HIV and Infant Feeding: Framework for Priority Action, Guidelines and Related Tools

2004

World Health Organization

Timing and risks of HIV transmission in absence of interventions

During pregnancy 5-10% During labour and delivery 10-15%During breastfeeding 5-20%Overall without breastfeeding 15-25%Overall with breastfeeding until 6 months 25-35%Overall with breastfeeding until 18 to 24 months 30-45%

Adapted from De Cock et al., JAMA 2000

Relative risk of infectious disease mortality among non-breastfed infants

<2 2 to 3 4 to 5 6 to 8 9 to 11 12 to 23

age group (months)

4.1

2.6

1.81.4 1.6

5.8

WHO, Lancet 2000

Rela

tive

risk

UN recommendations

HIV- or status unknownExclusive breastfeeding (EBF) for 6 months and continued breastfeeding for 2 years or beyond

HIV+When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first months of lifeCounselling should include information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option

Global Strategy for Infant and Young Child Feeding (2002)

Sets context for all actions, including in exceptionally difficult circumstances“The HIV pandemic and the risk of mother-to-child transmission of HIV through breastfeeding pose unique challenges to the promotion of breastfeeding, even among unaffected families. “

The IYCF strategy and HIV

Mother's milk is unsuitable only under exceptional circumstancesOnly health workers should demonstrate preparation of breast-milk substitutes, and only to mothers who need to use itInfants who are not breastfed constitute a risk groupAll HIV-infected mothers should receive counsellingAdequate replacement feeding is needed for infants born to HIV-positive mothers who choose not to breastfeed

HIV and Infant Feeding: Framework for Priority Action (2003)

Purpose:To recommend key priority actions, related to infant and young child feeding, that cover the special circumstances associated with HIV/AIDS. The aim is to create and sustain an environment that encourages appropriate feeding practices for all infants, while scaling-up interventions to reduce HIV transmission.

(WHO/UNICEF/UNFPA/UNAIDS/World Bank/UNHCR/WFP/FAO/IAEA)

HIV and Infant Feeding Framework:Priority action areas

Comprehensive policy

Promote research

Provide support to HIV+ women

Code of Marketing

Promote IYCF in context of HIV, including BFHI

HIV and Infant Feeding Framework:Priority Area 1

Develop a comprehensive national IYCF policy, including HIV and infant feeding– Draft or revise existing policy to reflect current knowledge

on appropriate feeding practices in general and in relation to HIV

– Build consensus among stake-holders – Promote consistency with other policies– Develop means for implementation

HIV and Infant Feeding Framework:Priority Area 2

Implement the Code of Marketing (and subsequent relevant WHA resolutions)– Implement the Code at the national level– Monitor compliance– If the country has decided to provide replacement feeding,

establish appropriate supplies/logistics systems and mechanisms in accordance with the Code and subsequent relevant WHA resolutions

HIV and Infant Feeding Framework:Priority Area 3

Protect, promote and support appropriate IYCF practices in the context of HIV:– increase priority given to IYCF– develop and implement guidelines on IYCF, including HIV– build capacity for promoting primary prevention of HIV– revitalize and scale-up the BFHI

HIV and Infant Feeding Framework:Priority Area 4

Provide support to HIV+ women in their chosen infant feeding method– Expand access and demand for improved ANC and VCT – Integrate counselling into MCH services– Support orientation of managers and capacity development

of counsellors and health workers on breastfeeding counselling and HIV and infant feeding

– Provide follow-up of mothers and infants, including nutritional support to mothers

– Strengthen follow-up and supervision of health workers– Develop and implement comprehensive communications

strategy

HIV and Infant Feeding Framework:Priority Area 5

Promote research on HIV and infant feeding, monitoring and evaluation– Carry out formative research on local feeding options– Promote assessment and evaluation of programmes related

to HIV and Infant Feeding– Disseminate results and other information – Revise national guidelines in response to new knowledge

HIV and Infant Feeding Framework:What’s New

Global Strategy recognizes that HIV-positive mothers need special supportFramework recognizes that support to HIV-positive mothers requires an environment in which breastfeeding is promoted, supported and protectedStrategy and Framework both build on previous and ongoing efforts such as the Code, BFHI and other child health and reproductive health initiativesPrevention of HIV transmission to infants and young children should include activities outlined in Framework

Revised HIV and Infant Feeding tools:HIV transmission through breastfeeding: A review of

available evidence (1)

Audience: policy-makers, planners, researchersPurpose: provide technical background and rationale for guidance

(WHO/UNICEF/UNAIDS/UNFPA, 2004)

Revised HIV and Infant Feeding tools:HIV transmission through breastfeeding: A review of available

evidence (2)

Presents available scientific evidence on transmission of HIV through breastfeeding:– describes benefits of breastfeeding– summarizes evidence on relative risk of MTCT during

pregnancy, delivery, and breastfeeding– focuses on HIV transmission through breastfeeding: rates,

mechanisms, timing, risk factors and approaches for prevention

Revised HIV and Infant Feeding tools:Guidelines for decision-makers

Audience: policy-makers, planners and senior administratorsPurpose: provide guidance on key issues and highlight areas of special concern

(WHO/UNICEF/UNAIDS/UNFPA, 2003)

Revised HIV and Infant Feeding tools:A guide for health-care managers and supervisors

Audience: “Mid-level” managersPurpose: to help plan, implement and strengthen services

(WHO/UNICEF/UNAIDS/UNFPA, 2003)

Major revisions: Guidelines and Guide

Incorporate recommendations from 2000 Technical ConsultationWithin context of Global Strategy on IYCFProgrammatic experienceOrganization around HIV and IF FrameworkMore guidance for countries considering providing free or subsidized formula

Guidelines and Guide: Content - Feeding options for first six months (1)

Replacement feeding:– Commercial infant formula– Home-modified animal milk

Breastfeeding:– Exclusive with early cessation

Breast-milk feeding options:– Expressed and heat-treated BM– Wet-nursing– BM banks

Guidelines and Guide: Content - Feeding options for first six months (2)

DefinitionsFor each option:– Explanation of risks– Programme experience– Considerations for decision-makers and managers

Breastfeeding:– Early cessation– Transition– Safety in terms of HIV

Improved guidance based on programme experiences: counselling on infant feeding options (1)

Formative research to determine local optionsTypes of counsellors: health workers, lay counsellorsTraining of counsellors: all health workers, BFC and HIVCIntegration of counselling into MCH: for all mothersTiming of counselling: at key points

Improved guidance based on programme experiences: counselling on infant feeding options (2)

Content and process of counselling:– benefits, risk and challenges of local infant feeding options– whether replacement feeding is AFASS– implications of feeding options for mother and child– guidance on most suitable option

Follow-up and support– independent of mother's choice

Decision-makers: ART and infant feeding

No evidence yet available on impact of ARV use during breastfeeding on health of mother or infantWhatever ARVs used, infant feeding recommendations in guidelines still applyQuestions remaining:– Can ARVs reduce postnatal transmission– Drugs to infant, mother or both– Health consequences for mother and baby

Decision-makers: Example of practical changes (1)

AFASS defined, e.g. Acceptable:– The mother perceives no barrier to replacement feeding.

Barriers may have cultural or social reasons, or be due to fear of stigma or discrimination. This concept includes:

• There is no social or cultural pressure attached to using replacement feeding.

• The mother is supported by family and community, or the mother will be able to cope with pressure from family and friends to breastfeed and she will be able to deal with possible stigma if people see her with replacement food.

Decision-makers: Example of practical changes (2)

Key steps and issues for decision-makers:Has a situation assessment and analysis on infant and young child feeding in the context of HIV been completed on which to base policy, strategy and guidelines?► No Carry out assessment and analysis (section 3.2

and Annex 1)► Yes Update the assessment as necessary over the

course of the programmeUse information as a baseline for national policy (section 3.1) and for monitoring and evaluation (section 7)

Decision-makers:Example of practical changes (3)

Guidance on provision of formula (1):Free or subsidized infant formula could be provided when:– Uninterrupted supply guaranteed– Code respected– Procured through normal channels

Formula up to 6 months, and formula or milk up to 1 year neededConsider provision of equal support for women choosing other options

Decision-makers:Example of practical changes (4)

Guidance on provision of formula (2):Pre-requisites to be in place before distribution:– Trained counsellors– Guidelines for distribution– Practical demonstrations– Monitoring of health outcomes

What are the options: Using formative research to adapt global recommendations on HIV and infant feeding to the local context (1)

For programme managers, researchers and policy-makersProvides guidance on how to conduct local assessments of feeding options based on AFASS

(WHO/UNICEF, 2004)

What are the options: Using formative research to adapt global recommendations on HIV and infant feeding to the local context (2)

Assessment useful for developing:– national policies and guidelines for health workers– content for training of counsellors– behaviour change communications strategies

Describes 12-step process for formative researchRecommends research methodsGives suggestions for:– analysing findings– disseminating results

Breastfeeding and replacement feeding practices in the context of mother-to-child transmission of HIV: an assessment tool for research

For researchersProvides guidance on establishing association between infant feeding patterns and HIV transmission

Counselling and infant feeding practices of mothers in programmes to prevent mother-to-child transmission of HIV

For researchersEvaluates counselling strategies

(WHO, 2001)

(UNICEF, 2002)

HIV and Infant Feeding: Counselling Course

For health workers/counsellorsRequires background in breastfeeding counselling, or combined courseProvides skills and knowledge needed to counsel and support HIV-positive mothers in feeding decisionsExtensive practice in counselling and in preparing replacement feeds

(WHO, 2000)

HIV and Infant Feeding: Counselling Tools

For health workers/counsellors trained in HIV and infant feedingTools consist of:– Counselling flow chart– Counselling cards to use with mothers– Take-home flyers– Reference guide– Orientation guide

Need for local adaptation

(WHO, UNICEF, AED, in press)

Other tools (1)

Guidelines for follow-up after training in breastfeeding counselling and HIV and infant feeding counselling courses (WHO and UNICEF, 2003)– For supervisors– For BF counselling and HIV and IF counselling

BFHI Health Administrators Course (under revision)– 2 versions – one for countries where HIV is significant

problem

Other tools (2)

Guidance on complementary feeding of the non-breastfed child (in process)– Review published as journal article– Guiding Principles for Feeding the Non-breastfed Child– March 2004 meeting report

Steps to promote use

Dissemination in regional workshops, conferences, meetings in conjunction with Global Strategy dissemination and planningBuild national capacityObtain feedback on utilization