PMTCT, and National's - Health Systems Trust

With only moderate support (one home visit two weeks after delivery, with repeat visits on
an as-needed basis or following a failed clinic appointment – i.e. no regular ongoing counselling
and no involvement of community or family members), HIV-infected women in Nairobi provided
with free infant formula reported 70% compliance (i.e. 30% used breastmilk) 6 . 100% compliance
may have been achieved with more intensive support for exclusive formula feeding. In the
breastfeeding arm (defined as any use of breastmilk), in the absence of support and against
a background of low exclusive breastfeeding rates in Nairobi, only 9% of women who chose
to breastfeed were exclusively breastfeeding at 6 months. This data indicates that with no or
moderate support it is difficult to achieve exclusive formula feeding, and even more difficult
to achieve exclusive breastfeeding.
Community support is especially important for women’s feeding choices in contexts where
decisions are not made by the mother alone, and where cultural or family practices are highly
influential in determining ultimate practices. A study of social and community perspectives on
PMTCT conducted in the Limpopo 11 province found that a common cultural belief in the region
is that babies cry because they do not receive adequate food. In relation to exclusive
breastfeeding, women may experience immense pressure from family members to mix breastmilk
with formula milk in order to ‘satisfy’ the infant. This was confirmed by the finding that 27%
of the individuals interviewed believed that breastmilk alone is not enough for an infant. When
asked about the sources of infant feeding information, respondents cited clinics or nurses as
the most common source of information (57%), followed by mothers and grandmothers (36%).
With the kind of social pressure described above, the current system of counselling within the
PMTCT programme is clearly inadequate to provide sufficient support to women in their infant
feeding choices. Initiatives outside of the health centre such as community and peer support
need to be explored to enhance safer infant feeding practices.
Infant feeding research: The South African National PMTCT Cohort Study
In anticipation of possible poor follow up of infants through the routine system, the national
research and evaluation framework developed by the Health Systems Trust and the National
DoH made provision for a prospective cohort study of mother-child pairs with active followup
and case finding to determine the impact of the programme on infant feeding practices
and vertical transmission rates. In order to estimate the proportion of children infected postnatally
through breastmilk, the cohort study is designed to track feeding practices and to
measure HIV status at 3 weeks, six months and nine months postpartum. The study sites are
nearing completion of recruitment and results are due in December 2004.
Designing an Appropriate Policy
Given the fact that all provinces are attempting to scale up PMTCT services, clear national
policies are required on the promotion of appropriate and safe infant feeding in the context
of HIV. Of particular importance is a decision on whether government should extend the pilot
programme protocol of providing free (state subsidised) formula to HIV positive mothers who
choose to exclusively formula feed. As there are still gaps in knowledge, and differences in
expert opinion, decisions need to be based on the best available data and on the basis of
sound public health arguments.
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