PMTCT, and National's - Health Systems Trust

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6.5 Infant Feeding Infant feeding remains one of the greatest challenges in the PMTCT programme. The dilemma is that breastfeeding prevents millions of infant deaths each year throughout the world, but causes at least one-third of all paediatric HIV infections. The HST’s interim report on the PMTCT programme highlighted infant feeding as the major policy issue for government with a caution that the policy of providing free formula may do more harm than good in many communities. The report also recommended that a national commission of experts be established to discuss infant feeding policy in the context of HIV. Such a commission has not been established; however, at the national scientific consultative forum hosted by the National DoH and HST in August 2002, a group of infant feeding experts worked together to produce a discussion document with clear policy options for the government. Members of this team included: Dr Mickey Chopra, Dr Mark Colvin, Professor Anna Coutsoudis, Ms Tanya Doherty, Dr Nigel Rollins, Dr Haroon Saloojee, Dr Christine Varga, Professor David Sanders, Dr Glenda Gray, Dr David Woods, Dr David McCoy and Dr Ameena Goga. This chapter presents the key findings of the 2 nd evaluation of the pilot sites, and makes recommendations for an infant feeding policy drawing on this evaluation and policy recommendations of the August 2002 National Scientific Consultative Forum. BACKGROUND The advent of HIV and the knowledge that the virus can be transmitted through breastmilk has led to the need for the promotion of breastfeeding to be qualified by information regarding the risks of HIV transmission through breastmilk. These risks however need to be weighed up against the immunological and nutritional benefits of breastfeeding, and the potential dangers of replacement feeding, even for infants born to HIV positive women. In recognition of the trade-off between harm and benefit, a WHO Technical Task Team has recommended that exclusive replacement feeding should only be encouraged in HIVinfected women if it is safe, feasible, acceptable, accessible and sustainable, but that if any of these conditions are not met, exclusive breastfeeding should be promoted 1 . Currently the PMTCT pilot programme in South Africa offers free formula milk for a period of six months to HIV positive women who choose not to breastfeed. With the low follow up rates displayed in this report, and the acknowledgement that routine data cannot be used to track cohorts of infants, very little is known about the actual infant feeding practices of HIV positive women nor of the impact of the provision of free formula milk on infant morbidity or on infant feeding practices in the non-HIV positive population. 37
KEY FINDINGS FROM THE EVALUATION Infant feeding intentions of HIV positive women in the pilot sites Public health concerns have been raised about the decision to supply free formula as part of the package of care for PMTCT. The interim report on the PMTCT pilot programme noted that the uptake of free formula varied considerably between sites with similar socio-economic contexts, and that free formula was being taken up by women under conditions that were not safe or feasible 2 . It was also indicated that some women who were provided with free formula did not formula feed exclusively, and often mixed fed with breastmilk. This evaluation found evidence of high rates of intentions to formula feed in both urban and rural sites. However, intentions to breastfeed have increased during the course of 2002 in many provinces. Figure 6.5.1 shows the infant feeding intentions that were recorded prior to discharge for all HIV positive women in the pilot sites during 2002. Figure 6.5.1: Infant feeding intentions of HIV positive women in the 18 pilot sites, 2002 Average (choices) Siloam (LP) Virginia (FS) Durban (KZN) Frankfort (FS) Mankweng (LP) Pietermaritzburg (KZN) Rustenburg (NW) Umzimkulu (EC) Paarl District (WC) Kimberley (NC) Evander (MP) Kalafong (GT) Lehurutshe (NW) De Aar (NC) East London Complex (EC) Shongwe (MP) Guguletu (WC) Natalspruit (GT) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Formula Feeding Breast Feeding 38
Page 3 and 4: An Evaluation of the Prevention of
Page 5 and 6: CONTENTS 1. Executive summary 2. In
Page 7 and 8: Dispensing of Nevirapine Nevirapine
Page 9 and 10: SCALING UP THE PMTCT PROGRAMME Ther
Page 11 and 12: AIM OF THE EVALUATION METHODOLOGY A
Page 13 and 14: OVERVIEW OF THE PMTCT PILOT SITES *
Page 15 and 16: DESCRIPTION OF ROUTINE PMTCT INDICA
Page 17 and 18: Nevirapine (NVP) dispensing rate to
Page 19 and 20: 6.1 Antenatal Counselling and Testi
Page 21 and 22: This rate has increased slightly si
Page 23 and 24: Group education followed by individ
Page 25 and 26: WHO 2 recommends that at least 50%
Page 27 and 28: APPENDIX 6.1: EXAMPLE OF A PEER COU
Page 29 and 30: Figure 6.2.1: Nevirapine dispensing
Page 31 and 32: 6.3 Infant Testing and Outcomes BAC
Page 33 and 34: DISCUSSION HIV Diagnosis in Infants
Page 35 and 36: Current Status of Infant Testing Cu
Page 37 and 38: Proposed Infant HIV Test Timelines
Page 39 and 40: 6.4 Maternal and Infant Follow Up I
Page 41: RECOMMENDATIONS FOR IMPROVING THE P
Page 45 and 46: There is a need for caution when in
Page 47 and 48: Differences in provincial policies
Page 49 and 50: With only moderate support (one hom
Page 51 and 52: 4. Ensure on-going Support After De
Page 53 and 54: 6.6 Health Care Infrastructure This
Page 55 and 56: Two options exist for the contracti
Page 57 and 58: B. TRAINING OF HEALTH CARE WORKERS
Page 59 and 60: Logistical and administrative suppo
Page 61 and 62: 6.6.2 Management A. NATIONAL MANAGE
Page 63 and 64: C. MANAGEMENT OF CONSUMABLES AND SU
Page 65 and 66: The changes made in data elements a
Page 67 and 68: Data flow The PMTCT pilot programme
Page 69 and 70: Appendix 6.6 MTCT REGISTER (to be k
Page 71 and 72: The key to high coverage of the int
Page 73 and 74: Health Care Infrastructure • Stre
Page 75 and 76: Strategies to integrate PMTCT into
Page 77 and 78: SUMMARY We need a fundamental rethi

PMTCT, and National's - Health Systems Trust

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