PMTCT, and National's - Health Systems Trust

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An average of 58% of HIV positive women expressed an intention to practice exclusive formula feeding and an average of 42% of HIV positive women intended to practice exclusive breastfeeding. These rates differ substantially between provinces and may be related to institutional or facility policies, different training initiatives or staff biases towards one or other option. Figure 6.5.2: Infant feeding intentions of HIV positive women according to urban/rural location % 100 90 80 70 60 50 40 30 20 10 0 Formula Breast feeding Rural Urban Figure 6.5.2 displays infant feeding intentions according to rural or urban location of the sites. It is clear that the predominant choice of HIV positive women across both locations is formula milk. Of concern is the slightly higher rate of intention to formula feed in rural areas compared with urban areas. In the two most rural sites, Shongwe hospital in Mpumalanga and Rietvlei hospital in the Eastern Cape, the formula feeding intention rates are 90% and 69% respectively. These are marked increases from the first evaluation where the formula feeding intention rate in Shongwe was 74% and in Rietvlei, 54%. In the Rietvlei site, there have been reports of formula supplies running out and generally limited access to formula as only a few of the feeder clinics maintain supplies. Despite the increases noted above, the finding in most provinces is that formula feeding intention rates have decreased since the first evaluation (January to December 2001). The most marked changes have been seen in the Free State, KwaZulu-Natal and Limpopo where both pilot sites showed a decrease in intentions to formula feed. In the Free State intentions to formula feed have decreased from 73% to 36%. In KwaZulu-Natal a similar decrease has been seen from 53% to 41%, and in Limpopo formula feeding intentions have decreased 73% to 37%. In the Western Cape and the Northern Cape the rates have decreased but remain above 70%. The only province showing an increase in formula feeding intention rates across both sites is the Eastern Cape where the rate increased from 62% to 80%. The decrease in intentions to formula feed and increase in the intentions to breastfeed are due to a variety of factors including: • The introduction of infant feeding training for health workers involved in PMTCT. • The stigma associated with the free distribution of formula milk from clinics. • The unreliable supply of formula to facilities, particularly feeder clinics. The provinces with the highest rates of breastfeeding intentions; Limpopo (64%), Free State (64%) and KwaZulu-Natal (60%) have all prioritised training on infant feeding counselling. In addition, the Free State PMTCT programme is managed through the MCWH directorate and not the HIV directorate and a decision has been made not to supply formula to new PMTCT sites. 39
There is a need for caution when interpreting these rates as these reflect stated intentions. There is no data on actual feeding practices nor the outcome of infants in relation to feeding practices as no prospective follow up was undertaken during this evaluation. A prospective cohort study commissioned by the National Department of Health is underway in three sites to monitor infant feeding practices. Infant feeding counselling and risk assessment Infant feeding counselling of pregnant women to make appropriate decisions for themselves is complex. Counselling can influence and bias the choice that mothers make regarding infant feeding practices. Evidence from this evaluation suggests that there is currently significant inconsistency and misinformation in infant feeding counselling at South African PMTCT pilot sites. In particular, we have seen that poor infant feeding counselling seems to lead to high intentions to exclusively formula feed in places where free formula milk is provided. As indicated earlier, in provinces where efforts have been made to increase the training of health workers on infant feeding, such as Limpopo, KwaZulu-Natal and the Free State, fewer HIV positive women choose to formula feed. In KwaZulu Natal, although the two PMTCT sites (Durban and Pietermaritzburg) are quite similar, more women intend to exclusively breastfeed at the Durban site compared with the Pietermarizburg site (including the rural area which is part of this site). It is possible that information on the relative risks of HIV transmission through breastfeeding versus the relative risks of not breastfeeding is presented differently at various PMTCT sites. This could be due to the fact that the PMTCT programme has embraced the opinions expressed by influential staff and infant feeding experts in different regions. The current PMTCT protocol for the pilot sites 3 recommends that counselling on safe infant feeding should take place both antenatally (during the post test counselling session) and postnatally before the first feed. Within the antenatal setting, formal counselling is conducted mostly by lay counsellors. Very little is known about the extent to which nurses or doctors reinforce infant feeding options during their consultations with clients. The training of lay counsellors is largely focussed on counselling for an HIV test and training typically consists of a 2-3 week VCT course run by organisations such as ATICC or Lifeline. The infant feeding component of counselling is inadequately covered in these training courses largely because the training was designed to prepare individuals to conduct VCT. Attempts by the DoH to focus more on infant feeding within PMTCT training have also been directed at professional health workers and not lay counsellors. This raises serious concerns regarding the ability of lay counsellors to accurately present infant feeding options to mothers. Some provinces have made impressive attempts to assist counsellors in the process of assessing the suitability of infant feeding options. The illustration below was developed in KwaZulu- Natal and was seen used at the rural Church of Scotland site. It provides a list of determinants that should be assessed in the counselling session to decide on an infant feeding option. Other international initiatives are also underway to develop similar counselling tools. The World Health Organisation has developed a set of counselling cards to guide health workers through various stages of antenatal and postnatal support for infant feeding. These cards have been field tested in South Africa and will be incorporated into the PMTCT and infant feeding training course. 40
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 and 42: RECOMMENDATIONS FOR IMPROVING THE P
Page 43: KEY FINDINGS FROM THE EVALUATION 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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