hiv and infant feeding framework for priority action un

8/8/2019 HIV and Infant Feeding Framework for Priority Action UN

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W o r l d B a n kW F PW H OF A O I A E AU N H C R

FRAMEWORK FORPRIORITY ACTION

HIVANDINFANT FEEDING


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World Health Organization, 2003

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WHO Library Cataloguing-in-Publication Data

HIV and infant feeding : framework for priority action.

1.HIV infections transmission 2.Acquired immunodeciency syndrome transmission

3.Breast feeding adverse effects 4.Disease transmission, Vertical prevention and control

5.Infant nutrition 6.Nutrition policy 7.United Nations 8.Guidelines I.Title.

ISBN 92 4 159077 7 (NLM classication: WC 503.3)


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Risk of HIV infection in infants and

young childrenThere are increasing numbers of

children infected with the HumanImmunodeficiency Virus (HIV), espe-cially in the countries most affectedby the epidemic. In 2002, an estimated3.2 million children under 15 years ofage were living with HIV/AIDS, a total of800 000 were newly infected and 610 000

died (UNAIDS/WHO, 2002).The overwhelming source of HIV infec-tion in young children is mother-to-childtransmission. The virus may be transmit-ted during pregnancy, labour and deliv-ery, or by breastfeeding (UNAIDS, 2000).In a recent paper (Walker, Schwrtlanderand Bryce, 2002), HIV/AIDS was esti-mated to account for 7.7% of all deathsin children under ve in sub-Saharan

Africa. In areas where the prevalence ofHIV in pregnant women exceeded 35%,the contribution of HIV/AIDS to child-hood mortality was as high as 42%.

Rates of mother-to-child transmissionrange from 1425% in developed andfrom 1342% in other countries (WorkingGroup on Mother-to-Child Transmissionof HIV, 1995). It is estimated that 520%of infants born to HIV-positive womenacquire infection through breastfeed-ing, which explains the different over-all transmission rates in these settings.Comparing data from various studies,breastfeeding may be responsible forone-third to one-half of HIV infectionsin infants and young children in Africa(De Cock et al., 2000).

HIV transmission may continue foras long as a child is breastfed (Miotti etal., 1999; Leroy et al., 1998; Read et al.,2002). Among women recently infectedwith HIV, the risk of transmission throughbreastfeeding is nearly twice as high as for

women infected before or during preg-

nancy, because of high viral load shortly

after initial infection (Dunn et al., 1992).

Health risks for non-breastfed infants

The risks associated with not breast-feeding vary according to the environ-ment, for example with the availability ofsuitable replacement feeds and safe wa-ter. It also varies with the individual cir-

cumstances of the mother and her family,including her education and economicstatus (VanDerslice, Popkin and Briscoe,1994; Butz, Habicht and DaVanzo, 1984;WHO, 2000).

Lack of breastfeeding compared to anybreastfeeding has been shown by meta-analysis to expose children to increasedrisk of malnutrition and life-threateninginfectious diseases other than HIV, es-pecially in the rst year of life (WHO,2000), and exclusive breastfeeding ap-pears to offer greater protection againstdisease than any breastfeeding (Victoraet al., 1987). This is especially the casein developing countries where 54% ofall under-ve deaths are associated withmalnutrition (Pelletier et al., 1993). Notbreastfeeding during the rst two monthsof life is also associated, in poor coun-tries, with a six-fold increase in mortalitydue to infectious diseases. This increasedrisk drops to two-and-a-half-fold at sixmonths, and continues to decrease withtime (WHO, 2000).

The ndings of the meta-analysis mostlikely underestimate the benets that ex-clusive breastfeeding1 has in loweringmortality. The conclusions are also some-

Infant feeding in the context of HIV/AIDS

1 Exclusive breastfeeding means breastfeeding while

giving no other food or drink, not even water, with

the exception of drops or syrups consisting of vita-

mins, mineral supplements or medicines. 1


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what limited in their application giventhat HIV infection was not taken into ac-

count. Studies from Africa, where mortal-ity rates and breastfeeding patterns aredifferent, were also excluded since there

were insufcient numbers of infants whowere not breastfed.

Health risks for mothers

Mothers who do not breastfeed, or

who stop breastfeeding early, are morelikely to become pregnant again rapidly,and this has implications for their healthand that of their infants.A recent study (Nduati et al., 2001)

raised the specific issue of whetherbreastfeeding affects the health of HIV-positive mothers. WHO reviewed theevidence and concluded that the newresults do not warrant any change incurrent policies on breastfeeding, nor oninfant feeding by HIV-infected women.However, theyemphasize the need forproper support to mothers who are in-fected with HIV and provide a further rea-son for women to know their HIV infec-tion status(WHO Statement, 2001).

Current recommendations

According to current UN recommenda-tions (WHO, 2001), infants should be ex-clusively breastfed for the rst six monthsof life to achieve optimal growth, devel-opment and health. Thereafter, infantsshould receive nutritionally adequate andsafe complementary foods while breast-feeding continues up to 24 months or be-

yond. However, given the need to reducethe risk of HIV transmission to infants

while minimizing the risk of other causesof morbidity and mortality, the guide-lines also state that when replacement

feeding is acceptable, feasible, afforda-

ble, sustainable and safe, avoidance ofall breastfeeding by HIV-infected moth-

ers is recommended.Otherwise, exclusivebreastfeeding is recommended during therst months of lifeand should then bediscontinued as soon as it is feasible 2.To help HIV-positive mothers make thebest choice, they should receive coun-selling that includes information aboutboth the risks and benets of various in-fant feeding options based on local as-sessments, and guidance in selecting the

most suitable option for their situation.They should also have access to follow-up care and support, including familyplanning and nutritional support.

For an individual mother, balancingrisks and benets is a complex, but nec-essary, task. In addition to HIV-positivemothers being provided with counsel-ling on infant feeding options, thereshould be an effort to ensure positiveperceptions of and attitudes towardsbreastfeeding within the general popu-lation. In addition, the unnecessary useof breast-milk substitutes by mothers whodo not know their HIV serostatus or whoare HIV-negative should be avoided. Allsuch mothers should be encouraged andsupported to breastfeed exclusively forsix months, and continue breastfeeding

with complementary feeding until 24months as this practice is best for theiroverall health and that of their children.Through this combined approach, itshould be possible to achieve the ul-timate goal of increasing overall childsurvival, while reducing HIV infectionin infants and young children.

2 This would normally imply the same conditions as

for replacement feeding from birth, that is, acceptable,

feasible, affordable, sustainable and safe.2


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licy

In May 2002, during the United

Nations General Assembly SpecialSession (UNGASS) for Children, gov-ernments pledged to reduce infant andunder-ve mortality by at least one-thirdduring the decade 20012010, and bytwo-thirds by 2015. Governments alsodeclared they would take action con-sistent with the June 2001 UNGASS onHIV/AIDS, to reduce the proportion ofthe infant population infected with HIV

by 20% by 2005, and by 50% by 2010. Toachieve these goals, the UN strategic ap-proach for preventing the transmissionof HIV to women and their children in-cludes four areas:1 prevention of HIV infection in gen-

eral, especially in young women, andin pregnant women;

2 prevention of unintended pregnanciesamong HIV-infected women;

3 prevention of HIV transmission fromHIV-infected mothers to their infants;and

4 provision of care, treatment and sup-port to HIV-infected women, their in-fants and family.

Prevention of HIV transmissionthrough breastfeeding is covered byareas 3 and 4. It should be consideredagainst a backdrop of promoting appro-priate feeding for all infants and youngchildren. The Global Strategy for Infantand Young Child Feeding was adoptedby the World Health Assembly in May2002 (WHO, 2002) and by the UNICEFBoard in September 2002. The opera-tional objectives of this strategy include:ensuring that exclusive breastfeeding isprotected, promoted and supported forsix months, with continued breastfeedingup to two years and beyond; promoting

timely, adequate, safe and appropriate

complementary feeding; and providingguidance on feeding infants and youngchildren in exceptionally difcult circum-stances, e.g. for infants of HIV-infected

women, in emergency situations and forlow birth-weight babies.

The current Framework has been de-veloped in accordance with the goals andstrategies of this integrated policy con-text. These in turn are based on evidence

reected in various technical consulta-tions and documents, particularly an in-ter-agency technical consultation held inOctober 2000 (WHO, 2001). In addition,there is a growing body of practical ex-perience from national programmes andprojects across a wide range of countriesthat serves to guide the priority actionsdescribed below.

HIV and infant feeding is a complex is-sue, and there are still signicant knowl-edge gaps, including whether antiretro-

viral prophylaxis for an infant duringbreastfeeding, or antiretroviral treatmentfor a breastfeeding mother, are safe andeffective in reducing HIV transmission.Identification and implementation ofgood practices requires a comprehen-sive approach in the context of a broadstrategy, such as that described above. Inaddition it will require an enabling envi-ronment where appropriate infant and

young child feeding is the norm and ef-forts to address broader issues of foodsecurity for HIV-affected families are inplace. Where breastfeeding in the gen-eral population is protected, promotedand supported, HIV-positive mothers willstill need special attention, so that theyare empowered to select and sustain thebest feeding option.

International policy context for the Framework

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purposeIn relation to the special circumstances

created by HIV/AIDS, ve priority areasfor national governments are proposedin the context of the Global Strategy forInfant and Young Child Feeding:

1 Develop or revise (as appropri-ate) a comprehensive national infantand young child feeding policy, whichincludes HIV and infant feeding.

Actions required:

Draft or revise policy to reect currentknowledge of appropriate infant and

young child feeding practices in gen-eral, as well as specically in relationto HIV. The policy should be based onnational qualitative studies on the lo-cal appropriateness of different feed-ing options.

Build consensus among stakeholderson the infant and young child feedingpolicy as it relates to HIV.

Review other relevant policies, suchas those on national HIV/AIDS pro-grammes, nutrition, integrated man-agement of childhood illness, safemotherhood, prevention of mother-to-child transmission of HIV/AIDS,

and feeding in emergencies, and en-sure consistency with the overall in-fant and young child feeding policy.

Work across sectors to strengthenhousehold food and nutrition secu-rity, so that infant and young childfeeding practices are not jeopardizedby food shortage or malnutrition inmothers.

Inform other sectors about the pol-icy, such as the labour ministry, whichhold responsibility for maternity en-titlements for pregnant and lactating

women. Develop means for implementing the

policy.

2 Implement and enforce theInternational Code of Marketingof Breast-milk Substitutes and sub-sequent relevant World Health

Assembly resolutions.

Actions required:

Implement existing measures adoptedto give effect to the Code, and, whereappropriate, strengthen and adoptnew measures.

The purpose of this Framework is torecommend to governments key actions,

related to infant and young child feeding,that cover the special circumstances asso-ciated with HIV/AIDS. The aim should beto create and sustain an environment thatencourages appropriate feeding practicesfor all infants, while scaling-up interven-tions to reduce HIV transmission.

The beneciaries of this Frameworkinclude national policy-makers, pro-

gramme managers, regional advisorybodies, public health authorities, UNstaff, professional bodies, non-govern-mental organizations and other interestedstakeholders, including the community.It has been developed in response toboth evolving knowledge and requestsfor clarication from these key sectors.

The Frameworks purpose and target audience

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Priority areas for governments


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Monitor Code compliance. Ensure that the response to the HIV

pandemic does not include the intro-duction of non Code-compliant dona-tions of breast-milk substitutes or thepromotion of breast-milk substitutes.

In countries that have decided to pro-vide replacement feeding for the in-fants of HIV-positive mothers who havebeen counselled, and for whom it is ac-ceptable, feasible, sustainable and safe(either from birth or at early cessation),

establish appropriate procurement anddistribution systems for breast-milk sub-stitutes, in accordance with the provi-sions of the Code and relevant WorldHealth Assembly resolutions.

3 Intensify efforts to protect, pro-mote and support appropriate infantand young child feeding practices ingeneral, while recognizing HIV as oneof a number of exceptionally difcultcircumstances.

Actions required:

Increase the priority and attentiongiven to infant and young child feed-ing issues in national planning, bothinside and outside the health sector.

Develop and implement guidelines oninfant and young child feeding, includ-ing feeding in exceptionally difcultcircumstances, for example, for lowbirth weight babies, in emergency sit-uations and for infants of HIV-infected

women. Facilitate coordination on infant and

young child feeding issues in im-plementing national HIV/AIDS pro-grammes, integrated management ofchildhood illness, safe motherhood,and others.

Build capacity of health care deci-sion-makers, managers, workers and,as appropriate, peer counsellors, lay

counsellors and support groups forpromoting primary prevention of HIV,

good nutrition for pregnant and lactat-ing women, breastfeeding and com-plementary feeding, and for dealing

with HIV and infant feeding. Revitalize and scale-up coverage of

the Baby-friendly Hospital Initiative(BFHI) and extend it beyond hospi-tals, including through the establish-ment of breastfeeding support groups,and making provisions for expansion

of activities to prevent HIV transmis-sion to infants and young children togo hand-in-hand with promotion ofthe Initiatives principles.

Ensure consistent application of recom-mendations on HIV and infant feedingin emergency situations, recognizingthat the environmental risks associated

with replacement feeding may be in-creased in these circumstances.

Consult with communities and de-velop community capacity for ac-ceptance, promotion and support ofappropriate infant and young childfeeding practices.

Support improved maternity care forall pregnant women.

Provide guidance for other sectors on leg-islation and related national measures.

4 Provide adequate support to HIV-positive women to enable them toselect the best feeding option forthemselves and their babies, and tosuccessfully carry out their infantfeeding decisions.

Actions required:

Expand access to, and demand for,quality antenatal care for women whocurrently do not use such services.

Expand access to, and demand for,HIV testing and counselling, beforeand during pregnancy and lactation, 5


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to enable women and their partnersto know their HIV status, know how

to prevent HIV/sexually transmittedinfections and be supported in deci-sions related to their own behavioursand their childrens health.

Implement other measures aimed atprevention of HIV infection in infantsand young children, including provi-sion of antiretroviral drugs during preg-nancy, labour and delivery and/or to theinfant and safer delivery practices.

Support the orientation of health caremanagers and capacity-building andpre-service training of counsellors (in-cluding lay counsellors) and health

workers on breastfeeding counsel-ling, as well as primary prevention ofHIV and infant feeding counselling, in-cluding the need for respect and sup-port for mothers feeding choices.

Improve follow-up, supervision andsupport of health workers to sustaintheir skills and the quality of counsel-ling, and to prevent burn-out.

Integrate adequate HIV and infant feed-ing counselling and support into ma-ternal and child health services, andsimplify counselling to increase its com-prehensibility and enhance the feasi-bility of increasing coverage levels.

Carry out relevant formative research,and develop and implement a compre-hensive communication strategy on ap-propriate infant and young child feed-ing practices within the context ofHIV.

Develop community capacity tohelp HIV-positive mothers carryout decisions on infant feeding,including the involvement oftrained support groups, laycounsellors and other volun-teers, and encourage the in-

volvement of family members,especially fathers.

Promote interventions to reduce stig-matization and increase acceptance of

HIV-positive women and of alternativefeeding choices.

5 Support research on HIV and in-fant feeding, including operationsresearch, learning, monitoring andevaluation at all levels, and dissemi-nate ndings.

Actions required: Carry out qualitative studies to assesslocal feeding options (including theiracceptability, feasibility, affordability,sustainability and safety), on whichpolicies, guidelines and capacity-build-ing should be based.

Carry out assessments and evalua-tions of programmes related to HIVand infant feeding, on infant feedingpractices and mothers and childrenshealth outcomes.

Disseminate results of research, tech-nical guidelines and related recom-mendations, and revise national pro-grammes and guidelines in responseto new knowledge and programmeexperiences and outcomes.

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Within the scope of this Framework,the UN agencies endorsing this

Framework will: Advocate the priority courses of ac-tion described above with global andregional advisory bodies and nationalgovernments. Through their global,regional and country ofces and UNTheme Groups on HIV/AIDS, UN agen-cies will disseminate this Frameworkand encourage responses that are inaccordance with the guidance of this

Framework.

Convene technical consultations, andprovide governments and other stake-

holders with technical guidance, infor-mation on best practices, guidelinesand tools related to HIV and infantfeeding.

Assist countries in mobilizing resourcesto carry out priority actions.

Support capacity development relatedto HIV and infant feeding for policy-makers, managers, health workers andcounsellors.

tions described in this Framework willcontribute to achieving the declared gov-ernmental goals of reducing child mor-tality and HIV transmission, while en-hancing support for breastfeeding among

Additional challenges

The overall challenge is to improvefeeding for all infants and young children,regardless of their mothers HIV status.Making a difference is often very difcultin an environment where poverty, foodinsecurity, mother and child malnutrition,and high disease rates prevail.

The optimal means of feeding an infantwhen the mother is HIV-positive is a com-plicated issue. The evidence base for pol-icy-making on this issue is still evolvingand answers to some key questions willnot emerge for months or years. In thiscontext, one of the greatest challengesin the area of HIV and infant feeding

is to communicate clearly the evidenceand eld experience to decision-makers,health workers and counsellors, as theycontinue to emerge, while ensuring con-sensus among technical experts and im-plementers on the ways forward.

Simultaneously, governments andagencies are being asked to respond tothe need to move quickly on priority ac-tions, despite limited resources. The dif-culties in implementing actions withinthe context of health (and social) sys-tems that require signicant strengthen-ing should not be underestimated.

Conclusion

Promoting improved infant and youngchild feeding practices among all women,irrespective of HIV status, brings substan-tial benets to individuals, families andsocieties. Implementing the priority ac- 7

Role of UN agencies


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the general population and promotingthe attainment of other child health-re-lated goals.

Although future research will providemore detailed information on relative risksand ways to further reduce HIV trans-mission through breastfeeding, immedi-

ate action is required. There is adequateknowledge of general risks and appro-priate programme responses to support

HIV-positive mothers and their children inrelation to infant feeding and for the ac-celeration of actions needed for a scaled-up response using this Framework.

References

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he purpose of this HIV and Infant FeedingFramework for Priority Action is to recommend to

governments key actions, related to infant and young

child feeding, that cover the special circumstances

associated with HIV/AIDS. The aim of these actions is

to create and sustain an environment that encourages

appropriate feeding practices for all infants, while

scaling-up interventions to reduce HIV transmission.

The beneciaries of the Framework include national policy-makers,

programme managers, regional advisory bodies, UN staff,

professional bodies, non-governmental organizations and other

interested stakeholders, including the community.This Framework has been developed as a collaborative effort

between all the UN agencies whose logos appear on the cover.

For further information, contact the Department of Child

and Adolescent Health and Development ([email protected]),

HIV/AIDS ([email protected]) or Nutrition for Health andDevelopment ([email protected]).

T

W o r l d B a n kW F PW H OF A O I A E AU N H C R

ISBN 92 4 159077 7

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