) of AZT for for two months. pMTCT. In India, an 11-centre study of AZT Need for public education and communi­ for pMTCT rated compliance as “good” in Country programs cation programmes: Various Asian studies 54% of the women, “fair” in 45%, and show pregnant women have limited un­ “poor” in one percent. Varying doses and Thailand. Thailand has taken MTCT seri­ derstanding of HIV and MTCT. Three Indian duration of AZT prophylaxis was part of ously. Its extensive pilot project experience studies reveal serious misconceptions about the problem. Early small study results with is well evaluated and has enabled scale-up transmission and prevention of HIV. Even NVP for pMTCT in China and India suggest with many pMTCT interventions. In 1998, in Thailand, which has had an aggressive it may be effective and affordable. (The a placebo-controlled clinical trial in the public education program, pregnant successful introduction of ARVs has impli­ northeast introduced VCT in public ante­ women appear to lack sufficient knowledge cations for post-delivery transmission of natal services used a simplified ZDV regi­ of MTCT according to one report. In an­ HIV and thus impacts future recommen­ men: 100,000 new antenatal clients were other nearly half of HIV-positive pregnant dations related to infant feeding.) tested for HIV, about 1% were infected, women who reported no casual sex part­ acceptance of HIV testing and adherence ners perceived themselves at little or no Promotion of exclusive breastfeeding/early to the ZDV regimen was high, and HIV risk of infection by their husbands. cessation: Evidence suggests that where transmission was reduced about 30% to support for exclusive breastfeeding has about 10%. An earlier 1997 pilot study in Health worker attitudes: Several studies been implemented properly, positive results six provinces in the north concluded that reveal major problems related to stigma and (up to 70% exclusive breastfeeding for the the simplified ZDV regimen reduced MTCT discrimination by health care workers to first three to five months) have been to eight percent. people living with HIV/AIDS. In south In­ achieved in the region. In many Asian cul­ dia, village nurses were unwilling to con­ tures, weaning foods are introduced as early

A Compilation of Programmatic Evidence 87 Cambodia. In Cambodia, a national pMTCT Myanmar. A pMTCT pilot program that in­ fant feeding, and optimal obstetric prac­ policy was finalized in 2000, focused on cludes strengthening primary prevention, tices. 6) Engage in discussions with all improving the acceptability, accessibility, introduction of VCT, NVP for HIV-positive stakeholders and partners to develop na­ and quality of health services and infor­ pregnant women and babies, improved tional strategies for pMTCT and to assure mation on reproductive health and HIV/ obstetric and postnatal care, counselling on adequate funding.7) Support operational AIDS/STIs. Due to very limited maternal care infant feeding, and improved birth spac­ and clinical research in pMTCT, as neces­ services, the government is studying a pack­ ing was started in 2000 and is being sys­ sary. 8) Link prevention activities with care age of pMTCT services through antenatal, tematically scaled up. The government in­ and support activities for families and com­ perinatal, and postpartum care. Three pilot tends to have 27 townships implementing munities affected by HIV/AIDS. 9) Contrib­ sites are underway. MTCT prevention activities by 2005. A study ute toward the creation of an enabling of IF practices and feeding options for HIV- environment for HIV prevention (includ­ India. Several programs are being tested. positive mothers was carried out in 2002. ing pMTCT). 10) Periodically review MTCT An efficacy study of a pilot program that (See Myanmar.) prevention packages for continuing rel­ includes AZT for the mother and infant, C- evance and appropriateness, given the rapid section before membranes rupture, and no Conclusions and changes in behavioural, biological, and breast milk concluded that MTCT was re­ recommendations of authors pharmaceutical developments. duced. An 11-center feasibility study of a package that included routine antenatal The authors of this review conclude that Methodological considerations/ VCT, short-course AZT regimen, iron folic Asian governments need to assess their reviewer’s comments acid and vitamin A, infant feeding coun­ situation with respect to MTCT, identifying seling, babies tested with PCR at 48 hours the most feasible and appropriate package Although there exists little concrete pro­ and 2 months, and an 18-month follow- of pMTCT interventions given the resources grammatic experience in the Asian region up for babies reached 150,000 antenatal available. The following comprehensive to draw from, the authors successfully women: 79% were counselled, 77% tested, actions were recommended to meet the weave together additional relevant coun­ and 1.8% were HIV-positive, of which 22% challenges: 1) Review the HIV/AIDS epide­ try evidence from other regions of the received AZT. Problems included late ante­ miology in each setting. 2) Ensure support world to outline a systematic approach to natal coverage, low rate of institutional for primary prevention of HIV/AIDS through the prevention of MTCT. This review un­ deliveries, maintaining confidentiality, so­ condom promotion and provision, derscores the need to address not only is­ cial stigma, low rates of exclusive behaviour change communication, preven­ sues of infant feeding in order to reduce breastfeeding, and insufficient links to tion and treatment of STDs, policy reform, the transmission of HIV, but also MCH ser­ communities. Based on the NACO AZT fea­ etc. 3) Ensure that safe, voluntary contra­ vices, VCT, ARVs, and optimal obstetric prac­ sibility study, the government developed a ception is available to prevent unwanted tices. As such, this report presents a useful firm policy on IF practices for HIV-positive pregnancies, especially in HIV-positive technical resource for policy makers and mothers: exclusive breastfeeding during the women. 4) Review existing maternal and program planners interested in developing first four months of life, gradual weaning child health services and infrastructure to a comprehensive pMTCT package. The au­ between four and six months, and termi­ prepare those services to enable them to thors’ conclusions and recommendations nation of all breastfeeding by the end of add prevention of MTCT services. 5) Iden­ provide practical guidance and are relevant the six months. tify opportunities to support core MTCT not only to the five focus countries, but interventions, including VCT, ARV, safe in­ also to other countries in the region.

88 HIV and Infant Feeding Methodology ■ Employ professional counsellors to sup­ Lessons Learned from HIV and port and mentor new counsellors. MCH Studies The lessons from HORIZONS HIV projects (Rutenberg et al, 2002) ■ Help institutions to fully use the skills were discussed at a three-day workshop of of trained health workers. HORIZONS study investigators and service Document title managers in Maasai Mara, Kenya, on July ■ Integrating HIV prevention and care into Work with national medical bodies to 23-25, 2001. The participants, who repre­ Maternal and Child Health care settings: also improve skills of private practitio­ lessons learned from Horizons studies sented Horizons projects from Kenya, Tan­ ners. zania, Uganda, Zambia, and Zimbabwe, pre­ Authors sented overviews of their project objectives, Rutenberg N, Kalibala S, Mwai C, Motivating staff activities (including AFASS), what worked, Rosen J outcomes, and plans/recommendations for ■ Emphasise that pMTCT is part of rou­ Institution replication and scale-up. Notes from that tine MCH. Population Council/HORIZONS Project meeting formed the first draft of this re­ ■ Involve senior staff to expand ‘owner­ Date Feb 2002 port. ship’. Country Multiple That workshop was followed by a one-day ■ Use supportive supervision to recognise Document type Published Report meeting in Nairobi, Kenya, the following and build on staff skills. July 27 attended by the workshop partici­ Source pants plus representatives from the Kenyan ■ Work with the Ministry of Health to Population Council’s Horizon Project government and several international de­ reduce the root causes of poor moti­ velopment agencies. Horizons intervention vation: working conditions, low pay, in­ Background studies were systematically reviewed to adequate supplies, understaffing, etc. identify factors related to the successful This report documents lessons learned from integration of HIV prevention into MCH Supervision of HIV-related services Horizons intervention studies that focus on settings. The write-up from the workshop the integration of HIV prevention and care ■ Standardise supervision by adapting was made available and then edited by and integrating the existing supervi­ into existing MCH settings, with a view to Horizons, resulting in the document re­ assisting in both the replication and scal­ sion checklist. viewed here. ing up of HIV programmes in the MCH set­ ■ Interact directly with mothers to su­ ting. Results pervise infant feeding (for example, exit (Summary of Lessons Learned) interviews to assess what mothers dis­ A number of key areas are discussed in de­ cussed during counselling, supervision tail, including training to improve health Training to improve performance of health of mother preparing replacement feeds worker performance, motivating health workers to ensure that information passed on workers, supervision of HIV services and fully). quality assurance of HIV testing, antenatal ■ Conduct in-service training to increase care for mothers, follow-up care for HIV- number of trained staff and to train Antenatal care for mothers positive women, risk avoidance, VCT ser­ replacements. vices, counselling on infant feeding, ARV ■ Effective pMTCT requires that all service to reduce MTCT and involving male part­ Provide job aids to prompt (e.g. prompt ners. This summary will focus on those ar­ topics to be covered in ANC counsel­ providers be aware of a woman’s HIV sta­ tus and several programmes have had suc­ eas of direct relevance and impact to in­ ling sessions). cess with this approach. However, progress fant feeding practices. ■ Follow up and monitor trainees. has been slow to integrate HIV education and counselling into routine antenatal care. ■ Integrate pMTCT into pre-service medi­ pMTCT sites often share the same difficul- cal and nursing curricula.

A Compilation of Programmatic Evidence 89 ties as ANC: inadequate supplies and regard to dealing with family members and ■ Include planning for practising formula understaffing. others who question their use of formula. feeding as part of counselling (mixing, Misconceptions (and remaining confusion etc.). Follow-up care of HIV-positive women about EBF and transmission) hamper health ■ Promote proper infant feeding through worker ability to provide balanced infor­ IMCI. Infants tend to be the focus of follow-up mation on feeding choices. However, train­ care, and women receive little or no pro­ ing does appear to have contributed in ■ Encourage the transition from EBF to active care after delivery. Many women who helping health workers to counsel mothers weaning by cup using expressed breast could discuss their HIV status within the to make informed decision, even in health milk. antenatal care setting are reluctant to go provider environments accustomed to mak­ elsewhere for psychosocial or medical sup­ ing decision for patients. ■ Develop complementary foods using port. Strategies to improve follow-up in­ locally available ingredients. clude: There is also some evidence that social class ■ Involve men in infant feeding coun­ influences the decision to formula feed, ■ selling. Develop a strategy for managing HIV with highly educated, independent women in the same way as other chronic dis­ able to resist social pressure to breastfeed ARVs eases. more effectively than poorer mothers. Poor ■ Change clinic procedures to provide mothers may also divert formula to other ■ Stress benefits of pMTCT for mother children, although this is difficult to moni­ incentives for follow-up. herself. tor. ■ Refer women needing comprehensive ■ Train TBAs to supervise use of ARV in HIV care to other health services and Rapid cessation of breastfeeding has been labour and birth registration to moni­ community groups that are accessible, recommended in some projects: the Zam­ tor ARV use outside hospital. affordable and acceptable. bia EBF study recommends expressing breast milk from 2 months and offering it Conclusions and VCT services to baby by cup, another Zambian study recommendations of authors recommends expressed breast milk from 5 ■ Expand education activities outside the ■ Make HIV-related care the norm in months, followed by stopping MCH care. ANC clinic. breastfeeding and introducing formula for ■ Shift the counselling emphasis from a few weeks at 6 months, followed by the ■ Strengthen ties between MCH and out­ pre-test to post-test support. introduction of other foods. (Note: This side sources of care. approach has not been evaluated and re­ ■ Diversify sources of post-test support. quires additional research to determine its ■ Promote incremental, low-cost change. feasibility, safety, etc.) ■ Work long-term to create a policy en­ Counselling on infant feeding vironment favourable to integration. Practical strategies to improve IF Counsel­ Helping women make informed decisions ling on infant feeding (IF) also has an impact Methodological consideration/ ■ reviewer’s comment on the acceptability of other pMTCT com­ Provide interim guidance on feeding, even though experts are still debating ponents. Many women decline to use for­ the best way to feed infants of HIV This report provides important insights re­ mula for fear it would disclose their status so there is no point in taking the ARV com­ positive mothers. lated to the integration of HIV prevention in MCH settings. The findings and recom­ ponent of the pMTCT programme. Despite ■ Expand and improve training. mendations should be useful to policy the increase in counselling on IF, many health workers still struggle to provide good ■ Document the challenging situations makers and program planners responsible for the design and/or implementation of information to mothers, especially with women face and how they handle them (case studies). pMTCT programmes.

90 HIV and Infant Feeding HEAT TREATMENT OF MILK AND SAFE WATER

to the HIV inactivation properties of breast Conclusions and Lipolysis or Heat for HIV in milk. This study investigated the efficacy recommendations of authors Breast Milk of heat-treating maternal milk or allowing (Chantry et al, 2000) ■ Bringing breast milk to the boil does breast milk to undergo lipolysis by stand­ destroy HIV; this study did not investi­ ing for 6 hours at room temperature in the Document title gate to what extent this also denatures inactivation of HIV-1. Effects of lipolysis or heat treatment on other breast milk component. HIV-1 provirus in breastmilk Methodology ■ Standing breast milk at room tempera­ Authors ture for six hours is inadequate for the Chantry CJ, Morrison P, Panchula J, destruction of HIV. Storage for more Hillyer G, Zorilla C, Diaz C Four mothers receiving antenatal care in Puerto Rico were recruited. They were in­ than24 hours may be necessary, but is Institution structed to exclusively formula feed, but not thought to be bacteriologically safe University of California, Davis, USA; stimulate breast milk production by pump­ without refrigeration facilities. University of Puerto Rico;Solano County ing several times a day. All were receiving Dept of Health and Social Services, ■ HIV is still present in the breast milk of California, USA combination ARV therapy at the time. Milk women on combination ARV therapy was collected twice weekly for three weeks Date 2000 with low or undetectable plasma HIV postpartum. Colostrum defined as milk on viral load. Country Puerto Rico day one-to-five, transitional milk day 6- to-14 and mature milk thereafter. Not all Document type mothers completed sample collection. Milk Journal article J AIDS 2000, 24 (4): 325– 29 HIV DNA and RNA were quantified by PCR in 1) fresh, 2) after standing for six hours Source UNICEF ESARO CD at room temperature and 3) after reaching the boiling point. Background Results Transmission of HIV through breast milk is associated with the presence of integrated Of the 17 breast-milk samples collected, viral DNA (provirus) in the mother’s milk 15 (88%) had detectable HIV DNA in the cells, although animal studies indicate that cellular fraction (HIV RNA undetectable in ingestion of a cell-free virus may be suffi­ aqueous phase of all samples), even though cient for transmission. The effect of ma­ all mothers had undetectable or low plasma ternal ARV therapy on breast milk HIV is viral load and mean CD4 count of 544 cells/ unknown. Heat treatment (pasteurisation ul. or boiling of breast milk) has been shown to inactivate infectivity. There is evidence Lipolysis by standing for six hours at room that simply allowing breast milk to stand temperature did not destroy HIV in six of may enable lipase to release free fatty ac­ seven (83%) samples. ids that may break down some viral enve­ lopes. Lipolytic activity increases with milk Bringing breast milk to the boil destroyed storage, and may not be significant in fresh HIV in all breast milk samples (n=8) milk. There have been conflicting results as

A Compilation of Programmatic Evidence 91 Methodology source rather than pouring resulted in Water Safety for Infant higher levels of coliform. Formula (Dunne et al, 2001) Koumassi district consists mostly of house­ holds of lower socio-economic status. The Feeding practices: Some caretakers gave Document title study evaluated the quality of water used infants drinking water during the first week Is drinking water in Abidjan, Cote d’Ivoire, to prepare infant formula and household safe for infant formula? of life and most did so by one month of knowledge, attitudes and practices regard­ age. The youngest child was drinking wa­ Authors ing water and infant formula. Data collec­ ter in 74% of households Only three of 97 Dunne EF, Angoran-B ni H, Kamelan- tors visited 120 randomly selected house­ women who described giving stored water Tano A, Sibailly TS, Monga BB, Kouadio holds in 9 neighbourhoods where mothers L, Roels TH, Wiktor SZ, Lackritz EM, to their youngest child treated this drink­ Mintz ED, Luby S attended the HIV clinic. Household surveys ing water; all three used boiling. Only 10% were conducted over 8 weeks in April to of caregivers were formula feeding at the Institution June, a dry season, in 1999. Information time of the study, but none of them boiled Centers for Disease Control, Project was collected using a field-tested question­ TETRO-CI (Abidjan) the water used to make the formula. Care­ naire and observations. Samples of water takers said it took 3-to-30 minutes to pre­ Date 2001 used to give the youngest child drinks and pare a bottle of formula and that the bottle Country Cote d’Ivoire samples of the (home-based) source of that would be given within two hours of prepa­ water were taken and tested for E. coli and ration. The average weaning age was 18 Document type coliform bacteria. months, ranging from 2-to-36 months. The Journal article J AIDS 2001 28 (4): 393– report does not indicate breastfeeding (BF) 398 Results rates but details water use. Source Internet

Access to safe water: Most people had ac­ Feeding beliefs: Virtually all (98%) Background cess to and collected good quality, munici­ caregivers believed BG was best, and 52% pal water: 90% of water samples collected expressed concerns about formula, includ­ While infant formula may be used to re­ at in-home (44%) or community (56%) taps ing risk of diarrhoea, need for meticulous duce the risk of MTCT, such use in devel­ had adequate chlorine levels and no de­ preparation and decreased nutritional oping countries is associated with higher tectable coliform bacteria, better than most value. rates of diarrhoeal morbidity and mortal­ developing country systems. ity. Some cases of diarrhoea are caused by Conclusions and formula prepared with contaminated wa­ Storage: Most (83%) of households stored recommendations of authors ter. The high nutrient content and low acid­ drinking water because taps were far from ity of formula make it an ideal medium for home and/or unreliable. Stored water was This study is important because in com­ bacterial growth. In Koumassi, Cote d’Ivoire, considerably more likely to be contami­ munities where water is treated, health care municipal water is treated with chlorine. nated that source water (74% versus 2%). providers may be assuming that household Chlorine’s protection, however, can be lost In households with children under three, water is safe when they counsel mothers over time through evaporation. Evapora­ 41% had detectable E. coli in their stored to formula feed. For mothers who choose tion can be reduced by using a tight-fit- water, failing WHO criteria for potability; FF in such communities, counsellors should ting lid. High levels of coliform bacteria 74% had coliform bacteria. Two samples urge mothers to store water in air-tight indicate reduced chlorine but these bacte­ of stored water had coliform and E. coli containers and not to store formula with­ ria are harmless. Escherichia coli (E. coli) bacteria too numerous to count. Both E. out refrigeration. faecal contaminants are associated with coli and coliform were higher in water diarrhoea. stored longer than 12 hours when com­ Where chlorination of municipal supplies pared to water stored less than 12 hours. is adequate, safe water storage is needed. Using a cup to remove water from the One option is for mothers to routinely boil

92 HIV and Infant Feeding water before use, but this is time consum- without developing unsafe levels of bac- Pretoria Pasteurisation ing, costly and bad for the environment. teria. The combined use of a safe water storage Bacterial Contamination (Jeffery et al, 2002a) container to prevent recontamination and Methodology point-of-use chlorination with low-cost Document title sodium hypochlorite solution may be a EBM samples (n = 58) were obtained from sustainable solution. Air-tight storage may Final Report: the effect of Pretoria Pasteurisation on bacterial contamination women in the postnatal ward at a second­ be all that is necessary: women in Koumassi of hand-expressed human breastmilk ary hospital in Pretoria; each sample was had paid on average US$ 2 for their stor­ split into control and pasteurised portions. Authors age containers; the authors identify a con­ The samples were kept in sterile containers tainer being made and sold in South Af­ Jeffery BS, Soma-Pillay P, Makin J, Moolman G and handled only with sterile gloves. All rica for US$ 2.30. samples were tested 4 times at 4-hour in­ Institution tervals (baseline and after 4, 8 and 12 hours) Methodological considerations MRC South Africa; University of Pretoria to assess bacterial contamination. Contami­ Date August 2002 nation is measured in semi-quantitative Weakness: The authors note study limita­ colony forming units (CFUs); a count was Country South Africa tions, including the facts that findings may deemed to be clinically significant if it con­ not be generalisable outside Koumassi and Document type tained 100,000 CFU/ml or more of com­ that water quality may vary from dry sea­ Report (for UNICEF, South Africa) mensal bacteria or 1000 CFU/ml of a known pathogen. son to wet. Source UNICEF

Strength: The study appears to be carefully Background Results conducted, providing a lot of detail on feeding practices and beliefs, as well as Out of the 58 pairs of samples, four of the Pretoria Pasteurisation is a simple, low-cost methodology. Background information and pasteurised samples had clinically signifi­ method, devised for domestic use in poor other developing country studies are well settings, which has been shown to inacti­ cant bacterial growth (6.8%), while 34 con­ summarised with references to 30 related trol samples (59%) had such growth, at vate HIV in breast milk. The method uses works. baseline. At 12 hours, 53 pasteurised passive transfer of heat from 450 ml of water heated to boiling point in an alu­ samples remained sterile compared to five of the controls. minium pot, into which breast milk (50­ 100 ml) is placed in a glass jar. Milk tem­ peratures of 56-62.5 degrees Celsius are Bacterial growth was rapid, with 28 out of maintained for approximately 15 minutes. 38 contaminated samples having clinically significant growth by four hours. The growth of pathogens was faster than that Studies have shown that expressed breast milk (EBM) is subject to bacterial contami­ for commensal organisms. In 10 cases the growth of commensal organisms dropped nation with commensal or pathogenic bac­ after baseline sampling. Rapid growth of teria. Heat treatment of expressed breast milk may reduce bacterial contamination bacteria occurred in pasteurised samples, indicating that the bacteriostatic property and prolong storage time. This study sought of breast milk was reduced, compared with to determine 1) whether Pretoria pasteurisation of expressed breast milk unprocessed EBM. eliminates commensal and pathogenic bac­ teria and 2) the length of time pasteurised Pasteurised samples contained different EBM can be stored at room temperature organisms than the control samples did,

A Compilation of Programmatic Evidence 93 suggesting that they had not survived the Results Pretoria Pasteurisation and pasteurisation but instead had been intro- Viral Loads duced afterwards (same pathogens in each No significant drop in viral load between (Jeffery et al, 2002b) and all in a batch, indicating lapse in tech- colostrums and mature milk (7509 +/- 2333 nique). copies/ml versus 1280 +/- 2983 copies/ml). Document title Interim Report: Viral loads in the milk of Conclusions and lactating HIV infected mothers In 4 samples, breast milk viral load was recommendations of authors higher than plasma and a moderate corre­ Authors Jeffery BS, Webber L, Makin J lation was found between plasma and ■ Hygiene is important: Women should Institution breast milk viral load. be reminded to wash hands before ex­ MRC South Africa; University of Pretoria pressing. Women who had difficulties expressing at Date October 2002 ■ Bacterial contamination of unproc­ follow-up had breast milk with very high essed EBM occurred by 4 hours at room Country South Africa viral load. temperature, casting doubt that EBM Document type may be safely stored for eight hours Report (for UNICEF, South Africa) Conclusions and without refrigeration. recommendations of author Source UNICEF ■ Pretoria pasteurisation effectively de­ Viral load was lower than previously found stroys bacteria in EBM samples and Background (possibly due to time to sample process­ keeps breast milk safe for 12 hours, IF ing, which was longer and could have re­ it is kept sealed and not handled. Once Pretoria Pasteurisation is a simple, low-cost sulted in reduction of detectable viral load) bacteria have been introduced after method, devised for domestic use in poor but similar to studies by other groups. pasteurisation, the reduced bacterio­ settings, which has been shown to inacti­ static activity results in rapid patho­ vate HIV in breast milk. The method uses No significant drop in viral load between gen growth. passive transfer of heat from 450ml of colostrums and mature milk, although the water heated to boiling point in an alu­ ■ Because of the potential for bacterial authors caution that this could be due to minium pot, into which breast milk (50­ contamination after pasteurisation, difficulties in expression in some women 100ml) is placed in a glass jar. Milk tem­ milk that is to be stored after Pretoria at follow-up. peratures of 56-62.5 degrees Celsius are Pasteruisation should not be handled maintained for approximately 15 minutes. after pasteurisation. If too much milk is expressed for one feeding, the por­ As part of a study on the effectiveness of tion intended for storage should be Pretoria Pasteurisation, breast milk viral pasteurised in a separate jar and kept loads were measured. sealed in that jar until use.

Methodology

EBM samples (30-50ml) were obtained from 30 women in the postnatal ward at Kalafong Hospital and again two weeks later. Plasma viral load was also measured at the time of first breast milk. HIV viral load was determined by NASBA method­ ology (not clear what this is) and branched DNA methodology.

94 HIV and Infant Feeding Infants in the neonatal intensive or high Five of 10 requested immediate assistance Pretoria Pasteurisation and care units, who are often low birth weight, in pasteurising their milk to feed their in­ Mothers’ Attitudes are susceptible to a number of nosocomial fant, due to lack of financial resources and (Pullen et al, 2002) infections and benefit from breast-milk safe facilities for formula feeding. feeding. The Kalfong Hospital encourages Document title HIV testing of preterm infants and provides Two mothers expressed fears (unable to Final Report: attitudes of HIV infected counselling on infant feeding options. These produce enough milk and disclosure of HIV mothers towards expressed and pasteurised breast-milk for infant feeding infants would benefit from receiving status). Only half the women had disclosed pasteurised mother’s milk, with HIV inacti­ their status, and one had been abandoned Authors vated and the protective properties main­ by her husband as a result. Other women Pullen AE, Mokhondo KR, Jeffery BS tained. were unsure about disclosure, for fear of Institution breaks in confidentiality and abandonment. MRC South Africa; University of Pretoria Methodology

Date August 2002 Conclusions and Structured open-ended questionnaires recommendations of author Country South Africa were administered to 10 women recruited ■ Due to their social and economic vul­ Document type after delivery, including mothers of high- nerability and disempowerment, these Report (for UNICEF, South Africa) risk low birth weight infants. Information mothers did not have the means to on the Pretoria Pasteurisation method was Source UNICEF practice alternatives to breastfeeding. provided before obtaining consent. ■ Traditionally breastfeeding is accepted Background Results and expected.

Pretoria Pasteurisation is a simple, low-cost ■ Women did not foresee any problems Women were mostly dependent on family method, devised for domestic use in poor with pasteurisation and some requested for housing and half lived in informal hous­ settings, which has been shown to inacti­ immediate help to establish this ing. Only 20% of women had their own vate HIV in breast milk. The method uses method of feeding their infant. residence and an average of 4.4 people passive transfer of heat from 450 ml of shared each home. All women had access water heated to boiling point in an alu­ ■ Concerns regarding disclosure of sta­ to tap water and 90% had electricity. minium pot, into which breast milk (50­ tus require further investigation to de­ 100ml) is placed in a glass jar. Milk tem­ termine whether this method would be Women did not see themselves as primary peratures of 56-62.5 degrees Celsius are feasible in the domestic setting. maintained for approximately 15 minutes. decision makers and indicated that parents or sister of partner were decision maker, Although this study provides some inter­ depending on who they stayed with. Many social and economic factors prevent esting information, it is difficult to draw HIV-positive mothers from having access conclusions as to the acceptability of this to or making use of formulas feeds. As the All mothers interviewed were positive about method outside the hospital and to assess the Pretoria Pasteurisation method and felt Pretoria Pasteurisation method does not whether women’s positive response to the that they could use the method at home require large economic outlay and preserves method was not as a result of being inter­ the protective factors in breast milk, it may as well as in the hospital (simple method viewed by those who were recommending and equipment readily available at home). be a suitable alternative to formula feed­ it. ing by HIV positive mothers.

A Compilation of Programmatic Evidence 95 ENDNOTES

1 UNAIDS. HIV and Infant Feeding: A 15 to become infected with HIV over 13 Bijlsma M. Infant Feeding and HIV for policy statement developed col­ the course of about two years of Eastern and Southern Africa, 1999 laboratively by UNAIDS, UNICEF and breastfeeding. This would leave 63 in­ 2001. UNICEF Eastern and Southern WHO, 1997. www.unaids.org/publica- fants uninfected, despite being African Region (ESARO). (CD-ROM) tions/documents/mtct/sitanag.pdf. breastfed (De Cock et al cited above). October 2001.

2 The term mother-to-child transmission 6 Dunn DT, Newell ML, Ades AE, et al. Risk 14 These documents are available at (MTCT) is used in this document (and of human immunodeficiency virus type www.qaproject.org. the updated United Nations guidelines 1 transmission through breastfeeding. 15 on HIV and infant feeding), although Lancet 1992; 340:585-8. Definitions presented within the the more technical term for this phe­ synthesis are derived from the 2003 7 Piwoz E, Huffman S, Lusk D, Zehner E, nomenon is vertical transmission. Other revised WHO, UNICEF, UNFPA and and O’Gara C. Issues, Risks, and Chal terms, such as parent-to-child-trans- UNAIDS. HIV and Infant Feeding: mission (PTCT), have been proposed but lenges of Early Breastfeeding Cessa Guidelines for Decision-Makers tion to Reduce Postnatal Transmission not generally adopted. Other methods (Geneva. 2003), with the exception of HIV in Africa. Academy for Educa­ of transmission that are seldom men­ of several working definitions devel­ tioned and little studied are rape or tional Development. Washington, DC. oped by the editors, including ‘breast­ 2001. sexual violence against children and milk feeding’, ‘early cessation of breastfeeding’, and ‘predominant medical transmission via non-sterilised 8 Flores M and Filtreau S. Effect of lacta­ breastfeeding’. needles and equipment. tion counseling on sub-clinical mastisis among Bangladeshi women. Annals of 16 3 De Cock KM, Fowler MG, Mercier E, et Author-date citations indicate sources Tropical Paediatrics 2002; 22, 85-88. al. Prevention of mother-to-child HIV included in this compilation. transmission in resource poor countries 9 United Nations. HIV and Infant Feed­ 17 ‘Weaning’ is a non-specific term some­ —Translating research into policy and ing Framework for Priority Action. times referred to as the process of ces­ practice. JAMA 2000; 283:1175-82. 2003. sation of breastfeeding and sometimes

4 to the process of cessation of all baby Coutsoudis A, Pillay K, Kuhn L, et al. 10 WHO. Global Strategy on Infant and food (breast milk and substitutes) and Method of feeding and transmission Young Child Feeding. Geneva, 2003. of HIV-1 from mothers to children by initiation of family food. Both mean­ 15 months of age: Prospective cohort 11 The full report of the WABA-UNICEF ings are used on occasion here and in study from Durban, South Africa. AIDS HIV and Infant Feeding Colloquium, the summarised documents. held in Arusha, Tanzania, in September 2001; 15(3):379-87. 18 By the term “exclusive breastfeeding”, 2002, is available at www.waba.org.my. 5 Given current rates of MTCT, one would caretakers meant no other milks, but expect 7 in 100 infants born to HIV- 12 WHO. “HIV and Infant Feeding: A Guide water and over-the-counter medica­ positive mothers (receiving no inter­ for Health-Care Managers and Super­ tion would be permitted. There was vention) to be infected with HIV in visors.” Geneva. 2003b and WHO. “HIV widespread use of water and medica­ utero, another 15 to become infected and Infant Feeding: Guidelines for tion. during labour and delivery, and another Decision-Makers.” Geneva. 2003c.

96 HIV and Infant Feeding BIBLIOGRAPHY: DOCUMENTS ON REVIEWED PROGRAMMES

AED (Academy for Educational Develop- Bond V, Chase E, Aggleton P. Article in press: de Paoli M, Manongi R, Klepp K-I. Coun­ ment)/LINKAGES Project. Evaluation “Breaking the silence, ending the sellors’ perspectives on antenatal HIV Results Document: “Linkages/Zambia stigma: stigma, HIV/AIDS and preven­ testing and infant feeding dilemmas PMTCT results reporting.” December tion of mother-to-child transmission facing women with HIV in northern 2002a. in Zambia.” ZAMBART Project, London Tanzania. Reproductive Health Matters. School of Hygiene and Tropical Medi­ (in press as of September 2002). AED (Academy for Educational Develop- cine, Lusaka, Zambia; Institute of Edu­ Dunne EF, Angoran-B ni H, Kamelan-Tano ment)/LINKAGES Project. Newsletter cation, University of London, London. A, Sibailly TS, Monga BB, Kouadio L, article: Zambia, World Linkages. Sep­ 2002. tember 2002b. Roels TH, Wiktor SZ, Lackritz EM, Chantry CJ, Morrison P, Panchula J, Hillyer Mintz ED, Luby S. Is drinking water in Baek C, Rodriguez MX, Escoto LR. Program G, Zorilla C, Diaz C. Effects of lipolysis Abidjan, Cote d’Ivoire, safe for infant evaluation (under review, not for cir­ or heat treatment on HIV-1 provirus in formula? J AIDS 2001 28: 393-398. culation). “Report on the Qualitative breastmilk, J AIDS 2000 24 (4): 325– 2001. Rapid Assessment of the UN-Supported 29. University of California, Davis, USA; Hope Humana, LINKAGES Project, National PMTCT Pilot Program in Honduras.“ University of Puerto Rico, IBCLC (Con­ Food and Nutrition Commission, Ndola December 2002. sultant to Ministry of Health, Zimba­ District Health Management Team, bwe); Solano County Dept of Health Bakaki PM. Word-processed document: HORIZONS Project, Zambia Integrated and Social Services, California, USA. “Lessons and experiences with early Health Project. “Ndola Demonstration 2000. abrupt cessation of breast feeding Project: a midterm analysis of lessons among HIV infected women in Chitsike I. PowerPoint presentation “Infant learned.” Nairobi: Population Council. Kampala, Uganda.” Makerere Univer- feeding, which way?” Undated, perhaps November 2002. sity-Johns Hopkins University Research 2000. Collaboration (MU-JHURC). January Isiramen V. MSc dissertation: “Early and 2002. Chopra M, Shaay N, Sanders D, Sengwana Abrupt Cessation of Breastfeeding In J, Puoane T, Piwoz E, Dunnett L. Re­ The Nigerian Context: Is This An Op­ Bentley J, Coutsoudis A, Kagoro H, Newell search report: “Summary of the find­ tion For HIV Positive Women?” Insti­ M-L. Manuscript: “Breastfeeding pro­ ings and recommendations from a for­ tute of Child Health, University College, motion and infant feeding practices in mative research study from the London; Ahmadu Bello University South African women living in an area Khayelitsha MTCT programme, South Teaching Hospital, Kaduna, Nigeria. of high HIV prevalence.” University of Africa.” University of the Western Cape August 2002. Natal, South Africa; Medical Research Public Health Programme; USAID/SARA Israel-Ballard K (MPH Thesis), and Israel- Council, South Africa; University Col­ Project; DoH Provincial Authority of Ballard K, Padian N, Chantry C, Chipato lege, London. 2002. Western Cape. May 2000. T, Chirenje Z, Morrison P, Chitibura L Bond G and Ndubani P with Nyblade L. Re­ de Paoli M, Manongi R, Helsing E, Klepp K­ (presentation of same name at 130th port in PDF: “Formative research on I. Exclusive breastfeeding in the era of Annual Meeting of the American Pub­ mother to child transmission of HIV/ AIDS. J Hum Lact 17(4); 313-320. July lic Health Association, November 10­ AIDS in Zambia.” ZAMBART Project, 2001. 13, 2002). Zimbabwean Attitudes and School of Medicine, UTH, Zambia; Resource Accessibility as a Measure of Institute for Economics and Social Re­ de Paoli M, Manongi R, Klepp K-I. Report: the Feasibility and Acceptability of Heat search (INESOR), UNZA, Zambia; Inter­ “Breastfeeding promotion and the di­ Treating Expressed Breastmilk for Pre­ national Centre for Research on lemma posed by AIDS in Tanzania.” vention of Mother to Child Transmis­ Women (ICRW), Washington. 1999. Maternal and Child Health List, MCH sion of HIV. 2002. News #15. 2000.

A Compilation of Programmatic Evidence 97 Jeffery BS, Soma-Pillay P, Makin J, Matovu JN, Bukenya R, Musoke PM, Omari AAA, Luo C, Kankasa C, Bhat G, Bunn Moolman G. Report (for UNICEF, South Kikonyogo F, Guay L. “Experience of J. Word-processed document: “Infant Africa): “Final Report: the effect of providing free generic infant formula feeding practices of mothers of known Pretoria Pasteurisation on bacterial to mothers in the nevirapine imple­ HIV status in Lusaka, Zambia.” Univer­ contamination of hand-expressed hu­ mentation program at Mulago hospi­ sity Teaching Hospital, Lusaka, Zambia; man breastmilk. MRC South Africa and tal in Kampala, Uganda.” Abstract Liverpool School of Tropical Medicine. University of Pretoria. August 2002a. MoPeE3748 from Barcelona AIDS Con­ 2000. ference, Presentation to EGPAF Call to Jeffery BS, Webber L, Makin, J. Report (for Action (CTA) meeting in Zambia, Au­ Pham P, Musemakweri A, Stewart H. Pro­ UNICEF, South Africa): “Interim Report: gram evaluation (under review, not for gust 2002, and personal communica­ Viral loads in the milk of lactating HIV circulation): “Report on the Rapid As­ tion from Laura Guay, January 2003. infected mothers”. MRC South Africa sessment of the UN-Supported PMCT and University of Pretoria. October McCoy D, Besser M, Visser F, Doherty T. Initiative in Rwanda: Pilot interventions 2002b. Published report: “Interim findings on at Kicukiro, Muhura, and Gisenyi Health the National PMTCT pilot sites. Lessons Centers.” December 2002. Kankasa C, Mshanga A, Baek C, Kalibala S, and recommendations.” Health Systems Rutenberg N. Program Report (under pMTCT Advisory Group, 2001. Draft report: Trust, for National Department of review, not for circulation): “Report on “Evaluation of Infant Feeding Practices Health, South Africa. February 2002. the Rapid Assessment of the UN-Sup- by Mothers at pMTCT and non-pMTCT ported PMTCT Pilot Program in Zam­ NDHMT (Ndola (Zambia) District Health Sites in Botswana.” pMTCT Reference bia.” December 2002. Management Team). “Ndola Demon­ Group, Botswana Food and Nutrition stration Project to integrate infant Unit, Family Health Division, Ministry Latham MC, Kisanga P. Draft report in PDF: feeding counseling and HIV voluntary of Health Botswana. 2001. “Current status of protection, support counseling and testing into health care and promotion of breastfeeding in four Preble AE, Piwoz EG. “Prevention of and community services: A summary African countries: Actions to protect, of the findings and recommendations Mother-to-Child Transmission of HIV support and promote breastfeeding in in Asia: Practical Guidance for Pro­ from the formative research carried out Botswana, Kenya, Namibia, and grams.” Washington, D.C: Academy for in Lubuto, Main Masala, Twapia and Uganda.” Based on a rapid review—2nd Kabushi Health Center areas, Ndola, Educational Development. June 2002. October-3rd November 2000; for Zambia.” National Food and Nutrition Pullen AE, Mokhondo KR, Jeffery BS. Re­ UNICEF ESARO. January 2001. Commission, LINKAGES, SARA. 1999. port (for UNICEF, South Africa): “Final Leroy V, Becquet L, Ekouevi DI, Viho I, Oguta TJ, Omwega AM, Sehmi JK. Word- Report: attitudes of HIV infected moth­ Castetbon K, Sakarovitch CI, Elenga N, ers towards expressed and pasteurised processed document: “Maternal knowl­ Dabis F, Timité-Konan M. Poster breastmilk for infant feeding.” MRC edge of MTCT of HIV and breast milk MoPeD3677 at Barcelona: “Uptake of alternative for HIV positive mothers in South Africa; University of Pretoria. infant feeding interventions to reduce August 2002. South-Western Kenya.” Applied Nutri­ postnatal transmission of HIV-1 in tion Programme, Dept of Food Tech­ Rollins NC, Bland RM, Thairu L, Coovadia Abidjan, Côte d’Ivoire.” Also “Exclusive nology & Nutrition, University of breastfeeding and early cessation of HM. Draft manuscript. “Counseling Nairobi. 2001. HIV-infected women on infant feed­ breastfeeding to prevent HIV-1 trans­ ing choices in rural South Africa.” mission through breastmilk,” presented Oguta TJ. “Infant feeding practices and at the Ghent Workshop on Prevention breastmilk alternatives for infants born Africa Centre for Health and Popula­ tion Studies, South Africa; Dept Paeds of HIV Transmission Through to HIV-infected mothers in Homa-Bay and Child Health, University of Natal, Breastmilk, December 12-13 2002, District.” MSc Thesis, June 2001. which was based on the same mate­ South Africa; Centre for HIV/AIDS Net­ working, University of Natal, South rial. The DITRAME PLUS ANRS 1202 Africa; Dept Nutritional Anthropology, project, Abidjan, Côte d’Ivoire, March 2001–May 2002. Cornell University, USA. October 2002.

98 HIV and Infant Feeding Rutenberg N, Kalibala S, Mwai C, Rosen J. Swartzendruber A, Msamanga G, PMTCT Vilakati D and Shongwe N. Report: “Rapid Published Report: “Integrating HIV Pre­ Evaluation Team. Programme Report: situational analysis of the BFHI in vention and Care into Maternal and “Evaluation of the UNICEF-Sponsored Swaziland.” May 2001. Child Health Care Settings: Lessons Prevention of Mother-to-Child HIV Williams C. Word-processed documents (3): Learned from HORIZONS Studies.” Transmission (PMTCT) Pilot Sites in Tan­ (July 23-27 2001, Maasai Mara, Kenya). zania.” Centers for Disease Control and “Country Adaptation of Global HIV and Infant Feeding Guidelines and Devel­ February 2002. Prevention; Tanzania Ministry of opment of Replacement Feeding Health; Institute of Public Health, Sarna A. Program Report (under review, not Muhimbili University College of Health Guidelines for Myanmar, 2001-2002. for circulation): “Report on Discussions Stage I: Review of currently used in­ Sciences. December 2002. with National AIDS Control Organiza­ fant feeding guidelines and informa­ tion and Visits to Two Pilot Program Talawat S, Dore GJ, le Coeur S, Lallemant tion on infant feeding practices in Sites.” December 2002. M. Infant feeding practices and atti­ Myanmar.” UNICEF. December 13, 2001. tudes among women with HIV infec­ Seidel G, Sewpaul V, Dano B. Experiences Williams C, Zin MM, Mon AA. UNICEF Con­ tion in northern Thailand, AIDS Care of breastfeeding and vulnerability (2002) 14 (5), 625–31. National Centre sultant Report (under review, not for among a group of HIV positive women circulation): “Country Adaptation of in HIV Epidemiology and Clinical Re­ – discussions with a peer support group Global HIV and Infant Feeding Guide­ search, University of New South Wales, of HIV positive mothers at King Edward Australia; Institut National d’Etudes lines and Development of Replacement Hospital, Durban, KwaZulu-Natal, Feeding Guidelines for Myanmar, 2001­ Demographiques, Paris; Institut de South Africa. Health Policy and Plan 2003. Stage II: Formative research and Reserche pour le Developpement, ning 2000 15(1):24-33. 2000. Chiang Mai, Thailand; Harvard School development of replacement feeding guidelines for site 1: Monywa.” Janu­ Shapiro R, Lockman S, Thior I, Stocking L, of Public Health, Boston. 2002. ary 2003. Kebaabetswe P, Wester C, Peter T, Tavengwa N, Piwoz E, Gavin L, Zunguza C, Marlink R, Essex M, Heymann S. Con­ Marinda E, Iliff P, Humphrey J, cerns regarding adherence to recom­ ZVITAMBO Study Group. Conference mended infant feeding strategies presentation: “Education and counsel­ among HIV-infected women: results ling make a difference to infant feed­ from the pilot phase of a randomized ing practices and those feeding trial to prevent mother-to-child trans­ practices make a difference to infant mission in Botswana. In press (AIDS mortality.” ZVITAMBO Project, Univer­ Education and Prevention). 2003. sity of Zimbabwe; Harare City Health South India AIDS Action Programme, Com­ Department, Zimbabwe. WABA Global munity Health Education Society Tamil Forum 2, Arusha, Tanzania. September Nadu, Dr MGR Medical University, 23-27 2002. Macfarlane Burnet Institute for Medi­ Tlou S, Nyblade L, Kidd R, Field ML. Report: cal Research and Public Health, Inter­ “Working report on community re­ national Health Unit. Karu: Chennai HIV sponses to initiatives to prevent child survival project: Report of a situ­ mother-to-child transmission of HIV in ational analysis: January to September Botswana.” University of Botswana; 2001. Australia-India Council. India. International Center for Research on Undated. Women, Washington; PEER Consult­ ants, Botswana; Society for Women and AIDS, Botswana; Youth Matters, Botswana. June 2000.

A Compilation of Programmatic Evidence 99 LIST OF ADDITIONAL REFERENCES

Bijlsma M. Infant Feeding and HIV for East­ Dunn DT, Newell ML, Ades AE, et al. Risk of UNAIDS. HIV and Infant Feeding: A policy ern and Southern Africa, 1999-2001. human immunodeficiency virus type 1 statement developed collaboratively by UNICEF Eastern and Southern African transmission through breastfeeding. UNAIDS, UNICEF and WHO, 1997. Region (ESARO). C-ROM. October 2001. Lancet 1992; 340:585-8. www.unaids.org/publications/docu- ments/mtct/sitanag.pdf. Coutsoudis A, Pillay K, Kuhn L, et al. Flores M and Filtreau S. Effect of lactation Method of feeding and transmission of counseling on sub-clinical mastisis WABA-UNICEF. HIV and Infant Feeding: A HIV-1 from mothers to children by 15 among Bangladeshi women. Annals of Report of a WABA-UNICEF Colloquium. months of age: prospective cohort Tropical Paediatrics 2002; 22, 85-88. 2002. www.waba.org.my. study from Durban, South Africa. AIDS 2001;15(3):379-87. Piwoz E, Huffman S, Lusk D, Zehner E, and WHO. Global Strategy on Infant and Young O’Gara C. Issues, Risks, and Challenges Child Feeding. Geneva, 2003a. De Cock KM, Fowler MG, Mercier E, et al of Early Breastfeeding Cessation to Prevention of mother-to-child HIV Reduce Postnatal Transmission of HIV WHO. “HIV and Infant Feeding: A Guide for transmission in resource-poor countries in Africa. Academy for Educational Health-Care Managers and Supervi­ – Translating research into policy and Development. Washington, DC. 2001. sors.” Geneva. 2003b. practice. JAMA 2000; 283:1175-82. WHO. “HIV and Infant Feeding: Guidelines for Decision-Makers.” Geneva. 2003c.

100 HIV and Infant Feeding CONTACT INFORMATION FOR AUTHORS, EDITORS AND REVIEWERS

Name/Affiliation Mailing E-mail/Web/Phone

Carolyn Baek Horizons, Population Council [email protected] 4301 Connecticut Ave NW, Suite 280 Tel: 202 237 9400 Washington, DC 20008 Fax: 202 237 8410

Paul Bakaki P.O. Box 27403, Kampala, Uganda [email protected]

Margaret E. Bentley Professor of Nutrition and Associate Dean of Global Health [email protected] www.sph.unc.edu School of Public Health, University of North Carolina Tel: 919 966 9575 or 919 843 9962 Chapel Hill, NC 27516 Fax: 919 966 9159

Virginia Bond Zambart Project, School of Medicine, [email protected] University Teaching Hospital, P.O. Box 50110 Tel/Fax: 260 1 254 710 Lusaka, Zambia Mobile: 097 846 726

Bart Burkhalter 7200 Wisconsin Avenue, Suite 600 [email protected] Bethesda, MD 20814 USA Tel: 301 941 8456

Caroline Chantry Associate Professor of Clinical Pediatrics [email protected] Ticon II, Suite 334 Tel: 916 734 4455 University of California Davis Medical Center Fax: 916 456 2236 2516 Stockton Blvd., Sacramento, CA 95817

Inam Chitsike University of Zimbabwe Tel: 263 4 303211 Clinical Epidemiology Unit, School of Medicine Mazowe Street, P.O. Box A 178 Avondale, Harare Zimbabwe

Micky Chopra University of the Western Cape, Private Bag X17, [email protected] Bellville 7535, Republic of South Africa

Luis Roberto Escoto Health & Nutrition Officer [email protected] UNICEF Honduras Tel: 504 220 1100 Fax: 504 232 5884

Ted Greiner Senior Nutritionist at PATH, 1800 K Street, NW [email protected] Washington, DC 20006 Tel: 202 822 0033

Arun Gupta National Coordinator BPNI [email protected] Regional Coordinator IBFAN AP Tel: 91 11 27312445 BP-33 Pitampura Res: 91 11 27026426 Delhi 110088 India Fax: 91 11 27315606 Mobile: 91 9810076306

Marina Manuela de Paoli Department of Nutrition, University of Oslo [email protected] P.O. Box 1046, Blindern Tel: 47 22851345 (work) O316 Oslo, Norway Tel: 47 63978730 (home) Fax: 47 22851341

A Compilation of Programmatic Evidence 101 Name/Affiliation Mailing E-mail/phone

Health Systems Trust 401 Maritime House, Salmon Grove [email protected] www.hst.org.za Victoria Embankment Tel: (031) 307 2954 Durban 4001, South Africa Fax: (031) 304 0775

Peggy Henderson CAH WHO [email protected] 1211 Geneva Tel: 41 22 791 2730 Switzerland Fax: 41 22 791 4853

Horizons Program Horizons Program, Population Council [email protected] P.O. Box 17643 www.popcouncil.org/horizons Nairobi, Kenya Tel: +254 2 713480

Peter Iliff No. 1 Borrowdale Road, Borrowdale [email protected] Harare, Zimbabwe Tel: 263 4 850732/3

Dr. Yahya Ipuge Head of Diagnostic Services & PMTCT Coordinator 255 22 2120261 Tanzania Ministry of Health Samora Machel Avenue, P. O. Box 9083 Dar es Salaam, Tanzania

Dr. Victoria Isiramen Assistant Project Officer, Protection and Participation [email protected], UNICEF Nigeria [email protected] Kaduna Field Office, 53 Yakubu Avenue, P.O. Box 581 Tel: 234 62 240114-5 Kaduna, Nigeria Fax: 234 62 244694 (office)

Kiersten Israel-Ballard University of California, School of Public Health [email protected] 140 Warren Hall, Tel: 510 381 6335 Berkeley, CA 94720 Fax: 510 849 4832

Bridget Jeffery Medical Research Council of South Africa, 2001 Tel: 27 (0) 21 9380911 PO Box 19070, 7505 Tygerberg, South Africa Fax: 27 (0)21 9380200

Sam Kalibala Regional Representative, IAVI [email protected] 16th Floor Rahmutulla Tower, Upperhill Road P.O. Box 340 KNH, Nairobi, Kenya, 00202

Chipepo Kankasa University Teaching Hospital [email protected] Prevention of Mother to Child Transmission of HIV Nationalist Road, A-Block, Room 123 Lusaka, Zambia, RW 1

Pauline Kisanga Regional Coordinator, IBFAN Africa, [email protected] P.O.Box 781 Tel: 268 404 5006 Mbabane, Swaziland Fax: 268 404 0546

Peggy Koniz-Booher 7200 Wisconsin Avenue, Suite 600 [email protected] Bethesda, MD 20814 USA Tel: 301 941 8534 (w) Tel: 301 963 3935 (h)

Miriam Labbok UNICEF NYHQ, 3 UN Plaza [email protected] New York, NY 10017 USA

102 HIV and Infant Feeding Name/Affiliation Mailing E-mail/phone

Michael Latham Cornell University [email protected] Ithaca, NY 14853, USA

V Leroy Institut de Santé Publique, d’Epidémiologie et de Développement INSERM U330, Université Victor Segalen Bordeaux 2, France

LINKAGES Project Academy for Educational Development (AED) Headquarters Tel: 202 884 8000 1825 Connecticut Ave., NW Fax: 202 884 8400 Washington, DC 20009-5721

Chessa Lutter Regional Advisor, Nutrition [email protected] WHO Regional Office for the Americas (PAHO) Tel: 202 974 3000 525 23rd Street, N.W. Fax: 202 974 3663 Washington, DC 20037 USA

José Martines Coordinator, HNI/CAH, WHO, [email protected] 1211 Geneva, Switzerland Tel: 41 22 791 2634 Fax: 41 22 791 4853

Joyce Matovu [email protected]

Anne Mshanga MTCT Working Group [email protected] Tel.: 260 1 252118

Ruth Nduati [email protected]

TJ Oguta Applied Nutrition Programme, Department of Food Technology & Nutrition, University of Nairobi, P.O. Box 442, Uthiru-Nairobi, Kenya

Aika A.A.Omari Department of Child Health, [email protected] Liverpool School of Tropical Medicine, Pembroke Place, Tel: 0151 708 9393 Liverpool L3 5QA, England Fax: 0151 708 8733

Ellen Piwoz SARA Project [email protected] Academy for Educational Development (AED) Headquarters 1825 Connecticut Ave., NW Washington, DC 20009-5721

Elizabeth A. Preble, MPH International Health Consultant [email protected] 1400-B Cerro Gordo Road Santa Fe, NM 87501 USA

Marina Xioleth Rodriguez UNICEF/Honduras [email protected] 4TO. PISO, CASA DE LAS NACIONES UNIDAS COLONIA PALMIRA, TEGUCIGALPA, MDC, Honduras

Nigel C Rollins Dept. of Peadiatrics, University of Natal [email protected] Private Bag 7, Congella 4013 Tel: 2731 260 43 68 Durban, South Africa Fax: 2731 260 43 88

A Compilation of Programmatic Evidence 103 Name/Affiliation Mailing E-mail/phone

Naomi Rutenberg Horizons, Population Council [email protected] 4301 Connecticut Avenue, N.W., Suite 280 Tel: (202) 237 9400 Washington, DC 20008 USA Fax: (202) 237 8410

SARA Project Academy for Educational Development (AED) Headquarters Tel: 0483 C 2178-00 1825 Connecticut Ave., NW Washington, DC 20009-5721

Andrea Swartzendruber PMTCT Technical Advisor, Global AIDS Program, Tel: 404 498 2759 US Centers for Disease Control and Prevention 1600 Clifton Road, MS-04, Atlanta, GA 30333

S. Talawat National Centre in HIV Epidemiology and Clinical Research, Tel: 9332 4648 University of New South Wales, Australia Fax: 9332 1837

Sheila Tlou University of Botswana, Department of Nursing Education and Society for Women and AIDS, Botswana Branch (SWAABO), Gaborone, Botswana

Thorkild Tyllesksar Centre for International Health, Armauer Hansen Building [email protected] No-5021 Bergen, Norway Tel: 4755974975

Constanza Vallenas CAHWHO, 1211 [email protected] Geneva, Switzerland Tel: 41 22 791 4143 Fax: 41 22 791 4853

Danisile B Vilakati HEAD Swaziland National Nutrition Council [email protected] Secretariat, P O Box 4918 Tel: 268 4043852 Mbabane, Swaziland Fax: 268 4043852

Arjan de Wagt UNICEF, Project Officer PMTCT, [email protected] UNICEF East Asia and Pacific Regional Office Tel: 66 2 356 9468 Bangkok, Thailand Fax: 66 2 280 7056

Carol Williams Institute of Child Health, University College London [email protected] 30 Guilford Street, London WC1N 1EH

Juana Willumsen 28 Kildare Road, Glenwood [email protected] Durban, South Africa

104 HIV and Infant Feeding KEY WORD INDEX

The key words indexed here refer readers only to the page numbers where summaries start. For instance, while “safe” is discussed in the synthesis, that discussion is not referenced here. Also, while “safe” is used on the third page of the summary starting on page 26, only the first page of the summary is referenced.

Acceptable ...... 30, 32, 45, 68, 71, 81, 83, 95. See also AFASS AFASS ...... 68, 83 Affordable ...... 40, 45, 47, 55, 58, 65, 81, 83. See also AFASS ANC/MCH settings ...... 37, 61, 73 Animal milk ...... 36, 40, 43, 54, 58, 59, 60, 71, 81 Antiretroviral therapy ...... 86 ARVs ...... 61, 73 BFHI ...... 42, 57, 71, 85 Bottles ...... 26 Breast Appearance ...... 59 Problems/health ...... 26, 43, 45, 66 Breastfeeding ...... 55 Belief in protectiveness ...... 29, 37, 47, 50, 60 Cessation/weaning ...... 26, 30, 32, 42, 43, 45, 58, 65, 66, 71, 73, 85, 86, 89 Exclusive ...... 26, 30, 32, 36, 40, 42, 43, 45, 49, 50, 52, 54, 58, 59, 66, 71, 73, 77, 78, 81, 82, 85, 86, 89 Expressed and heat-treated breast milk ...... 40, 43, 50, 54, 58, 60, 73, 81, 83, 91, 93, 94, 95 Knowledge of HIV transmission through ...... 81 Predominant ...... 32 Care And support ...... 37, 47 HIV+ children ...... 32 Nutritional support ...... 57, 68 Client-provider relations ...... 47, 78 Community Disclosure of status ...... 29, 58, 61, 66, 70, 83, 95 Male involvement ...... 29, 32, 47, 60, 61, 73, 78, 89 Norms/influences ...... 29, 30, 50, 54, 55, 66, 71, 83 Peer pressure ...... 66, 71 Stigma ...... 26, 29, 32, 34, 40, 47, 50, 52, 54, 55, 58, 60, 65, 66, 70, 71, 81, 89, 95 Community awareness ...... 26, 29, 47, 78 Confidentiality ...... 29, 37

A Compilation of Programmatic Evidence 105 Counselling ...... 34, 36, 45, 78, 86 Confidentiality ...... 71 Duration and quality ...... 58 Family ...... 71, 73, 83 Home visits ...... 49, 68 Infant feeding ...... 30, 32, 40, 50, 54, 57, 58, 61, 65, 66, 71, 73, 77, 82, 83, 89 Quality ...... 71 Social support ...... 40, 55, 73 Counsellors ...... 49, 52, 54, 61 Decision making ...... 29, 32, 54, 55, 81, 82 Demonstration of food preparation ...... 36, 66, 71 Discrimination ...... 37, 61 Education ...... 40 Education materials ...... 47, 57, 61, 78 Feasible ...... 45, 60, 68, 71, 77, 83. See also AFASS Frequency of feeding ...... 42, 65 Health workers ...... 70 Home visits ...... See Counselling: Home visits Infant feeding practices ...... 37, 45, 71, 82, 92 Intended ...... 59, 60, 65, 73, 77 Integration of services ...... 73 IPC/C ...... 47 Job aids ...... 54, 61 Knowledge of HIV transmission through breast milk ...... 29, 60 Logistics ...... 68, 71 Mass media ...... 49, 66, 73 Mixed feeding ...... 30, 32, 45, 49, 50, 58, 66, 68, 71, 73, 82 Pre-lacteal feeding ...... 43, 59 Monitoring ...... 26 Peer pressure ...... See Community: Peer pressure Policy ...... 26, 30, 57, 85, 86 Pre-lactal feeding ...... See Mixed feeding: Pre-lactal feeding Programme support ...... 26 Replacement feeding Breast-milk substitute ...... 73, 77 Free formula ...... 30, 32, 34, 49, 50, 52, 61, 65, 68, 85, 86 Infant formula ...... 26, 30, 32, 36, 40, 42, 43, 47, 49, 50, 52, 54, 55, 57, 60, 65, 68, 71, 78, 81, 85, 89, 92 Obstacles to ...... 43, 58, 60

106 HIV and Infant Feeding Safe ...... 36, 47, 50, 54, 65, 68, 77, 78, 83, 93. See also AFASS Safe sex ...... 37 Scaling up ...... 34, 36, 47, 61, 73, 78, 86 Spillover ...... 26, 34, 52, 71, 85 Stigma ...... 37, 61, 73, 78 Sustainable ...... 68, 83. See also AFASS Training ...... 26, 34, 36, 45, 47, 52, 54, 78, 85 Health workers ...... 71, 73, 89 Infant feeding counselling ...... 49, 57, 61, 73, 89 Transmission beliefs ...... 37 VCT ...... 37, 61, 70, 71, 73, 86, 89 Water safety ...... 92 Wet-nursing ...... 40, 43, 45, 71, 73

A Compilation of Programmatic Evidence 107 This publication was made possible through a Memorandum of Understanding between the Quality Assurance Project (QAP), managed by University Research Co., LLC (URC), and UNICEF. Support was provided to QAP/URC by the United States Agency for International Development (USAID) under the terms of Grant No. GPH-C-00-02-00004-00. The opinions expressed here are those of the editors and do not necessarily reflect the views of USAID.

108 HIV and Infant Feeding