The latest guidelines on infant-feeding options for HIV-positive mothers in Africa have not been disseminated in many countries, leaving women dangerously confused about the best nutritional path to protect their children from contracting the virus, a new report shows.
The UN World Health Organization's (WHO) 2010 guidelines recommend exclusive breastfeeding with an antiretroviral (ARV) treatment intervention for the first six months of a child's life to reduce transmission, and continued breastfeeding - with complementary feeding - until the child is at least a year old. Alternatively - where it is acceptable, feasible, affordable, sustainable and safe - WHO recommends complete avoidance of all breastfeeding.
For HIV-positive mothers in most sub-Saharan African nations, exclusive breastfeeding is the most practical option. According to a large African study, Kesho Bora, giving HIV-positive mothers a combination of three ARVs during pregnancy, delivery and breastfeeding cuts HIV infections in infants by 43 percent by the age of 12 months and reduces transmissions during breastfeeding by 54 percent compared with WHO's 2006 recommendations, where ARV drug regimens ended at delivery.
"The six months of exclusive breastfeeding is what is crucial for mothers to understand - that not doing it is what raises the child's HIV risk; but we are finding that while many countries have officially adopted the WHO guidelines, they have not trickled down, and health centres, policy-makers and communities are still unclear on what advice to give mothers," said Aditi Sharma, of the International Treatment Preparedness Coalition (ITPC), and coordinator of a report, The Long Walk: Ensuring comprehensive care for women and families to end vertical transmission.
Based on new research by community health workers from Cameroon, Cote d'Ivoire, Ethiopia and Nigeria, the report - launched at the 16th International Conference on AIDS and STIs in Africa (ICASA) in Addis Ababa, Ethiopia - found that prevention of mother-to-child transmission programmes were focused too narrowly on the provision of ARVs to HIV-positive pregnant women, rather than more comprehensive approaches that involved family planning, maternal healthcare and exclusive breastfeeding.
Confusion
"Nutritional counselling doesn't exist in rural areas," the report quoted one Cameroonian woman as saying. "Health personnel are not trained and women do not know how to care for their children."
In Cote d'Ivoire, the report found that national guidelines did not meet the most recent WHO recommendations on infant feeding.
Although the Nigerian government had revised guidelines to comply with the WHO, consensus did not exist in support of the recommendations, and some clinicians and researchers continued to oppose breastfeeding because they believed it deliberately exposed babies to possible HIV infection. Several focus group participants indicated they assumed that replacement feeding was preferable to breastfeeding, and that it had been recommended by health practitioners.
"The guidance on infant-feeding options needs to urgently get into the curriculum and training of health workers and other people who support community healthcare, such as traditional birth attendants," said Sharma, adding that efforts needed to be made to support mothers to exclusively breastfeed their children.
"It is not enough to issue guidelines - in places where women may complain of insufficient breast milk or inadequate nutrition, they need nutritional support to ensure they can continue to exclusively breastfeed," she added.
Conference speakers said community health systems were crucial to the success of prevention of mother-to-child HIV transmission services, as community health workers and traditional birth attendants were often the first port of call for a confused mother. Community health systems can also be used to engage men - frequently absent from ante-natal visits - in their wives' experiences.
Supporting partners
Beatrice Ochieng, author of a study on infant feeding choices in poor settings in the Kenyan capital, Nairobi, noted that just 23 percent of 357 women in the study discussed their chosen feeding option with their partners. "There is a need to support partner involvement through partner counselling and testing, during antenatal and postnatal care," she said.
According to Ncumisa Vika, who works with the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) in South Africa, male involvement in reproductive health services, including PMTCT, remains low, creating challenges and barriers around disclosure of HIV-positive status to a partner, psychosocial support, adherence to treatment, and infant-feeding decisions. In 2010, in collaboration with community health organizations in South Africa's Tshwane District, EGPAF was able to send invitation letters to the partners of all HIV-positive women who attended antenatal clinics, which boosted male participation in reproductive and family health matters.
Overall, ITPC's Sharma said, there was a need for more comprehensive delivery prevention of mother-to-child services in Africa. "Countries must ensure that policy filters down to the women in all aspects of PMTCT - from HIV prevention for women to family planning, to the best ARV prophylaxis option to proper infant feeding to proper healthcare for the mother, child and family," she said. "It is the only way we can achieve the 2015 targets of reducing vertical transmission by 90 percent."