Doherty, T. et al. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS 21, 1791-1797

Department of Women's and Children's Health, Uppsala University, Uppsala, Uppsala, Sweden
AIDS (Impact Factor: 5.55). 09/2007; 21(13):1791-7. DOI: 10.1097/QAD.0b013e32827b1462
Source: PubMed


The World Health Organization (WHO) and UNICEF recommend that HIV-positive women should avoid all breastfeeding only if replacement feeding is acceptable, feasible, affordable, sustainable and safe. Little is known about the effectiveness of the implementation of these guidelines in developing country settings.
To identify criteria to guide appropriate infant-feeding choices and to assess the effect of inappropriate choices on infant HIV-free survival.
Prospective cohort study of 635 HIV-positive mother-infant pairs across three sites in South Africa to assess mother to child transmission of HIV. Semistructured questionnaires were used during home visits between the antenatal period and 36 weeks after delivery to collect data concerning appropriateness of infant feeding choices based on the WHO/UNICEF recommendations.
Three criteria were found to be associated with improved infant HIV-free survival amongst women choosing to formula feed: piped water; electricity, gas or paraffin for fuel; and disclosing HIV status. Using these criteria as a measure of appropriateness of choice: 95 of 311 women who met the criteria (30.5%) chose to breastfeed and 195 of 289 women who did not meet the criteria (67.4%) chose to formula feed. Infants of women who chose to formula feed without fulfilling these three criteria had the highest risk of HIV transmission/death (hazard ratio, 3.63; 95% confidence interval, 1.48-8.89).
Within operational settings, the WHO/UNICEF guidelines were not being implemented effectively, leading to inappropriate infant-feeding choices and consequent lower infant HIV-free survival. Counselling of mothers should include an assessment of individual and environmental criteria to support appropriate infant-feeding choices.

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    • "From 2002 to 2011, the infant feeding options for South African HIV-infected mothers were either exclusive formula feeding for the first 6 months of life where AFASS criteria were met, or EBF. However, the interpretation of AFASS has been problematic at provider–client level (Doherty et al. 2007; Leshabari et al. 2007; Buskens and Jaffe 2008), and consequently many women ended up mixed feeding. Coutsoudis et al. (2002) argue that mixed feeding, rather than compliance with formula feeding, was the result of easy access to formula milk. "
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    ABSTRACT: BACKGROUND: In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme. OBJECTIVE: To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa. METHODS: An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis. RESULTS: Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change. CONCLUSION: There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.
    Full-text · Article · Nov 2012 · Health Policy and Planning
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    • "We also show that the effect of NBF or MBF on infant HIV-free survival was site-dependent, and that avoiding breastfeeding was beneficial in Paarl, but deleterious in Rietvlei and Umlazi. Based on our previous work [29] we know that NBF was appropriate in Paarl, but inappropriate (not guided by IMR or infrastructure) in Umlazi and Rietvlei. Our data on feeding practice and hazard of HIV or death confirms that in Paarl breastfeeding is inappropriate, increasing the hazard of HIV or death. "
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    ABSTRACT: We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival. Infant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival. Six hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%). Although feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.
    Full-text · Article · Apr 2012 · International Breastfeeding Journal
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    • "In short, my study demonstrates how some HIV-positive women are actively negotiating and refashioning the discourse of global health agendas and of international rights movements in local idioms to serve their own interests. Other studies have tended to use ethnographic evidence to make a case for specific policy changes, such as more forceful advocacy in favor of breastfeeding in " resource poor " countries, particularly in cultural contexts where breastfeeding is the norm and is associated with good mothering (Coutsoudis et al. 2008); or recommendations to use specific indicators to direct counseling (Doherty et al. 2007); or to include grandmothers or spouses in decision making to have more adherence to a feeding method (Kerr et al 2008; Traoré et al. 2009). "
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    ABSTRACT: This article describes how local responses to global health initiatives on infant feeding for HIV-positive mothers reflect and transform sociocultural values in Tamil Nadu, India. Drawing from ethnographic research conducted from 2002 to 2008, the article compares guidelines for counseling HIV-positive mothers established by UNICEF and WHO with decision-making processes and perceptions of HIV-positive mothers. In addition to the financial considerations, three factors are identified as impinging on this decision: (1) a strong sociocultural value in favor of breastfeeding linked to historical traditions and contemporary state and international development discourses, (2) constructions of class identity, (3) the influence of a rights-based discourse in HIV/AIDS advocacy. This wide range of factors points to the difficulty of implementing the international protocols. This is the first study of its kind to closely examine the complex determinants in HIV-positive women's decisions and evaluations of infant feeding methods in India.
    Full-text · Article · Dec 2011 · Medical Anthropology Quarterly
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