Clarifying the Balance of Risks
An estimated 700,000 children are infected with HIV each year. About 42 percent of this transmission is through breastfeeding. Appropriate feeding strategies are an important factor in prevention of mother-to-child transmission of HIV (PMTCT). Several simulation studies have calculated mortality risks for infants of HIV mothers under different feeding scenarios. AED carried out an investigation to calculate survival for five different feeding scenarios at seven age intervals in resource-poor settings.
This important analysis, published in the American Journal of Public Health,[1] demonstrates that the risk of death from replacement feeding exceeds the risk of mother-to-child transmission from breastfeeding throughout the first four months of life. After six months, replacement feeding is the safest alternative.[2]
The simulation also accounts for certain strategies that can make breastfeeding “safer”—especially exclusive breastfeeding and prevention and treatment of breast problems—and demonstrates how much the risk of transmission can be reduced in different months.
The month-by-month analysis provides policy makers with important evidence for formulating national policies and providing practical guidelines for counseling mothers. Turning this information into effective counseling materials and training programs, however, is a challenge.
Many early lessons emerged from a ground-breaking program in Zambia, centered in Ndola District. Up to one third of women attending antenatal clinics there are HIV-positive. As in many African communities, women did not have access to anti-retrovirals when the program began. Activities were launched in 1997 by the USAID-funded LINKAGES project managed by AED, and the Ndola District Health Management Team and other partners. The collaboration demonstrated that it is feasible to integrate infant feeding and HIV counseling and testing with maternal and child health and community services.
AED designed distinct curricula and training-of-trainer workshops for program managers, health care providers, community workers, and community outreach groups (such as members of village health committees). The intervention provided mothers with infant feeding counseling at multiple points: as part of the voluntary counseling and testing (VCT) if they chose to be tested, after delivery, at growth monitoring visits, and at outreach posts.
An external evaluation of the project after the first two years showed that infant feeding practices improved significantly among both mothers who knew their HIV status as well as those who did not. In addition, the percent of women who believed nothing could be done to prevent mother-to-child transmission dropped from 31.8 percent to 3.9 percent
The Zambian Ministry of Health, with assistance from the LINKAGES Project, subsequently expanded the Ndola model to 66 sites in nine districts. After four years, research showed that the number of children under six months of age who were given "mixed feeding" (a harmful practice for infants of any status) had fallen from 44 to 26 percent. (See figure 1)
Replacement feeding was barely practiced at the baseline, and no infants at all were replacement fed at the end of the project, perhaps due to the dire socio-economic conditions in the program areas
With the provision of PMTCT services, the project increased counseling and testing of pregnant women during the course of four years, and almost all women by the end of the project got their test results. The percent of partners who also were tested more than doubled, and almost all of them shared their results with their partner. (See figure 2)
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Between 2004 and 2005 the LINKAGES Project also mounted an intensive media campaign throughout the country. The campaign, called Act Now! included print materials for women and health workers as well as seven radio and seven television spots aimed at the general public.
Messages encouraged men to be tested for HIV for the sake of their partners and unborn children, and urged them to support their partners in being tested and in making decisions about infant feeding. After one year, exposure to the seven spots ranged from 41 to 63 percent of the target population (with variation according to the spot). In areas that only received the media portion of the intervention, "viewers" were also significantly more likely to practice desired behaviors than "non-viewers." Among viewers, 30 percent had been tested for HIV, in contrast to 19 percent of non-viewers. And 22 percent of viewers had used a condom at last sexual encounter, as opposed to only 6 percent of non-viewers.
In Tanzania, the Ministry of Health and UNICEF initiated a pilot PMTCT program in 2000 in four national hospitals to integrate PMTCT into routine Reproductive and Child Health Services throughout the country. PMTCT services were then scaled up to other districts with the support of various partners.
In 2004 USAID funded the LINKAGES Project to provide technical assistance to the MOH through The Tanzania Food and Nutrition Centre, the Reproductive and Child Health System (RCHS), Council Health Management Teams, and other partners. The goal was to assist in integrating infant and young child feeding in the context of HIV/AIDS into RCHS and community health services at target sites in Arumeru District in Arusha Region and Kilombero District in Morogoro Region.
AED focused on capacity building of health providers and community health workers to use behavior change communication methodologies and advocacy meetings with health providers, policy makers, district departmental heads, village leaders, and village committee members to enlist support for interventions and create a sense of ownership.
A rapid assessment in Arumeru District in April–May 2006 showed the following results compared with the 2005 baseline:
- Mothers who reported receiving information, advice, or counseling on infant feeding: increased from 29 to 35 percent
- Mothers who cited community health workers as sources of infant feeding information, advice, or counseling: increased from 9 to 58 percent
- Mothers who reported initiating breastfeeding within 1 hour of birth: increased from 85 to 91 percent
- Mothers who reported breastfeeding their infants exclusively (measured by 24-hour recall): increased from 29 to 78 percent
- Mothers who reported being tested and counseled for HIV: increased from 46 to 82 percent
- Mothers who reported that their partners had been tested for HIV: increased from 18 to 28 percent
- Mothers who cited at least one of primary mode of vertical transmission of HIV: increased from 75 to 88 percent
The results demonstrate the effectiveness of integrating counseling of community women and their families on maternal nutrition and IYCN in the context of HIV/AIDS into the national PMTCT program to complement clinical training of health providers.
Sources:
Contributing to Long-term Improvements in Health in a World of Short-term Commitments and Shrinking Funds: Seven Innovations. AED. 2006.
LINKAGES Project and Tanzania Food and Nutrition Centre. Report of Follow-up Survey in Arumeru District, Tanzania. April 29–May 6, 2006
[1] Ross, JA, Labbok MH. (2004) Modeling the effects of different infant feeding strategies on infant survival and mother-to-child transmission of HIV.
American Journal of Public Health 94/7: 1174-1180. The study was carried out under AED’s LINKAGES project, funded by USAID.
Click here for the full spreadsheet.
[2] For any
individual mother, when replacement feeding is acceptable, feasible, affordable, sustainable, and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life.
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