Rapid assessment of infant feeding support to HIV-positive women accessing prevention of mother-to-child transmission services in Kenya, Malawi and Zambia

Health Systems Research Unit, Medical Research Council, Francie Van Zyl Drive, Parow, Western Cape 7535, South Africa.
Public Health Nutrition (Impact Factor: 2.68). 05/2009; 12(12):2323-8. DOI: 10.1017/S1368980009005606
Source: PubMed


The possibility of mother-to-child transmission (MTCT) of HIV through breast-feeding has focused attention on how best to support optimal feeding practices especially in low-resource and high-HIV settings, which characterizes most of sub-Saharan Africa. To identify strategic opportunities to minimize late postnatal HIV transmission, we undertook a review of selected country experiences on HIV and infant feeding, with the aims of documenting progress over the last few years and determining the main challenges and constraints.
Field teams conducted national-level interviews with key informants and visited a total of thirty-six facilities in twenty-one sites across the three countries--eighteen facilities in Malawi, eleven in Kenya and seven in Zambia. During these visits interviews were undertaken with key informants such as the district and facility management teams, programme coordinators and health workers.
A rapid assessment of HIV and infant feeding counselling in Kenya, Malawi and Zambia, undertaken from February to May 2007.
Infant feeding counselling has, until now, been given low priority within programmes aimed at prevention of MTCT (PMTCT) of HIV. This is manifest in the lack of resources - human, financial and time--for infant feeding counselling, leading to widespread misunderstanding of the HIV transmission risks from breast-feeding. It has also resulted in lack of space and time for proper counselling, poor support and supervision, and very weak monitoring and evaluation of infant feeding. Finally, there are very few examples of linkages with community-based infant feeding interventions. However, all three countries have started to revise their feeding policies and strategies and there are signs of increased resources.
In order to sustain this momentum it will be necessary to continue the advocacy with the HIV community and stress the importance of child survival--not just minimization of HIV transmission - and hence the need for integrating MTCT prevention.

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Available from: Tanya Doherty, Jun 04, 2015
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    • "We acknowledge that in many poor settings, resources are not made available to ensure that the safe substitution of breast milk is possible, as we have done in Haiti [33,34]. Research has also now opened the door to other safe alternatives for HIV-infected women who wish to continue to breastfeed their infants--specifically by continuing ART use during breastfeeding. "
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    ABSTRACT: ABSTRACT: Partners In Health (PIH) works with the Ministry of Health to provide comprehensive health services in Haiti. Between 1994 and 2009, PIH recommended exclusive formula feeding in the prevention of mother-to-child transmission (PMTCT) of HIV program and provided support to implement this strategy. We conducted this study to assess HIV-free survival and prevalence of diarrhea and malnutrition among infants in our PMTCT program in rural Haiti where exclusive formula feeding was supported. We reviewed medical charts of PMTCT mother-infant pairs at PIH between November 2004 and August 2006 through a retrospective longitudinal study and cross-sectional survey. We performed household surveys for each pair and at control households matched by infant's age and gender. 254 mother-infant pairs were included. 15.3% of infants were low birth weight; most births occurred at home (68.8%). 55.9% of households had no latrine; food insecurity was high (mean score of 18; scale 0-27, SD = 5.3). HIV-free survival at 18 months was 90.6%. Within the cohort, 9 children (3.5%) were HIV-infected and 17 (6.7%) died. Community controls were more likely to be breastfed (P = 0.003) and more likely to introduce food early (P = 0.003) than PMTCT-program households. There was no difference in moderate malnutrition (Z score ≤ 2 SD) between PMTCT and community groups after controlling for guardian's education, marital status, and food insecurity (OR = 1.05; 95% CI: 0.67, 1.64; P = 0.84). Diarrhea was 2.9 times more prevalent among community children than PMTCT infants (30.3% vs. 12.2%; P < 0.0001). In a PIH-supported program in rural Haiti that addressed socioeconomic barriers to ill-health, breast milk substitution was safe, acceptable and feasible for PMTCT for HIV-infected women choosing this option.
    AIDS Research and Therapy 10/2011; 8(1):37. DOI:10.1186/1742-6405-8-37 · 1.46 Impact Factor
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    • "This may also be related to lack of clarity of infant feeding recommendations, to stigma associated with not breastfeeding, and/or to lack of safe alternatives to breast milk. Other recent studies from Malawi, Kenya and Zambia described this lack of clarity among health workers and the low priority for infant feeding counseling within PMTCT programs [11-13]. Taha and colleagues conducted a series of trials in Malawi studying the effectiveness of NVP and combination therapy and the impact of breastfeeding on MTCT [14-17]. "
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    ABSTRACT: HIV prevalence among pregnant women in Malawi is 12.6%, and mother-to-child transmission is a major route of transmission. As PMTCT services have expanded in Malawi in recent years, we sought to determine uptake of services, HIV-relevant infant feeding practices and mother-child health outcomes. A matched-cohort study of HIV-infected and HIV-uninfected mothers and their infants at 18-20 months post-partum in Zomba District, Malawi. 360 HIV-infected and 360 HIV-uninfected mothers were identified through registers. 387 mother-child pairs were included in the study. 10% of HIV-infected mothers were on HAART before delivery, 27% by 18-20 months post-partum. sd-NVP was taken by 75% of HIV-infected mothers not on HAART, and given to 66% of infants. 18% of HIV-infected mothers followed all current recommended PMTCT options. HIV-infected mothers breastfed fewer months than HIV-uninfected mothers (12 vs.18, respectively; p < 0.01). 19% of exposed versus 5% of unexposed children had died by 18-20 months; p < 0.01. 28% of exposed children had been tested for HIV prior to the study, 76% were tested as part of the study and 11% were found HIV-positive. HIV-free survival by 18-20 months was 66% (95%CI 58-74). There were 11(6%) maternal deaths among HIV-infected mothers only. This study shows low PMTCT program efficiency and effectiveness under routine program conditions in Malawi. HIV-free infant survival may have been influenced by key factors, including underuse of HAART, underuse of sd-NVP, and suboptimal infant feeding practices. Maternal mortality among HIV-infected women demands attention; improved maternal survival is a means to improve infant survival.
    BMC Public Health 06/2011; 11(1):426. DOI:10.1186/1471-2458-11-426 · 2.26 Impact Factor
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    • "Original Article review of programmatic experience by the World Health Organization (WHO)/United Nations Children's Fund found a number of shortcomings in the coverage and quality of infant feeding counselling and support in most prevention of mother-to-child transmission programmes (World Health Organization 2007a). Inadequate infant feeding counselling was found in programmes in Kenya, Malawi and Zambia (Chopra et al., 2009). Mothers may therefore be confused about what feeding mode is best for their infants. "
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    ABSTRACT: Choosing an infant feeding mode is complex for human immunodeficiency virus (HIV)-infected African women. We documented infant feeding choices by 811 mothers of infants aged less than 18 months enrolled in the Chilenje Infant Growth, Nutrition and Infection Study of fortified complementary or replacement foods. We also conducted 20 interviews and 4 focus group discussions among women and nurses to explore the issues in depth. Practices of most HIV-infected women did not closely follow national or international guidelines: 26% never initiated breastfeeding, and 55% were not breastfeeding by 6 months post partum. Women of lower socio-economic status and those not meeting criteria for safe replacement feeding were more likely to initiate breastfeeding, to continue longer and to stop at 6 months when provided with free food within the trial. Most HIV-negative women and women of unknown HIV status continued breastfeeding into the infant's second year, indicating limited 'spillover' of infant feeding messages designed for HIV-infected women into the uninfected population. Qualitative work indicated that the main factors affecting HIV-infected women's infant feeding decisions were the cost of formula, the advice of health workers, influence of relatives, stigma and difficulties with using an exclusive feeding mode. Rapidly changing international recommendations confused both mothers and nurses. Many HIV-infected women chose replacement feeding without meeting criteria to do this safely. Women were influenced by health workers but, for several reasons, found it difficult to follow their advice. The recently revised international HIV and infant feeding recommendations may make the counselling process simpler for health workers and makes following their advice easier for HIV-infected women.
    Maternal and Child Nutrition 04/2011; 7(2):148-59. DOI:10.1111/j.1740-8709.2010.00264.x · 3.06 Impact Factor
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