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Implementation of the new WHO recommendations on HIV and infant feeding: challenges and the way forward.

INTRODUCTION

Breast milk is the ideal food for infants. It provides all the nutrients needed by the infant especially in the first six months of life. It also protects the growing infant from pneumonia, diarrhoea, and malnutrition, which are the major causes of morbidity and mortality in the African Region [1,2,3]. However, breastfeeding is also known to transmit Human Immuno-deficiency Virus (HIV) from mother to the child. HIV transmission through breastfeeding could be responsible for over a third of all HIV infections among children if there are no interventions to reduce HIV transmission during pregnancy and delivery, [4.5]. Getting the right balance between the risk of infants being exposed to HIV through breastfeeding and the risk of death from causes other than HIV if infants are not breastfed therefore remains a challenge.

To address this challenge a number of recommendations and guidelines on the most appropriate methods to feed HIV exposed infants have been developed. In the last decade (2000-2010) there has been three such guideline documents produced by WHO on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-agency Task Team on Mother-to-child Transmission of HIV. These recommendations and guidelines were issued in 2001, 2006 and 2010. The 2001 guidelines emphasized on preventing infants from becoming infected with HIV by counselling HIV-infected mothers to avoid all breastfeeding. The recommendation stated that "when replacement feeding is Acceptable, Feasible, Affordable, Sustainable, and Safe (AFASS), avoidance of all breastfeeding by HIV-infected mothers is recommended; otherwise, exclusive breastfeeding for the first few months of life is recommended"[6]. Although replacement feeding with infant formula prevents all transmission of HIV through breastfeeding it also increases the risk of death from other causes in many resource poor environments. Programme implementers and researchers reported difficulties in implementing the 2001 and 2006 recommendations and guidelines on HIV and infant feeding within health-care systems. Particularly the lack of clarity on what AFASS meant to the health workers and mothers led to increased mixed feeding of HIV exposed children.

The 2006 revision of the WHO's recommendations and guidelines on infant feeding and HIV was to address some of the problems noted above. It identified exclusive breastfeeding as a safer option than mixed feeding. Exclusive breastfeeding means the infant only receives breast milk without any additional food or drink, not even water) while mixed feeding is defined as the infant receiving breast milk as well as other milks, water or food. Research data on HIV and infant feeding had then become available to back the revision of the 2001 recommendations and guidelines [5,7].

By 2009 there was new evidence to show that giving Anti-retrovirals (ARVs) to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of transmitting HIV through breastfeeding [8,9]. Thus the 2010 recommendations were developed through the WHO guideline development process which took consideration of the available evidence, including Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, systematic reviews, risk-benefit analysis, the potential impact of the recommendations on human rights issues, and costs. These findings and other programmatic experiences have informed the current 2010 revised recommendations and guidelines. Principally, it has changed how HIV infected mothers should feed their infants, and how health workers should support them [11].

In 2010 WHO issued the latest guidelines on HIV and infant feeding entitled Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. These guidelines state that national health authorities should promote a single infant feeding practice as the standard of care. While information about other practices should be made available to mothers, health services would mainly support one approach. This is a major difference from the 2006 WHO recommendations on HIV and Infant feeding which suggested that health workers in clinics should individually counsel all mothers known to be HIV-infected, who would then each determine the most appropriate infant feeding strategy for their circumstances [10,11].

This paper describes the process of adapting the 2010 global HIV and infant feeding recommendations and guidelines at national level. It also reviews the challenges encountered in implementing previous and current guidelines and proposes the way forward in addressing these challenges.

Adaptation process for the WHO 2010 HIV and infant feeding guidelines

The WHO Guideline Development Group met to review and update the 2010 recommendations and guidelines on infant feeding in the context of HIV. The meeting was coordinated with similar but separate meetings to update the guidelines for the use of ARV interventions to prevent mother to child transmission of HIV and guidelines on Anti-retroviral Therapy for HIV infected adults and children. A number of participants took part in all the three meetings. This process was significant as it demonstrated good coordination and collaboration between various stakeholders and ensured coherence among all the four HIV related guidelines.

Following this, the WHO Regional Office for Africa conducted orientation workshops on all the revised guidelines for countries in the three sub-regions (East and Southern Africa, West Africa and Central Africa). The orientation workshops were conducted in collaboration with partners, including: UNICEF, Clinton Foundation, President's Emergency Plan For AIDS Relief (PEPFAR), International Baby Food Action Network (IBFAN) and United States Agency for International Development (USAID).

In East and Southern Africa, more than 150 participants attended the orientation workshop from 15 countries (i). The West African sub-regional workshop brought together 27 participants from 6 countries (ii) and another 47 participants from 6 countries (iii) attended the meeting in Central Africa. In addition to disseminating the revised guidelines, the meetings provided technical guidance for country adaptation of the guidelines. The potential impact of the new guidelines on national programs, particularly implications for the existing health systems was discussed and solutions to overcome potential challenges duly considered. From the workshop, countries developed draft action plans on how to implement the guidelines.

Eight countries (iv) have since conducted national adaptations on all the four guidelines in a coordinated manner with support from WHO and other partners. In Nigeria a national consultation was held for nutritionists, dietitians, obstetricians and paediatricians who were members of the national Prevention of Mother To Child Transmission PMTCT technical task team, members of the Federal Ministry of Health's divisions of nutrition, child health and HIV/AIDS as well as implementing partners and UN agencies. The meeting concluded by issuing a consensus statement on infant feeding in the context of HIV in Nigeria which called for the development of an implementation framework to support the scaling up of the recommendations and a comprehensive communication strategy to explain the recommendations to all relevant stakeholders.

The adaptation meeting in Botswana was attended by representatives from several departments of the Ministry of Health (MOH), University of Botswana and private paediatricians The meeting agreed that programmatic experience and data should be collected through a planned five-district pilot study and impact study to inform the most effective way to implement and support the new recommendations at scale. However the critical issues raised were the additional cost of revising ART eligibility criteria for pregnant HIV-infected women to CD4<350; providing triple ARV prophylaxis as interventions to prevent postnatal transmission; and promote child survival. In Botswana adopting the WHO recommendations would result in an additional 16% pregnant HIV-infected women becoming eligible for ART [3].

South Africa has already revised their PMTCT guidelines and made changes to the infant feeding sections. The new guidelines recommend the continued provision of free formula milk through public health facilities for women opting not to breastfeed. Doherty et al argue that the new guidelines did not determine which feeding practice will maximize HIV-free survival nationally [12]. A choice between two feeding options (exclusive breastfeeding or exclusive feeding with free formula milk) is still recommended. This implies that the Government's continuous provision of free commercial infant formula could be an incentive that may lead to confusion in infant feeding decisions of some mothers.

What is new about the WHO 2010 Revised Guidelines?

The WHO 2010 guidelines include nine guiding principles and seven revised recommendations. The guiding principles define the values and context within which recommendations are implemented. They take into considerations relevant programmatic experiences, while the recommendations are based on the best available evidence.

Though the 2010 guidelines build on previous guidelines clarifying some concepts such as AFASS, it also introduces new concepts including the following:

The provision of antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding [11]. Therefore mothers known to be HIV-infected should now be provided with lifelong antiretroviral therapy or antiretroviral prophylaxis interventions [13,14]. National authorities in each country can decide which infant feeding practice, i.e. breastfeeding with an antiretroviral intervention to reduce transmission or avoidance of all breastfeeding, will be primarily promoted and supported by Maternal and Child Health services. This differs from the previous recommendations in which health workers were expected to individually counsel all HIV-infected mothers about the various infant feeding options, and then mothers had to decide which to adopt. [11].

Where ARVs are available, mothers known to be HIV-infected are now recommended to exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided [15].

Mothers who decide to stop breastfeeding should stop gradually within one month; stopping breastfeeding abruptly is not advisable [16,17].

What is the added value of the new guidelines?

Breastfeeding is the predominant mode of feeding infants in most resource poor countries especially in the African Region. The fact that ARV intervention can make breastfeeding safer and reduce the risk of HIV transmission is of significant importance in environments where (AFASS) conditions for safe replacement feeding are difficult to achieve. Breastfeeding of HIV exposed infant improves their HIV-Free survival chances and an important contribution towards child survival. The new guidelines give national authorities adequate basis to decide on the predominant infant feeding practice that would be supported and promoted. When such decision is taken centrally it gives both health workers and mother a certain degree of relief from the stress of making the decisions themselves and removes the uncertainty of how and who will provide the needed support for the implementation of the decision. Mothers will be particularly spared the burden of responsibility associated with making their infant feeding choice when they were not assured of the resources and support to implement it [20].

HIV exposed infants who breastfeed beyond 6 months have a better chance to survival than those who don't [15]. Continuing breastfeeding to 12 means that abrupt cessation of breastfeeding at 6 months with all the challenges for both mother and baby is no longer necessary as was the recommendation in 2006. This ensures that the mother--baby pair can gradually stop breastfeeding within a period of one month.

Experience and challenges of implementing HIV and infant feeding guidelines

Evidence-based knowledge and programmatic experience on infant feeding in the context of HIV are rapidly evolving so it is not surprising that since it became known that the HIV virus could be transmitted through breastfeeding, several guidelines and updates have been developed to guide policy makers, health workers and mothers on the most appropriate methods to feed HIV exposed infants [18,19,20]. Sometimes before a global guideline is adapted and fully implemented in the country, a new version is already available.

Disagreement among various national stakeholders has led to the absence of national consensus on global guidelines. This has resulted in mix messages, confusion, and poor counseling of mother. The fear and confusion the HIV infected mother faces in tackling her own HIV status and the possibility of infecting her baby has driven some mothers to choose replacement feeding even when it was obvious that they could not meet the AFASS condition. These mothers eventually resort to mixed feeding with replacement feeding and breastfeeding. The difficulties in accepting the concept of exclusive breastfeeding or exclusive formula feeding for the HIV exposed infant in the first six months of life has led to un-compliance with national guidelines. The involvement of male partners in infant feeding decision making is critical in most African countries. However, counseling and messages on feeding of HIV exposed children exclude men. The HIV infected mother needs all available support to take care of herself and her baby and a male partner who fully understands her infant feeding choice is a great help. When making infant feeding decision, some mothers go through psycho-social distress due to the heavy burden of responsibility of achieving recommended infant feeding advice to avoid HIV transmission that is felt to be downloaded on mothers with the least capacity to implement them [21,22,23]. The above are some of the reasons that have led to differences between infant feeding practices and the previous WHO guidelines on HIV and infant feeding [24].

One of the difficulties of implementing global guidelines at national (MOH) level in the past has been how local adaptation was done. The adaptation process of the HIV and infant feeding guidelines was spearheaded mainly by the Nutrition Division with little involvement of the HIV Division. Thus the concerns of HIV Division were not adequately addressed in the adapted materials. Similarly national adaptation of guidelines for anti retroviral therapy and prophylaxis for both children and adults was done by the HIV Division with minimum participation of Nutrition Division. This vertical adaptation process of national guidelines led to lack of awareness and the beginning of mixed and confused messages by health workers to mothers and the general public.

The current training of health care workers providing PMTCT services does not have enough sessions on infant feeding counselling. The trainings curricula have a few hours to a maximum of one day on infant feeding counselling. Often the sessions on infant feeding are reserved for the last day and mostly rushed through. As a result most PMTCT providers were not comfortable counselling mothers on infant feeding. It was not surprising that most of them actively promoted infant formula.

Training in PMTCT has gone faster than infant feeding training. The integrated infant and young child feeding counselling course is the comprehensive training package that provides the necessary knowledge and tools for health workers. Scaling up of this training has been rather slow in most countries with high HIV prevalence. While in these same countries PMTCT training may be scaling up because of the availability of funds from donors such as the Global Fund for AIDS, TB and Malaria and PEPFAR. This imbalance in the number of trained health workers in PMTCT and infant feeding has resulted in fewer experts to support the PMTCT programmes on infant feeding issues.

Networking among PMTCT providers and trained infant feeding counsellors even in the same health facility is poor. Referrals between these two cadres are not well established, mothers who need more detailed infant feeding counselling may not be referred for appropriate counselling.

Updating current PMTCT protocols with the 2010 WHO guidelines will have budget implications. The provision of ARVs to mothers during the breastfeeding period would incur additional start-up costs and thus higher drug costs for the programme, however, the subsequent operational costs to support breastfeeding and ARVS would be significantly less than providing formula milk. There is additional cost of revising ART eligibility criteria for pregnant HIV-infected women to CD4<350 and to provide triple ARV prophylaxis to prevent postnatal transmission and promote child survival. In Botswana for example, adopting the WHO recommendations would result in an additional 16% pregnant HIV-infected women becoming eligible for ART. Presently, about 31% HIV-infected pregnant women are thought to have CD4<250 and eligible for ART; this would increase to about 47% if eligibility criteria moved to CD4<350 [25].

The knowledge and attitudes of health workers, public health messaging and community perceptions significantly influence the infant feeding practices of all mothers (HIV-infected and uninfected). Regardless of the feeding practice recommended for HIV-exposed infants by health authorities, if women are to exercise choice in how they feed their infant, then there should be accurate information on the following: i) the transmission risks associated with breastfeeding if women are receiving effective ARV prophylaxis, ii) the risks of serious morbidity and mortality associated with not breastfeeding, iii) the support available from health services in assisting mothers in their feeding practice and also the interventions needed and available if infants become ill, and, iv) the autonomy within their community and household to implement their decision.

In the past communicating messages on infant feeding in the context of HIV was bedevilled with inaccurate information. Health workers were found to significantly over-estimate the risk of HIV transmission through breastfeeding while the risks of non-breastfeeding were rarely communicated to mothers even though reports of high mortality have been reported among infants who were formula fed [26]. All countries need comprehensive communications strategy to inform health workers and communities of the basis for change and to ensure that accurate information including the importance of food hygiene is given to mothers.

WAY FORWARD

Financial implications of revising current PMTCT protocol

To address the concerns about additional cost of providing ARV to prevention transmission an estimate of the cost of commodities over the short-term, medium-term and long term should be done. For countries that provide free formula but want to introduce breastfeeding with ARV intervention, a phased approach by gradual withdrawal of formula is advised. Additional costs related to initial training/support and for communication strategies should also be estimated.

In figure 1 data from the PMTCT programme of one country (which currently provides formula milk to all HIV infected mothers) in the African Region was used to prepare a potential budget forecast (commodity cost only) of possible short term, medium term and long term periods. The forecast examined provides Combivir and NVP as the ARV prophylaxis. The following assumptions were made:

Short-term: Year 1: Women in need of lifelong ART (CD4<350) receive full ART package. Other women receive triple ARVs through pregnancy starting from 14 weeks. Infants receive 6 wks AZT. 90% mothers give their infants formula milk and 10% breastfeed. Women who are not eligible for ART and breastfeeding receive triple ARV prophylaxis for 12m.

Medium term: Years 2-3: The same as above but 50% mothers breastfeed and 50% give formula milk.

Long- term: Years 4-5: The same as above but 100% mothers breastfeed and no formula milk.

[FIGURE 1 OMITTED]

Figure 1 shows that short term costs are more than the long term. Over time, providing ARVs to all breastfeeding mothers costs less than half of providing formula milk to "all" (where "all" mean the short term, with 90% mothers giving their infants formula milk). The major cost driver in the overall cost is the formula milk.

It is also important to note that this budget forecast is for only commodity cost. Future estimates of cost-effectiveness of investments made in PMTCT should consider other cost such as initial training for health workers and for communications strategies. The estimates should also reflect lifetime gains due to HIV free survival Disability-Adjusted Life Years (DALYs) rather than just cost per infection averted.

Develop and implement a phased implementation approach.

There is strong evidence that breastfeeding and ARVs can improve HIV free survival of HIV-exposed infants; however, experience of how to scale-up this approach is minimal. The introduction of major changes in infant feeding recommendations for HIV-infected women and mothers will require a well thought out implementation plan with in-built monitoring and supervision components. This approach should be able to incorporate learning from initial introduction to inform subsequent implementation and scale-up.

The following are proposed key steps for the phased implementation approach [25]:

A. Develop and implement a phased strategy to introduce breastfeeding with ARV prophylaxis for HIV-infected mothers with short-term (6-12 months), mid-term (12-24 months) and long-term (24-48 months) coverage targets. The approach should devise district level operational plans that incorporate scheduled objective assessments and data feedback to identify solutions to implementation challenges and to optimize maternal and child health outcomes.

B. Planning and implementation of the above strategy should be undertaken jointly by the HIV/PMTCT team together with the nutrition and MCH teams in the MOH.

C. Introduction of Breastfeeding and ARVs for HIV-infected mothers should capitalize on, and be informed by quality improvement approaches that i) use early learning platforms in the short-term to, ii) guide expansion to additional sites in the mid-term, and iii) lead to scale-up and consolidation in all sites in the longer term.

D. Link up interventions directed at HIV-infected women and mothers to other related interventions to improve infant feeding practices in the general population with the aim of reducing infant under-nutrition and reducing infant and child mortality rates nationally.

Develop a comprehensive national communications strategy

A comprehensive communication strategy is needed for advocacy and to inform key opinion leaders, health workers, communities (pregnant women/mothers) about optimal infant feeding practices and ARV interventions available through health facilities to reduce HIV transmission through breastfeeding. The major recommendations include:

A. Design and implement an effective communication strategy to correct the knowledge of health workers and inform about opportunity to improve HIV free survival of infants through breastfeeding and ARVs;

B. Position HIV-free survival of infants and improved health and survival of mothers as the primary goal of integrated HIV care and treatment interventions;

C. Link with communications to support improving infant feeding in the general population including active awareness creation campaigns to inform mothers about the changes in infant feeding practices and explain the child survival benefits of the changes;

D. Develop parallel communication strategies for policy makers including opinion leaders in medical/nursing professions; implementers such as health workers; and the communities including mothers and the general population, see Table 1.

Capacity building of health workers

The competences of health workers need to be aligned with the new guidelines. Training a critical mass of health workers to ensure that correct and accurate information is provided to mothers is very important. Trained health workers will need to be followed up and supported at their place of work to effectively implement their knowledge and skills. The content of training materials needs urgent revision and the curricula of training institutions should be reviewed to take account of the changes.

Improving the links between the community and the health facility

It has long been recognized that community support for infant feeding practices need strengthening, however, the links between the community and the health facility equally require attention. This is especially so now because supporting breastfeeding and ARV prophylaxis is critical. Mothers and their babies will need regular follow up and support to ensure compliance with ARVs and report side effects and complications of the medicines. The capacity of peer counsellors, mother support groups and community health workers need to be strengthened to support mothers in the community and be a potential bridge for the mothers to quickly access services at the health facilities.

Documentation of best practices

Programmatic experience of the adaptation and implementation of the 2010 guidelines need to be documented for future planning and programme improvement. Lessons learned at country level should be used to inform the scaling up plans.

CONCLUSION

The 2010 WHO guidelines on HIV and infant feeding highlight the importance of going beyond preventing mother to child transmission of HIV virus to HIV free survival of the child. By providing ARVs to either the mother or the child, breastfeeding is made safer because the transmission rate is greatly reduced while the child benefits from optimal nutrition and is protected from infections. The adaptation and implementation of guidelines at national level have met challenges including funding the additional cost of ARVs and communicating the recommendations in the new guidelines clearly to mothers, health workers and policy makers. To address these challenges a phased implementation approach has been proposed to ensure successful scaling up over time. Providing ARVs and supporting breastfeeding will ensure HIV free survival of HIV exposed children in the Region and thus contribution towards the achievement of MDG 4.

REFERENCES

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[2.] Mwiru RS, Spiegelman D, Duggan C, Peterson K, Liu E, Msamanga G, Aboud S and WW Fawzi Relationship of exclusive breast-feeding to infections and growth of Tanzanian children born to HIV-infected women. Public Health Nutr. 2011; 16:1-8.

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[5.] Coovadia HM, Rollins NC, Bland RM, Little K, Bennish ML and ML Newell Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007; 369:1107-1116.

[6.] World Health Organization. New data on the prevention of mother-to-child transmission of HIV and their policy implications: Conclusions and recommendations. Technical consultation on behalf of the UNFPA/UNICEF/WHO/UNAIDS inter-agency task team on mother-to-child transmission of HIV. WHO, Geneva, 2001.

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[9.] Kesho Bora Study Group. Eighteen-month follow-up of HIV-1-infected mothers and their children enrolled in the Kesho Bora study observational cohorts. Acquir Immune Defic Syndr. 2010;54(5):533-41.

[10.] WHO, UNAIDS, UNFPA, UNICEF. HIV and Infant Feeding: Update. Based on the Technical Consultation. Technical Consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants, Geneva, Switzerland, 25-27 October 2006. WHO, Geneva, 2007.

[11.] WHO, UNAIDS, UNFPA, UNICEF. Guidelines on HIV and infant feeding: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO, Geneva, 2010.

[12.] Doherty T, Sanders D, Goga A and D Jackson Implications of the new WHO guidelines on HIV and infant feeding for child survival in South Africa. Bulletin of the World Health Organization. 2011;89(1):62-7.

[13.] Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E, Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C, Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L and M Essex Anti-retroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010;362(24):2282-94.

[14.] Homsy J, Moore D, Barasa A, Were W, Likicho C, Waiswa B, Downing R, Malamba S, Tappero J and J Mermin Breastfeeding, mother-to-child HIV transmission, and mortality among infants born to HIV-Infected women on highly active antiretroviral therapy in rural Uganda. J Acquir Immune Defic Syndr. 2010; 53(1):28-35.

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[16.] Kuhn L, Aldrovandi GM, Sinkala M, Kankasa C, Semrau K, Kasonde P, Mwiya M, Tsai WY and DM Thea Zambia Exclusive Breastfeeding Study (ZEBS). Differential effects of early weaning for HIV-free survival of children born to HIV-infected mothers by severity of maternal disease. PLoS One. 2009; 26:4(6).

[17.] Kuhn L, Aldrovandi GM, Sinkala M, Kankasa C, Semrau K, Mwiya M, Kasonde P, Scott N, Vwalika C, Walter J, Bulterys M, Tsai WY and Thea. Zambia Exclusive Breastfeeding Study. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med. 2008;359(2):130-41.

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[19.] Ziegler J, Johnson R, Cooper D and J Gold. Postnatal transmission of AIDS-associated retrovirus from mother to infant. The Lancet. 1985; 325 (8434):896-898.

[20.] Moland KM, de Paoli MM, Sellen DW, van Esterik P, Leshabari SC and A Blystad Breastfeeding and HIV: experiences from a decade of prevention of postnatal HIV transmission in sub-Saharan Africa. Int Breastfeed J. 2010 ; 5:10.

[21.] Levy JM, Webb AL and DW Sellen "On our own, we can't manage": experiences with infant feeding recommendations among Malawian mothers living with HIV. Int Breastfeed J. 2010;5:15.

[22.] Engebretsen IMS, Moland KM, Nankunda J, Karamagi CA, Tylleskar T and JK Tumwine Gendered perceptions on infant feeding in Eastern Uganda: continued need for exclusive breastfeeding support. Int Breastfeed J. 2010; 5:13.

[23.] Chinkonde JR, Sundby J, de Paoli M and VC Thorsen The difficulty with responding to policy changes for HIV and infant feeding in Malawi. Int Breastfeed J. 2010; 5:11.

[24.] Fadnes LT, Engebretsen IM, Wamani H, Wangisi J, Tumwine JK and T Tylleskar Need to optimise infant feeding counselling: a cross-sectional survey among HIV-positive mothers in Eastern Uganda. BMC Pediatr. 2009 ; 9:2

[25.] World Health Organization. Mission report: Joint WHO/UNICEF consultative meeting on the New WHO recommendation on ART, PMTCT and Infant Feeding in the context of HIV:Gaborone, Botswana. July 2010.

[26.] Chopra M and N Rollins Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008; 93:288-291.

(i) Botswana, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe

(ii) Burkina, Cote d'Ivoire, Ghana, Mali, Nigeria and Togo

(iii) Angola, Burundi, Cameroon, Central African Republic, Chad and Democratic Republic of Congo

(iv) Botswana, Cameroon, Ethiopia, Kenya, Namibia, Nigeria, Tanzania and Zimbabwe

* Corresponding author email: sagoemosesc@afro.who.int

Sagoe-Moses C (1) *, Mwinga K (1), Habimana P (1), Toure ID (1) and Ketsela T (1) (1) WHO Regional Office for Africa.
Table 1. Proposed Messages from the Revised WHO guidelines/
recommendations on Infant Feeding and HIV 2010 **

Recommendations        Community              Implementers

1. Ensuring mothers    All pregnant women     All pregnant women
receive the care       should seek            should seek
they need              antenatal care early   Antenatal care early
Mothers                (within the first 3    in the 1st trimester
known to be HIV-       months) to know        to know their HIV
infected should be     their HIV status and   status. HIV positive
provided with          if positive get        pregnant women
lifelong ART or ARV    treatment from 14      should start ARV
prophylaxis            weeks to help          prophylaxis from 14
interventions to       prevent transmission   weeks to prevent
reduce HIV             to their babies.       MTCT. If a pregnant
transmission through   Pregnant women         woman is already on
breastfeeding          already on AIDS        antiretroviral
according to WHO       treatment should       treatment, she
recommendations.       continue to seek       should get continued
                       care to protect        care to ensure
                       their babies.          optimal treatment to
                                              protect her baby

2. Which               HIV positive mothers   HIV positive mothers
breastfeeding          should [now]           should [now]
practices and for      breastfeed             breastfeed
how long               exclusively (give      exclusively for the
In settings            breastmilk only) for   first 6 months.
where national or      the first 6 months.    After 6 months
sub-national           After 6 months         introduce
authorities have       introduce other        complementary foods
decided that           foods (complementary   and continue to
maternal, newborn      foods) and continue    breastfeed up to 12
and child health       to breastfeed up to    months while the
services will          12 months while        baby or the mother
principally promote    receiving HIV drugs    is on ARVs to
and support            (ARV) to improve the   improve the baby's
breastfeeding and      baby's chances of      chance of survival
ARV interventions      survival and reduce    and reduce the risk
Mothers known to be    the risk of HIV        of HIV transmission.
HIV-infected (and      transmission to her    After 12 months
whose infants are      baby. After 12         nutritionally
HIV uninfected or of   months nutritionally   adequate and safe
unknown HIV status)    adequate and safe      diet without breast
should exclusively     diet without breast    milk should be
breastfeed their       milk should be         provided.
infants for the        provided.
first 6 months of
life, introducing
appropriate
complementary foods
thereafter, and
continue
breastfeeding for
the first 12 months
of life.
Breastfeeding should
then only stop once
a nutritionally
adequate and safe
diet without breast
milk can be
provided.

3. When mothers        HIV positive mothers   HIV positive mothers
decide to stop         who decide to stop     who decide to stop
breastfeeding          breastfeeding at any   breastfeeding at any
In settings where      time should do so      time should stop
national or sub-       gradually [within]     gradually [within]
national authorities   over one month.        over one month.
have decided that      Mothers or infants     Mothers or infants
maternal, newborn      who have been          who have been
and child health       receiving HIV drugs    receiving ARV
services will          (ARV prophylaxis)      prophylaxis should
principally promote    should continue on     continue prophylaxis
and support            these for one week     for one week after
breastfeeding and      after breastfeeding    breastfeeding is
ARV interventions      is fully stopped.      fully stopped.
Mothers known to be    Stopping               Stopping
HIV-infected who       breastfeeding          breastfeeding
decide to stop         suddenly is not        abruptly is not
breastfeeding at any   recommended.           advisable.
time should stop
gradually within one
month. Mothers or
infants who have
been receiving ARV
prophylaxis should
continue prophylaxis
for one week after
breastfeeding is
fully stopped.
Stopping
breastfeeding
abruptly is not
advisable.

4. What to feed        When an HIV positive   When an HIV positive
infants when mothers   mother decides to      mother decides to
stop breastfeeding     stop breastfeeding     stop breastfeeding
In settings where      at any time, the       at any time, infants
national or sub-       baby should be         should be provided
national authorities   provided with safe     with safe and
have decided that      and adequate           adequate replacement
maternal, newborn      replacement feeds to   feeds to enable
and child health       enable normal growth   normal growth and
services will          and development. For   development. For
principally promote    babies below 6         babies below 6
and support            months the options     months the options
breastfeeding and      include commercial     include commercial
ARV interventions      infant formula or      infant formula or
When mothers known     the use of expressed   the use of expressed
to be HIV-infected     breast milk that is    breastmilk that is
decide to stop         heat treated. Animal   heat treated. Animal
breastfeeding at any   milk is not            milk is not
time, infants should   recommended for        recommended for
be provided with       feeding babies         feeding babies
safe and adequate      younger than six       younger than six
replacement feeds to   months.                months.
enable normal growth   For children
and development.       over six months        For children over
Alternatives to        commercial infant      six months
breastfeeding          formula or animal      commercial infant
include:               milk can be used.      formula or
                                              animal milk can be
For infants less                              used.
than six months of
age: Commercial
Formula or EHT-
Breast milk

For children over
six months of age:
Commercial Formula
or Animal milk

5. Conditions needed   If HIV positive        If HIV positive
to safely formula      mothers decide to      mothers decide to
feed                   give commercial        give commercial
                       infant formula milk    infant formula milk
Mothers known to be    as a replacement       as a replacement
HIV-infected should    feed to their babies   feed to their babies
only give commercial   the following          the following
infant formula milk    conditions must all    conditions must all
as a replacement       be in place:           be in place:
feed to their HIV-
uninfected infants     a. the home and        a. the home and
or infants who are     community should       community should
of unknown HIV         have constant supply   have constant supply
status, when           of safe water and      of safe water and
specific conditions    sanitation             sanitation
are met:               facilities; and        facilities; and
                       b. mother, or other    b. mother, or other
a. safe water and      caregiver should       caregiver should
sanitation are         ensure sufficient      ensure sufficient
assured at the         and continuous         and continuous
household level and    supply of commercial   supply of commercial
in the community;      infant formula         infant formula to
and                    to support normal      support normal
                       growth and             growth and
b. the mother, or      development of the     development of the
other caregiver can    infant; and c. the     infant; and
reliably provide       mother or caregiver
sufficient infant      can prepare the milk   c. the mother or
formula milk to        cleanly and            caregiver can
support normal         frequently enough to   prepare the milk
growth and             reduce the risk of     cleanly and
development of the     diarrhoea and          frequently enough to
infant; and            malnutrition; and      reduce the risk of
                                              diarrhoea and
c. the mother or       d. the mother or       malnutrition;
caregiver can          caregiver can give     and
prepare it cleanly     only infant formula    d. the mother or
and frequently         milk, in the first     caregiver can give
enough so that it is   six months; and        only infant formula
safe and carries a                            milk, in the first
low risk of            e. the family is       six months; and
diarrhoea and          supportive of this     e. the family is
malnutrition; and      practice; and          supportive of this
                       f. the mother or       practice; and
d. the mother or       caregiver can          f. the mother or
caregiver can, in      regularly take the     caregiver can
the first six          child to health        regularly take the
months, exclusively    facilities for care.   child to health
give infant formula                           facilities for care.
milk; and

e. the family is
supportive of this
practice; and

f. the mother or
caregiver can access
health care that
offers comprehensive
child health
services.

6. Heat-treated,       Heat treating breast   Heat-treated,
expressed breast       milk can be used for   expressed breast
milk                   a short period of      milk is an interim
Mothers known          time by HIV positive   feeding strategy:
to be HIV-infected     mother as an infant    --in special
may consider           feeding option: This   circumstances such
expressing and heat-   can be done if a       as when the infant
treating breast milk   child is unable to     is born with low
as an interim          suckle, if a mother    birth weight or is
feeding strategy:      is unable to           otherwise ill in the
                       breastfeed for short   neonatal period and
--in special           period or if a         unable to
circumstances such     mother needs to stop   breastfeed; or
as when the infant     AIDS drugs (ARV) for
is born with low       a short time           --when the mother is
birth weight or is                            unwell and
otherwise ill in the                          temporarily unable
neonatal period and                           to breastfeed or has
unable to                                     a temporary breast
breastfeed; or                                health problem such
                                              as mastitis; or
-when the mother is                           -to assist mothers
unwell and                                    to stop
temporarily unable                            breastfeeding; or
to breastfeed or has
a temporary breast                            --if antiretroviral
health problem such                           drugs are
as mastitis; or                               temporarily not
                                              available.
--to assist mothers
to stop
breastfeeding; or

--if antiretroviral
drugs are
temporarily not
available.

7. When the infant     If infants and young   If infants and young
is HIV-infected If     children are known     children are known
infants and young      to be HIV-infected,    to be HIV-infected,
children are known     mothers are strongly   mothers are strongly
                       encouraged to give     encouraged to
to be HIV-infected,    breast milk only       exclusively
mothers are strongly   (exclusive) for the    breastfeed for the
encouraged to          first six months.      first six months of
exclusively            After 6 month          life. After 6 months
breastfeed for the     introduce other        introduce
first six months of    foods and continue     complementary foods
life and continue      to breastfeed up to    and continue
breastfeeding as per   2 years or beyond.     breastfeeding up to
the recommendations                           2 years or beyond.
for the general        The mother or          The mother or
population, that is,   caregiver can          caregiver can
up to two years or     regularly take the     regularly take the
beyond.                child to health        child to health
                       facilities for care.   facilities for care.

Recommendations        Policymakers

1. Ensuring mothers    Virtual elimination
receive the care       of MTCT can be
they need              achieved through the
Mothers                early use of more
known to be HIV-       effective drugs.
infected should be     More HIV positive
provided with          pregnant women will
lifelong ART or ARV    now be eligible for
prophylaxis            earlier treatment.
interventions to       HIV positive
reduce HIV             pregnant women not
transmission through   yet on treatment
breastfeeding          will receive ARV
according to WHO       prophylaxis to
recommendations.       prevent MTCT

2. Which               Child survival can
breastfeeding          be improved while
practices and for      achieving virtual
how long               elimination of MTCT.
In settings            HIV positive mothers
where national or      should [now]
sub-national           breastfeed
authorities have       exclusively for the
decided that           first 6 months, and
maternal, newborn      continue to
and child health       breastfeed with
services will          (complementary
principally promote    foods) to 12 months
and support            while the baby or
breastfeeding and      the mother is on ARV
ARV interventions      to improve the
Mothers known to be    babies chance of
HIV-infected (and      survival while
whose infants are      reducing the risk of
HIV uninfected or of   HIV transmission.
unknown HIV status)    After 12 months
should exclusively     nutritionally
breastfeed their       adequate and safe
infants for the        diet without breast
first 6 months of      milk should be
life, introducing      provided.
appropriate
complementary foods
thereafter, and
continue
breastfeeding for
the first 12 months
of life.
Breastfeeding should
then only stop once
a nutritionally
adequate and safe
diet without breast
milk can be
provided.

3. When mothers        Prior guidance for
decide to stop         abrupt caessation of
breastfeeding          breastfeeding for
In settings where      HIV positive mothers
national or sub-       has been replaced
national authorities   with recommendation
have decided that      for gradual stopping
maternal, newborn      of breastfeeding
and child health       over one month
services will          period to ensure
principally promote    optimal nutrition
and support            and improved child
breastfeeding and      survival. ARVs
ARV interventions      should continue for
Mothers known to be    one after
HIV-infected who       breastfeeding has
decide to stop         fully stopped
breastfeeding at any
time should stop
gradually within one
month. Mothers or
infants who have
been receiving ARV
prophylaxis should
continue prophylaxis
for one week after
breastfeeding is
fully stopped.
Stopping
breastfeeding
abruptly is not
advisable.

4. What to feed        Animal milk is no
infants when mothers   longer recommended
stop breastfeeding     as a suitable
In settings where      alternative for
national or sub-       children under 6
national authorities   months of age. HIV
have decided that      positive mothers who
maternal, newborn      decide to stop
and child health       breast feed can have
services will          the following
principally promote    alternatives: For
and support            infants less than
breastfeeding and      six months of age:
ARV interventions      Commercial infant
When mothers known     Formula or EHT-
to be HIV-infected     Breast milk For
decide to stop         children over six
breastfeeding at any   months of age:
time, infants should   Commercial Formula
be provided with       or Animal milk
safe and adequate
replacement feeds to
enable normal growth
and development.
Alternatives to
breastfeeding
include:

For infants less
than six months of
age: Commercial
Formula or EHT-
Breast milk

For children over
six months of age:
Commercial Formula
or Animal milk

5. Conditions needed   As an alternative to
to safely formula      breastfeeding an HIV
feed                   positive mother can
                       choose replacement
Mothers known to be    feeding. In order to
HIV-infected should    minimize the
only give commercial   associated risk of
infant formula milk    childhood mortality
as a replacement       from diarrhoea and
feed to their HIV-     respiratory diseases
uninfected infants     the follow minimum
or infants who are     conditions should be
of unknown HIV         met: These include
status, when           safe water and
specific conditions    sanitation;
are met:               sufficient supply of
                       infant formula milk;
a. safe water and      hygienic and
sanitation are         adequate
assured at the         preparation; ability
household level and    for exclusive
in the community;      formula feeding for
and                    the first 6 months
                       of life; supportive
b. the mother, or      environment; and
other caregiver can    access to health
reliably provide       care services.
sufficient infant
formula milk to
support normal
growth and
development of the
infant; and

c. the mother or
caregiver can
prepare it cleanly
and frequently
enough so that it is
safe and carries a
low risk of
diarrhoea and
malnutrition; and

d. the mother or
caregiver can, in
the first six
months, exclusively
give infant formula
milk; and

e. the family is
supportive of this
practice; and

f. the mother or
caregiver can access
health care that
offers comprehensive
child health
services.

6. Heat-treated,       HIV positive mothers
expressed breast       or infants in
milk                   special
Mothers known          circumstances can be
to be HIV-infected     supported to ensure
may consider           optimal infant
expressing and heat-   feeding. Heat
treating breast milk   treated express
as an interim          breast milk can used
feeding strategy:      as an interim
                       feeding strategy to
--in special           reduce HIV
circumstances such     transmission and
as when the infant     maximize child
is born with low       survival
birth weight or is
otherwise ill in the
neonatal period and
unable to
breastfeed; or

-when the mother is
unwell and
temporarily unable
to breastfeed or has
a temporary breast
health problem such
as mastitis; or

--to assist mothers
to stop
breastfeeding; or

--if antiretroviral
drugs are
temporarily not
available.

7. When the infant     For HIV positive
is HIV-infected If     infants or young
infants and young      children, feeding
children are known     recommendations
                       remain the same as
to be HIV-infected,    the general
mothers are strongly   population. Mothers
encouraged to          are strongly
exclusively            encouraged to
breastfeed for the     exclusively
first six months of    breastfeed for the
life and continue      first six months of
breastfeeding as per   life. After 6 months
the recommendations    introduce
for the general        complementary foods
population, that is,   and continue
up to two years or     breastfeeding up to
beyond.                2 years or beyond.
                       The mother or
                       caregiver can
                       regularly take the
                       child to health
                       facilities for care.

** Proposed messages for a comprehensive communication strategy
developed by participants at an IBFAN Africa meeting in September 2010
in Mauritius for country specific field testing and adaptation
COPYRIGHT 2012 Rural Outreach Program
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2012 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Sagoe-Moses, C.; Mwinga, K.; Habimana, P.; Toure, I.D.; Ketsela, T.
Publication:African Journal of Food, Agriculture, Nutrition and Development
Article Type:Report
Geographic Code:60AFR
Date:Jun 1, 2012
Words:7663
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