HIV and Infant Feeding:Summary of Findings from the Good Start Study.

June 2007p o l I c y b r I e F

SOUTHAFRICANMEDICALRESEARCHCOUNCIL

methods and only one third intended to discuss their feeding option with a family member or friend.

Infant feeding counselling, as currently implemented, does not prepare women for the challenges of adhering to their infant feeding choice.2

Counsellors have substantial influence over women’s decisions regarding their choice of infant feeding, and this influence has increased with the

Recommendations foR impRoving child suRvival in south afRica and Reducing postnatal

tRansmission of hivReview new evidence on exclusive breastfeeding and HIV transmission and the dangers associated with not breastfeeding or early cessation of breastfeeding with a view to updating the South African approach to infant feeding for HIV-positive women.Promote exclusive breastfeeding for six months as the optimal method of infant nutrition in the general population, and amongst HIV-positive women where avoiding breastfeeding is not safeStrengthen implementation of The Baby Friendly Hospital Initiative and Integrated Management of Childhood Illness (IMCI). Implementation of the BFHI, which supports exclusive breastfeeding, should be accelerated with targets for BFHI accreditation in all levels of hospitals in each province. This initiative also needs to accommodate the support of formula feeding amongst HIV-positive women who choose this option.Urgently ratify national policies to support safe infant feeding practices in South Africa including the Infant and Young Child Feeding Policy and the International Code for the Marketing of Breastmilk Substitutes.Rapidly scale up training on HIV and infant feeding counselling in maternal and child health services and provide the necessary health system infra-structure to assure comprehensive, high quality PMTCT counseling and programmes.Implement and strengthen community-based post-natal support for infant feeding, including nutritional support for HIV-infected breastfeeding mothers.Undertake periodic regular assessments of the quality of infant feeding counseling at clinics and hospitals.Prioritise HIV clinical staging or CD4 count testing and ART (if needed) for all HIV-positive pregnant or postpartum women.

IntroductionThe Good Start Study was a prospective cohort study of 665 HIV positive women who attended routine PMTCT services. The women and infants were followed for 36 weeks after birth with data collection during home visits every 2 weeks until 12 weeks and then monthly until 9 months. At each scheduled visit infant feeding practices were recorded through 24 hour and previous 3 day recall.The study was undertaken in three sites; Paarl (Western Cape), Umzimkulu (Eastern Cape) and Umlazi (KwaZulu-Natal). Sites were selected to highlight differences in socio-economic regions, health infra-structure, rural-urban locations, and HIV prevalence.

Key FindingsThe quality of infant feeding counselling is poor with inadequate information provided for women to make appropriate choices.1

Several gaps were found in the content of PMTCT and infant feeding counseling during pregnancy. Counsellors lacked confidence to take mothers through a logical process of assessing home circumstances, presenting risks and helping them to make a suitable infant feeding choice. Mothers knowledge about infant feeding remained poor after the counseling session. Half were planning to practice sub-optimal feeding

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How is research knowledge translated into policies? | JUNe 2007How is research knowledge translated into policies? | JUNe 2007

uncertainty associated with HIV transmission. However, family members have a strong influence on actual feeding practices in the home. Thus, poor quality counseling, low levels of disclosure, lack of involving key family members in supporting feeding decisions, low levels of self efficacy and limited, if any, postpartum support from the health services lead women to doubt their ability to carry out infant feeding recommendations, thus reducing adherence to their chosen method.

Women face new challenges in the postpartum period and ongoing community-based support and resources are important to sustain infant feeding practices.3

Women who maintained EBF had strong beliefs in the benefits of breastfeeding and a supportive home environment enabling them to stay with their infants. Amongst women who maintained exclusive formula feeding disclosure to close family or partner, having resources such as electricity, a kettle and a flask for night feeding and having the financial resources to purchase formula milk when supplies run out at the clinics were important.

Adherence to national feeding recommendations is low, regardless of infant feeding choice (exclusive breastfeeding or exclusive formula feeding).4

At 3 weeks 309 HIV-positive women (53%) were breastfeeding. Of the breastfeeding women 130 (42%) practiced exclusive breastfeeding, whilst 179 (58%) practiced mixed breastfeeding – these women commonly introduced over-the-counter / traditional medicines (61%), glucose (25%), water (22%), formula (21%) and cereal (6%). At 3 weeks 271 (47%) women reportedly avoided all breastfeeding. Of these women 90 (33.5%) exclusively formula fed whilst 181 (66.42%) gave their infants formula milk and other foods and fluids, most commonly over-the-counter/traditional medicines (60%), water (24%) glucose (20%) and cereal (9%). After 3 weeks the proportion of women practicing exclusive formula feeding decreased.

Poor infant feeding practices, underlying health systems problems and high maternal viral load contribute to lower overall infant HIV-free survival.5

Early transmission rates were similar across the three sites (Figure 1) However, by 36 weeks there was a greater than two fold difference in HIV free survival (Table 1). Maternal viral load was the single most important factor associated with HIV transmission or death [hazard ratio (HR), 1.54; 95% CI, 1.21–1.95]. Adjusting for health system variables (fewer than four antenatal visits and no antenatal syphilis test) explained the difference between Rietvlei and Paarl (adjusted HR, 1.81; 95% CI, 0.93–3.50). Exposure to breastmilk feeding (which was mainly mixed feeding) explained the difference between Umlazi and Paarl (adjusted HR, 1.41; 95% CI, 0.81–2.48).

Inappropriate infant feeding choices have important consequences for infant HIV-free survival.6

We assessed three criteria that could be used as a measure of appropriate formula choice (piped water in the house or yard; electricity, gas or paraffin as a source of cooking fuel; and disclosure of HIV status). Infants of women who had all three criteria were found to have a higher HIV–free survival compared to women with only one criteria (piped water) (HR 0.26, 95% CI 0.09-0.75 vs. 0.68, 95% CI 0.32-1.43). Amongst women who intended to formula feed, 195/289 (67.4%) women did not meet the 3 criteria listed above. Amongst women who intended to breastfeed 95/311 (30.5%) women met the criteria for appropriate formula feeding. Infants of women who made an inappropriate choice to formula feed (did not meet 3 the criteria) had the highest risk of HIV transmission or death (aHR 3.63; 95% CI 1.48-8.89).

Summary of Key findingsThe quality of infant feeding counselling is poor with inadequate information provided for women to make appropriate choices1

Infant feeding counselling, as currently implemented, does not prepare women for the challenges of adhering to their infant feeding choice2.Women face new challenges in the postpartum period and ongoing community-based support and resources are important to sustain infant feeding practices3.Adherence to national feeding recommendations is low, regardless of infant feeding choice (exclusive breastfeeding or exclusive formula feeding)4

Poor infant feeding practices, underlying health systems problems and high maternal viral load contribute to lower overall infant HIV-free survival.5

Inappropriate infant feeding choices have important implications for infant HIV-free survival.6

FundingSouth African National Department of Health, Centers for Disease Control & Prevention South Africa, UNICEF South Africa, SIDA/NRF

references:Chopra M, Doherty T, Jackson D, Ashworth A. Preventing HIV transmission to children: Quality of counselling of mothers in South Africa. Acta Paediatrica 2005;94:357-363.Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me”. Bull World Health Organ 2006;84(2):90-96.Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A Longitudinal Qualitative Study of Infant-Feeding Decision Making and Practices among HIV-Positive Women in South Africa. J Nutr 2006;136(9):2421-6.Goga A, Jackson D, Chopra M, Doherty T, Willumsen J, Levin J, Colvin M,Moodley P. Infant Feeding Patterns In The Context HIV: Results From PMTCT Sites In South Africa. International AIDS Conference. Toronto. August 2006.Jackson DJ, Chopra M, Doherty TM, et al. Operational effectiveness and 36 week HIV-free survival in the South African programme to prevent mother-to-child transmission of HIV-1. AIDS 2007;21(4):509-516.Doherty T, Chopra M, Jackson D, Goga AE, Colvin M, Persson LA. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV positive women: results from a prospective cohort study in South Africa. AIDS 2007;In Press.Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose Nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda:

HIVNET 012 randomised trial. Lancet 1999; 354(9181):795-802.

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Site HIV-Positive and/or Infant Deatha %

95% Confidence Interval

Paarl 16.0 10.8 to 23.3Umlazi 26.6 21.8 to 32.4Rietvlei 35.7 28.9 to 43.4p-value for differences across sitesb

chi-square=16.42 p=0.0003 (2 d.f.)

Table 1: Infant HIV+ and/or Death by 36 weeks of age by study site amongst infants born to HIV-positive Mothers5

Early transmission (3-4 weeks)

141210

86420

0.6

11.9

13.7

11.9

Paarl Umlazi Rietvlei HIVNET012(6weeks)

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