PMTCT, and National's - Health Systems Trust

Differences in provincial policies
In the absence of a national policy on HIV and infant feeding for the non-pilot sites, provinces
have developed their own policies based on their experiences with the pilot sites. As a result
there are various infant feeding policies being implemented across the country. In the Free
State and Northern Cape the decision was made not to supply free formula outside of the
pilot sites. The Free State made this decision based on findings from the pilot sites that despite
the availability of free formula milk, women still mix feed with breastmilk and formula milk.
It is interesting to note that the MCWH directorates and not the HIV directorates in these two
provinces manage the PMTCT programme. The Free State has the highest rate of breastfeeding
intention amongst HIV positive women in the pilot sites. This is most likely attributable to the
influence of the MCWH management and their commitment to lactation management training
and the Baby Friendly Hospital Initiative. The Free State plans to phase out the free formula
from the pilot sites as soon as they receive notification that the pilot sites have ended their
term.
The other seven provinces are supplying free formula to non-pilot sites, however, there are
reports from many sites of poor stock control and procurement and, in Mpumalanga, of
formula only being available at clinics and not hospitals. On discharge, mothers are informed
that they can collect formula from their nearest clinic.
Provinces will continue to develop their own policies in the absence of national guidance which
may be detrimental to infant nutritional safety and cause confusion amongst health workers.
DISCUSSION
Concerns about spillover
There have been concerns that the promotion of formula feeding in HIV positive women could
‘spill over’ into the general population 4 . ‘Spillover’ is considered to be increased use of formula,
either earlier introduction, increased use of formula feeds or stopping breastfeeding altogether
in HIV uninfected populations, or populations of unknown HIV status.
Data from Botswana 4 suggests that the provision of free formula by facilities could be perceived
by the general population as an official endorsement of formula feeding as being superior
to breastfeeding. Together with the low levels of knowledge about the value and benefits of
exclusive breastfeeding amongst health workers, and with the added confusion related to HIV
transmission, the policy could lead to an undermining of breastfeeding promotion and a
deterioration of child health outcomes. These concerns have been given further justification
by a UNICEF study of four countries in Southern Africa reporting that uncertainty over HIV
and infant feeding was leading to a dangerous demise in support for breastfeeding 5 .
The study in Botswana found that 95% of the women (unknown HIV status) at non-PMTCT sites
were breastfeeding, while only 76% of HIV uninfected women at PMTCT sites were breastfeeding.
The research concluded that the decrease in breastfeeding amongst uninfected women at
PMTCT sites was due to the availability and distribution of free infant formula, which indirectly
promotes infant formula as being a good form of feeding.
There is also evidence that the provision of commercial infant formula increases the potential
for, but does not guarantee, exclusive formula feeding. Data from Nairobi, showed that at
least 30% of HIV-infected women who chose to formula feed and who were provided with
subsidised formula milk, did not exclusively formula feed 6 . It is possible that when infant
formula is offered free of charge, clients might be tempted to choose formula feeding because
this option would increase the food security of the household and not because they are
committed to exclusive formula feeding. Hence the provision of free infant formula might
increase the likelihood of mixed feeding which is thought to be particularly dangerous.
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