Rapid assessment of infant feeding support to HIV-positive women accessing prevention of mother-to-child transmission services in Kenya, Malawi and Zambia
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.
Public Health Nutrition: 12(12), 2323–2328 doi:10.1017/S1368980009005606
Rapid assessment of infant feeding support to HIV-positive
women accessing prevention of mother-to-child transmission
services in Kenya, Malawi and Zambia
*, Tanya Doherty
, Saba Mehatru
and Mark Tomlinson
Health Systems Research Unit, Medical Research Council, Francie Van Zyl Drive, Parow, Western Cape 7535,
School of Public Health, University of the Western Cape, Cape Town, South Africa:
Eastern and Southern Africa Regional Ofﬁce, Nutrition Division, Nairobi, Kenya:
Department of Psychology,
University of Stellenbosch, Stellenbosch, South Africa
Submitted 15 September 2008: Accepted 8 February 2009: First published online 30 April 2009
Objective: 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 experi-
ences on HIV and infant feeding, with the aims of documenting progress over the
last few years and determining the main challenges and constraints.
Design: 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.
Setting: A rapid assessment of HIV and infant feeding counselling in Kenya,
Malawi and Zambia, undertaken from February to May 2007.
Results: 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.
Conclusions: 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
The transmission of HIV through breast milk has provided
signiﬁcant scientiﬁc and programmatic challenges in mini-
mizing mother-to-child transmission (MTCT) through pre-
vention of MTCT (PMTCT) programmes. The rate of
transmission of HIV infection in breast-fed infants is cumu-
lative and increases with duration of breast-feeding; the
estimated cumulative probability of transmission (with
antiretroviral prophylaxis at birth) between 4 weeks and 18
months of age is 9?3%
. Furthermore, approximately 42 %
of all HIV infections in infants are attributable to breast-
feeding in settings where prolonged breast-feeding is com-
. There is now substantial evidence that investment in
infant feeding support can substantially reduce late post-
natal transmission even in very resource-poor settings
Recent evaluations from routine PMTCT programmes
suggest that early MTCT can be signiﬁcantly reduced
through effective peripartum prophylaxis
; however, late
postnatal transmission remains disturbingly high
recent WHO/UNICEF review of programmatic experience
found a number of shortcomings in the coverage and quality
of infant feeding counselling and support across most
. A South African study found that
poor-quality infant feeding counselling resulted in inap-
propriate infant feeding choices being made by the mother,
*Corresponding author: Email email@example.com r The Authors 2009
leading to a threefold increase in risk of infant HIV trans-
mission or death
. Some commentators have suggested
that the HIV epidemic has seriously undermined breast-
feeding and child nutrition activities especially in Africa
The need to address the reversal of early gains in HIV-free
survival due to poor infant feeding practices and to
strengthen infant nutrition programmes are now widely
recognized as priorities.
In order to identify strategic opportunities to minimize
late postnatal HIV transmission, we undertook a review of
selected country experiences on HIV and infant feeding.
The main objectives of the review were to document the
progress of the last few years and determine the main
challenges and constraints.
Three sub-Saharan African countries highly affected by HIV
(Kenya, Malawi and Zambia) were purposively selected for
the ﬁeld work; selection was on the basis that the three
countries are approaching national coverage with their
PMTCT programmes and had recognized the need to
review infant feeding components of the programme. The
ﬁeld work was carried out between February and May,
2007. We reviewed recent relevant policy documents,
training materials, reports and minutes of interagency
coordination committee meetings. 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. Sites were purposively selected to
reﬂect the different settings (urban and rural) and pro-
gramme implementers (government v. non-governmental
organizations (NGO) v. UN) in each country. During these
visits interviews were undertaken with key informants such
as the district and facility management teams, programme
coordinators and health workers. The visits aimed to
determine where HIV and infant feeding counselling and
support had been implemented; review reporting and
monitoring mechanisms in facilities to determine coverage
of HIV and infant feeding counselling support; and explore
health workers’ perceptions of the use of primary health-
care infrastructure to support HIV-positive mothers with
Two semi-structured data collection tools were devel-
oped, one for interviews with national-level stakeholders
and one for ﬁeld-site interviews, and an observation tool
was developed for observations of facilities and outreach
posts. Sites for ﬁeld visits were purposively selected to
represent a range of areas that were performing well and
performing poorly and included health facilities, clinics,
outreach posts, schools and mobile units. Data analysis
involved reviews of national policy documents and
reports, and content analysis of interview transcripts to
identify commonly occurring themes.
According to the responses from interviews with national
and site managers, the Ministry of Health and PMTCT
implementation partners in all three countries welcomed
a focus on the infant feeding component of PMTCT
programmes, but their responses along with the facility
assessments raised some critical issues.
Infant feeding was low on the agenda when PMTCT
programmes were initiated. One respondent stated:
Infant feeding is so invisible because when it comes
to health prioritization it depends to a great degree
on who is pushing what agenda. What becomes
prioritized depends to a great extent on whether it
is being pushed by (for example) an obstetrician,
gynaecologist or nutritionist. It is about who is
pushing harder and shouting the loudest.
Unfortunately, nutrition did not have enough cham-
pions in these forums until recently. However, signs are
emerging that leadership is developing and key staff
are responding positively to the challenges. For example,
the Kenyan National AIDS and STI Control Programme
(NASCOP) used to have just one nutritionist but now
employs ﬁfty nutritionists speciﬁcally to be involved in
HIV service delivery points. In Zambia, the national
PMTCT technical working group, which operates under
the auspices of the National AIDS Council, is sympathetic
to infant feeding issues but it is only an advisory group.
HIV and Infant Feeding falls under the ‘feeding in difﬁcult
circumstances’ component of the Infant and Young Child
Feeding programme of the Nutrition Unit of the Ministry
of Health. In Malawi, the National PMTCT Task Force is
the coordinating body for MTCT prevention, with repre-
sentatives from all agencies that implement services. In
addition, infant feeding is handled by the nutrition unit,
which has an infant feeding coordinator. This person
works closely with the PMTCT coordinator to support
HIV and Infant Feeding activities, and is a member of the
national PMTCT working group.
Yet, there still remains a huge gap in the level of
political support that nutrition or infant feeding is able to
attract compared with the other components of the
PMTCT programme. Respondents across Kenya and
Zambia agreed that nutrition is the ‘poor cousin’ in the
Ministry of Health and that its position has become
weaker in the last decade. For example, in Zambia the
National Food and Nutrition Council was a strong and
independent group that advised the government on all
nutrition issues. However, it has recently suffered sig-
niﬁcant ﬁnancial cutbacks and is not able to perform its
role to the same extent. The Ministry of Health has only
two nutritionists at the central level and no nutritionist at
the provincial level. These power imbalances mean that
2324 M Chopra et al.
the HIV/AIDS division has largely driven PMTCT policies
and protocols, and hence training curricula.
Senior ofﬁcials in the HIV and PMTCT programmes
cited the support of UN agencies for formula feeding at
selected pilot sites during the 1990s and the subsequent
change in policy as an important reason for their confu-
sion around optimal infant feeding policy.* According to
one senior respondent:
There was then a signiﬁcant amount of confusion
over exclusive breast-feeding, especially as we were
also trying to scale up the Baby-Friendly Hospital
Initiativey I would say there was open warfare
amongst recipients regarding who was receiving
formula and who was not.
This does seem to also have translated into a sharp
slowdown in important breast-feeding interventions in
the countries (Box 1).
This also meant that nutrition policies said very little
about HIV and infant feeding during that time. For example,
the Zambian National Food and Nutrition Policy of 2003
mentions it only once, although Zambia later developed
the Infant and Young Child Feeding Operational Strategy
which elaborated the HIV and Infant Feeding strategies.
The divisions of nutrition in the ministries of health were
consistently weak, particularly in ﬁnancial resources. For
example, in one country, donor funding constitutes about
20 % of total ministry funding. Yet the division of nutrition
was dependent on donor funding for 80 to 90 % of its
budget – a clear sign that it was not being prioritized by the
ministry. In another country, the total monthly budget for
the whole nutrition department was one-third of the cost of
training thirty people for ﬁve days. The nutrition department
was weak in negotiating skills, making it hard to obtain
funds from PMTCT units to support infant feeding activities.
More encouragingly, a number of important donors
stated they were beginning to focus more on the challenges
of infant feeding and were setting aside substantially
increased funds for it in the coming ﬁnancial year. Kenya,
for example, has committed resources from the Global
Fund to employ ﬁfty nutritionists, who are now stationed
across the country. Malawi has also raised awareness of the
importance of nutrition. A key respondent said that the
budget for nutrition had doubled in the last few years to
about 1 % of the Ministry of Health’s budget.
Guidelines and protocols
At the regional and global levels, there is increasingly
strong advocacy in support of strengthening the HIV and
Infant Feeding components of the PMTCT programmes.
To this end, the present UN recommendation that HIV-
positive pregnant women should receive individual
counselling on various feeding options, including the
health beneﬁts and risks of breast-feeding and alternative
feeding, forms the basis of the infant feeding sections of
PMTCT guidelines and protocols in all three countries.
However, more work needs to be done. The criteria of
affordability, feasibility, acceptability, safety and sustain-
ability are outlined but local adaptation and examples of
what is meant by these terms were not found. The
documents include little or no mention of issues which
HIV and breast-feeding decline
Nutritionists across all three countries stated that the HIV epidemic has signiﬁcantly reduced investments in
nutrition in general and breast-feeding in particular. This is most directly felt in one important breast-feeding
initiative: the Baby-Friendly Hospital Initiative (BFHI).
Kenya. The number of baby-friendly hospitals fell from over 600 in 1996 to fewer than six in 2003. No formal
assessments have taken place for at least the last three years. However, signs of change are emerging, with a
number of institutions undergoing self-assessments before being reassessed externally.
Malawi. The mid- to late-1990s saw an explosion in BFHI and breast-feeding promotion activities, with a
corresponding increase in exclusive breast-feeding rates. However, respondents reported that confusion over
HIV and breast-feeding had signiﬁcantly diminished BFHI activities. They are now being prioritized again.
Zambia. The BFHI began in 1997 with accreditation of forty-six institutions. According to the National Food and
Nutrition Commission, it was working well, but the advent of HIV and confusion over infant feeding methods led
to signiﬁcant uncertainty, and the initiative faltered. No BFHI monitoring has taken place in many years. But
UNICEF has trained ﬁfteen people on the revised 2006 materials and tools, which incorporate HIV issues, and
plans call for extending the initiative into two provinces in 2007. The Commission believes that a baby-friendly
hospital is more likely to support HIV-positive women.
* It should be noted that at the time of the implementation of the pilot
PMTCT interventions by UNICEF the evidence from drug trials had been
based upon women who did not breast-feed their infants. Based on the
experience gained from the PMTCT pilot project, UNICEF developed its
policy in 2002 to end the procurement and distribution of free formula as
part of its support to PMTCT. The arguments against formula provision
are detailed in the UNICEF operational guidance note on infant feeding
and MTCT of HIV.
Rapid assessment of HIV and infant feeding counselling 2325
still remain critical, such as: cessation of breast-feeding
and what should be advised for the non-breast-fed child;
the type of infant feeding counselling that should be
offered now that many infants are receiving early HIV
testing by PCR at six weeks; and advice on maternal
nutrition, especially for HIV-positive lactating mothers.
Senior ofﬁcials expressed great concern about these
issues and requested urgent assistance in resolving them.
This uncertainty and confusion manifests itself at the
facility level through a great deal of variability in the
interpretation of guidelines (Box 2). Some donors and
NGO have started to implement algorithms and job-aids
to assist in counselling sessions. But the team did not ﬁnd
consistent use of such aids, nor was there any evidence of
their effectiveness (though the WHO is currently spon-
soring an evaluation in Zambia). The team consistently
found that nearly all health workers, including doctors
and nurses, massively overestimated the risk of HIV
transmission through breast-feeding or did not know
the risk. Most health workers providing infant feeding
counselling as part of the PMTCT programme report a
need for more training on infant feeding (described as
‘breast-feeding course’). Most said they do not receive
supervision, but feel supported by colleagues. The work-
load of many is high – up to twenty clients counselled on a
daily basis – and many described their working environ-
ment as stressful. The lack of capacity and supervision
leading to poor quality of infant feeding counselling was
especially worrying in the sites that offered free formula as
part of the package.
We did not ﬁnd any examples of detailed management
guidelines concerning the roles and responsibilities or
priority setting that would assist district and facility
managers in planning for integration of infant feeding
counselling into routine services. The consequences of
this absence were manifested in various ways, including
lack of HIV and infant feeding supervisory tools, hapha-
zard human resource planning in terms of who was sent
for training, complex monitoring and evaluation systems,
and duplication of training.
Despite these challenges, there were encouraging signs
that infant and young child feeding leaders are beginning to
reassert the role of optimal infant feeding for reducing
MTCT and improving child survival. In particular, the three
countries have adopted and adapted the Global Strategy for
Infant and Young Child Feeding
into policies and
guidelines that explicitly address HIV and infant feeding
issues within a broader nutrition framework.
In all three countries comprehensive PMTCT courses had
been developed based on the Generic Training Package
of WHO and the Centers for Disease Control and Pre-
Zambia offers a twelve-day course, in Kenya it has been
cut down to six days but in both countries only four hours
are spent on infant feeding counselling, with no time for
practical simulation. The content covered in this limited
about three days are given to infant feeding counselling,
including some time for practical simulations.
Analysis of the PMTCT curricula in all three countries
also revealed a strong bias against breast-feeding. The
curricula clearly outline and quantify the risk of MTCT
from breast-feeding – in the case of Kenya, over-
estimating this risk by a factor of three. However, the risk
of excess morbidity or mortality from replacement feed-
ing is not at all quantiﬁed. Instead it is mentioned as a
potential disadvantage, next to the possible advantages of
replacement feeding. Exclusive breast-feeding is given
the same amount of time and emphasis as other modes of
feeding such as modiﬁcation of cow’s milk, heat treat-
ment and replacement feeding. The curricula do not
cover common challenges in supporting exclusive breast-
feeding, such as responding to the mother’s perception
that her breast milk is not sufﬁcient.
Senior nutritionists reported that they had attempted to
participate in developing the PMTCT curriculum, but
clinicians had dominated the process and nutritionists
had been marginalized. In one country extensive lobbying
Confusing messages on HIV and breast-feeding
Interviews with medical ofﬁcers and senior nurses particularly in two out of the three countries revealed
widespread unease and uncertainty around the risks of breast-feeding, rapid weaning and the interpretation of
AFASS criteria (to determine whether breast-feeding is acceptable, feasible, affordable, sustainable and safe). Most
concerning was the resulting discordance in advice given to HIV-positive mothers:
We offer PCR infant testing at six weeks and then tell mothers of HIV-negative infants to stop breast-feeding.
(Kenyan medical ofﬁcer, Nairobi)
We only offer PCR testing two weeks after breast-feeding has stopped. (Kenyan medical ofﬁcer, Eldoret)
We tell all mothers to stop breast-feeding at six months. (Zambian medical ofﬁcer, Ndola)
We only stop mothers from breast-feeding when it is safe to do so. (Zambian medical ofﬁcer, Lusaka)
2326 M Chopra et al.
had at least succeeded in adding guidelines (as appen-
dices) to the training and participant manuals about how
to modify cow’s milk, heat breast milk and a number of
other components. Unfortunately when the manuals were
printed these appendices were left out, awaiting revisions
of the materials based on updated national infant and
young child feeding guidelines. Kenya is now revising its
PMTCT curriculum, and senior managers have promised
to involve the nutritionist more and to give more time to
A previous UNICEF outcome assessment of Kenya’s
course found no difference in health workers’ knowledge
of the risks of MTCT between those who had been trained
and those who had not – knowledge was uniformly poor
in both groups
. The team could ﬁnd no systematic
evaluation of the courses in Malawi or Zambia.
Nutritionists in all three countries are attempting to
address the gap in counselling capacity by implementing
additional HIV and infant feeding courses. Kenya is
establishing regional lactation management centres in
provincial hospitals and training nurses in the 40-hour
lactation course. But there is little funding from the Min-
istry of Health, and donor funding still remains limited.
Zambia was hoping to ﬁnalize a curriculum for a ﬁve-day
integrated course on Infant and Young Child Feeding by
the end of April 2007. No resources for conducting this
training had yet been secured. Malawi is also planning a
more intensive ﬁve-day HIV and Infant Feeding course.
Malawi, on the other hand, has made a concerted, suc-
cessful effort to incorporate HIV and infant feeding issues
into existing child health and nutrition courses such as
Integrated Management of Childhood Illness and Baby-
Friendly Hospital Initiative training and has included
them as part of the Essential Nutrition Actions framework.
In a majority of the site visits, it was the medical ofﬁcer,
either at facility or district level, who seemed to have the
greatest inﬂuence on the tone and focus of infant feeding
counselling. Therefore, the ongoing integrated course on
Infant and Young Child Feeding, including HIV and Infant
Feeding counselling, plus periodic updates on HIV and
Infant Feeding, need to especially target medical practi-
tioners in all three countries.
Monitoring and evaluation
A focus on outputs, such as numbers of clients tested and
numbers on treatment, has been an important feature of
the successful scaling up of PMTCT across the region.
This approach is now being used to scale up the number
of infants on treatment. But none of the three countries
has clear output or outcome indicators related to infant
feeding counselling, which is a reﬂection of the global
reporting format for the PMTCT report card. To this end,
the Zambian National PMTCT and Pediatric Report Card
(January–December 2005) has no mention of infant
feeding. However, Kenya has taken the initiative to
strengthen key indicators on infant feeding in national
monitoring tools for HIV service provision at PMTCT
The number of women receiving infant feeding coun-
selling and the proportion of women selecting breast-
feeding were two common indicators collected. However,
senior managers and donors do not ﬁnd these indicators
very informative. First, they are poorly collected, and
second, they give no sense of the quality and hence
effectiveness of this component. Important outcome
indicators such as proportion of mothers exclusively
breast-feeding were not being routinely collected because
they are very difﬁcult to perform and likely to give poor-
quality data. Therefore, efforts are needed to collect such
information through periodic surveys.
In all three countries, infant health cards are being
revised to explicitly allow identiﬁcation of maternal HIV
status and to record infant feeding practices. Sharing of best
practices in this regard would be beneﬁcial. Finally, the
team consistently found that performance assessment tools
at the district and primary care level made minimal refer-
ence to infant feeding, thus requiring further attention.
We found a number of shortcomings that explain the pre-
sent weakness in infant feeding counselling. However,
signs are appearing that countries are developing and
responding positively to the challenges. For example, all
three countries have started to revise their infant and young
child feeding policies following the lead of and with sup-
port from UN agencies. This has led to the establishment of
strong working groups that have incorporated HIV and
infant feeding into the broader infant feeding strategy.
There are some limitations to this study. The purposive
sampling of countries that recognized the need for such
a review limits the generalizability of these ﬁndings. Limited
time and resources did not allow for systematic random
sampling of sites across the whole country and this may
have introduced a selection bias. However, there was con-
sistency across national sites in the ﬁndings reported here.
In order to sustain this momentum it will be necessary
to continue the advocacy with the HIV community of the
importance in investing in infant feeding within the
context of HIV programmes. Another key message needs
to be the wider recognition and prioritization of child
survival – not just minimization of HIV transmission – and
hence the need for integrating MTCT prevention. This
presents opportunities to reconsider the roles, responsi-
bilities and capacities of health workers and counsellors,
especially with respect to strengthening infant feeding
counselling and redesigning maternal and child health
cards. Finally, improving linkages with and strengthening
community-based support systems for child health will
beneﬁt not just HIV-exposed infants but also the greater
majority of non-exposed children.
Rapid assessment of HIV and infant feeding counselling 2327
This study was funded by UNICEF, Eastern and Southern
Africa Regional Ofﬁce. We have no conﬂicts of interest
to report. M.C., T.D. and M.T. designed the study and
developed the data collection tools. T.D. and M.T. trained
and supervised the data collection. All authors contributed
to the data analysis and writing of the manuscript.
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