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Review Provides Evidence Base for HIV and Infant Feeding Guidelines
by Cynthia F. Young, Senior Writer

HIV & Infant Feeding Compilation Cover
Photo by Peter Iliff, Zimbabwe

Ms. Peggy Koniz-Booher, URC Senior Technical Advisor for Nutrition and Behavior Change Communication, presented the findings of the Quality Assurance Project’s landmark study, “Compilation of Programmatic Experience Related to HIV and Infant Feeding” at a plenary session of the Congress of the Commonwealth Association of Paediatric Gastroenterology and Nutrition. The Sixth Annual Congress, attended by 125 health professionals from 26 countries, was held in Drackensberg, South Africa, May 19-21, 2003.

The HIV and infant feeding study represents the first systematic effort to collect and analyze a wide range of program experiences and research on infant feeding and the prevention of mother-to-child-transmission of HIV (PMTCT). Produced under a Memorandum of Understanding with UNICEF and in close collaboration with the World Health Organization (WHO), the study was commissioned to assist the international health community in updating and adapting guidelines on HIV and infant feeding and to inform national policy decisions related to the implementation of the new recommendations.

More than 100 documents from 17 countries were initially reviewed, including field research, program evaluations, rapid assessments, and conference abstracts. Of these, 46 reports were selected and summarized for their valuable insights and hard-to-find information on a variety of complex issues surrounding infant feeding in the era of HIV/AIDS.

The analysis drew on questions generated during a recent international colloquium on HIV and infant feeding, with additional input from a number of key informants. Results were clustered around seven broad issues: general universal findings, exclusive breastfeeding, exclusive replacement feeding, informed choice, male involvement, stigma and abuse faced by mothers perceived as having HIV, and formula use.

The research team examined the role of public education and behavior change communication programs, perceptions of health workers and mothers about infant feeding and their knowledge about transmission of HIV, as well as the scaling up of PMTCT programs.  The study also examined issues of informed choice, training of healthcare workers, the impact of counseling on decision making, the role of free or subsidized formula, and the accessibility of replacement feeding.

Findings underscored the multiple challenges faced by PMTCT programs related to training, counseling, logistics, community support, and behavior change, and highlighted the continuing confusion of healthcare workers and communities alike about the best infant feeding options for mothers with HIV.

Programs promoting alternative choice by HIV+ women have often not adequately addressed issues related to the acceptability, feasibility, affordability, sustainability, and safety of exclusive replacement feeding or early cessation of exclusive breastfeeding. Such programs have seldom addressed questions such as:

  • How does the mother feel about her options?
  • How will the mother explain to her family why she is not breastfeeding or abruptly weaning?
  • How will she afford to purchase powdered milk if program supplies are inadequate, irregular, or interrupted?
  • How will she safely prepare and store replacement milks?

Exclusive breastfeeding during the “first months of life” had been defined as anywhere from 3 to 6 months, causing confusion among counselors and mothers alike. Few PMTCT programs adequately assess the mother’s situation and ability to achieve either exclusive breastfeeding or exclusive replacement feeding. Recommendations related to early and abrupt cessation of breastfeeding and the transition to exclusive replacement feeding have been difficult for mothers to achieve.  Also, the provision of free formula to mothers by PMTCT pilot projects or research programs appears to have the negative effect of increasing the incidence of mixed feeding. Many projects report that mothers often do not return for new supplies.

The compilation of evidence study was coordinated by Ms. Koniz-Booher. Dr. Bart Burkhalter, Director of Operations Research for the Quality Assurance Project, and consultants Drs. Peter Iliff and Juana Willumsen assisted with summarizing source documents and preparing the overall analysis. Technical input was provided by Drs. Miriam Labbock and Arjan de Wagt of UNICEF and Dr. Peggy Henderson of WHO. The final QAP compilation of evidence report and a CD-ROM containing the source documents will be available this autumn, along with the updated international guidelines on HIV and infant feeding.

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.