WHLP MTCT HIV_AIDS.pdf - The network - Towards Unity For Health

MOTHER-TO-CHILD TRANSMISSION (MTCT) OF HIV/AIDSWomen and Health Learning PackageDeveloped by The Network: TUFH Women and Health TaskforceSecond edition, September 2006Support for the production of the Women and Health Learning Package (WHLP) has been providedby The Network: Towards Unity for Health (The Network: TUFH), Global Health through Education,Training and Service (GHETS), and the Global Knowledge Partnership. Copies of this and otherWHLP modules and related materials are available on The Network: TUFH website athttp://www.the-networktufh.org/publications_resources/trainingmodules.asp or by contacting GHETSby email at info@ghets.org, or by fax at +1 (508) 448-8346.About the authorRosebella O. Onyango, BEd, MSc, (Community Health), PhD (Childhood Nutrition)Senior Lecturer and Director, School of Public Health and Community DevelopmentMaseno UniversityMaseno, KenyaDr Onyango is a public health nutritionist and a trained teacher and researcher, with manyyears of teaching, administrative, and research experience at various educational levels.Eighteen years of that experience have been in teacher training institutions and universities.She is also an external examiner for nutrition exams in Egerton and Moi Universities, Kenya.She supervises postgraduate students on a variety of nutrition and public health researchprojects.Dr Onyango has carried out studies on infant feeding in the HIV/AIDS era, nutritional statusand health of children, and related family socioeconomic and environmental factors. Herresearch focus is on both pre-school children and women. She has worked with women’sgroups in slums and rural settings to improve of maternal and child health and nutrition. Sheis a member of Kenya Coalition for Action in Nutrition (K-CAN) and Regional Centre ofQuality Health Care (RCQHC). She is also a member of The Network: TUFH Women andHealth Taskforce.Her current research interests are in infant feeding in the HIV/AIDS era and home-basedhealth care for people living with HIV/AIDS (PLWHA). Dr Onyango is a trainer of trainersfor nurses and other health workers in prevention of mother-to-child transmission (PMTCT)of HIV.Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org1

MOTHER-TO-CHILD TRANSMISSION (MTCT) OF HIV/AIDSGlobal OverviewThe HIV/AIDS epidemic has become a major problem in many countries globally andcontinues to have a devastating effect on sub-Saharan Africa. The overwhelming majority ofHIV-infected people—more than 90%—live in developing countries. Adults living in sub-Saharan Africa are 10 times more likely to be infected with HIV than adults living in NorthAmerica, and 20 times more likely than adults living in Western Europe. Eighty percent ofwomen currently living with HIV are in sub-Saharan Africa, and out of all the children bornwith HIV globally, 90% are in this same region.Prevention of mother-to-child transmission (MTCT) of HIV—also known as vertical,perinatal or parent-to-child transmission (PTCT) to reflect the role of men in the overall chainof transmission— has become a priority for many developing country governments andagencies. This priority is consistent not only with the broader goals of HIV/AIDS prevention,but also with commitments to improving child health and survival.Infants and children in Africa are infected by HIV/AIDS in multiple ways. Those who aremost directly affected are children who acquire HIV/AIDS through MTCT. They face severemorbidity and near-certain death where sophisticated and costly treatments are nonexistentand even the availability of basic medicines to treat opportunistic infections is likely to beerratic. Infant mortality rates, although reduced between 1981 and 1986, have now risendramatically, largely due to AIDS. Almost all AIDS deaths in Africa in young children canbe traced back to MTCT.In developed countries, MTCT rates have fallen to as low as 2% of births among HIVinfectedmothers in recent years with the introduction of HIV counselling and testing, shortcoursezidovudine (ZDV) or azidothymadine (AZT) prophylaxis, elective Caesarean deliveryand safe use of infant formula instead of breastfeeding. In Africa, however, where prolongedbreastfeeding is the norm, about 25-35% of HIV-infected mothers pass on the disease to theirinfants.The severity of the MTCT problem in sub-Saharan Africa is due to a number of factors,including high rates of HIV infection in women of reproductive age, a large total populationof women of reproductive age, high birth rates, and a lack of effective MTCT preventioninterventions. Rates of infections in women are high in sub-Saharan Africa and are growingrapidly.Transmission of HIV through breast milk is of concern in many developing countries whereHIV infection in women is common and breastfeeding is universally practiced. In Africa, 30-40% of children born to HIV-infected women acquire HIV, and 30-50% of infected infantsacquire the disease through breastfeeding. This has reversed previous gains made in childsurvival and has eroded health worker confidence in recommending breastfeeding as the bestand safest form of infant feeding.Promotion of exclusive breastfeeding as the best possible nutrition for infants has been thecornerstone of child health and survival strategies for the past 20 years, and has played amajor part in lowering infant mortality in many regions of the world. Therefore, the evidencethat has accrued over recent years that breast milk is a significant source of HIV infection hasWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org2

caused a real dilemma for mothers, health personnel, and policymakers. Today, decisionsabout infant feeding in settings of high HIV prevalence require a careful balancing of risks,with the risk of transmitting HIV on one side and the risk of morbidity, mortality andstigmatisation that can result from not breastfeeding on the other. Breastfeeding is nearlyuniversal in Africa, making balancing the risks especially challenging.Malnutrition has been endemic in Africa for decades, complicated by a combination offactors and more recently by the impact of AIDS. It is estimated that one-third of all childrenunder five in sub-Saharan Africa are stunted, and more than half suffer from some form ofmicronutrient malnutrition. Malnutrition is also common among adults in most parts ofAfrica, where more than half of all pregnant women suffer from anaemia.HIV/AIDS and malnutrition are inextricably interrelated. Studies show that malnutritionincreases both the risk of HIV transmission from mothers to babies and the progression of theHIV infection. In turn, HIV infection exacerbates malnutrition through its attacks on theimmune system and its impact on nutrient intake, absorption, and utilisation. This puts thelives of HIV-infected infants at risk from both malnutrition and AIDS-related infections.The severity of the MTCT problem in sub-Saharan Africa is due to high rates of HIVinfection in women of reproductive age, a large total population of women of reproductiveage, high birth rates, and the lack of effective MTCT prevention intervention.An estimated 330,000 children younger than five died in the sub-Saharan Africa in 1999 fromHIV infections. Four countries (Botswana, Namibia, Swaziland, and Zimbabwe) have rates ofHIV-attributable under-five mortality of above 30 per 1000, and an additional 16 countrieshave rates between 10 and 25 per 1000.Regional Overview: KenyaWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org3

Population Profile: KenyaTotal Population31.3 millionAnnual Population growth Rate (%) 1.53Rate of annual increase in population 3.5%Total Fertility Rates (TFR) (15-49 years) 5.0Infant Mortality Rate (IMR)(Per 1000) 78Under-five Mortality Rate 114Crude birth rate (per 1000 live births) 29.35Crude death rate (per 1000 live births) 14.8Life expectancy (women)49 yearsHIV-infected1.4 millionAIDS deaths 140,000 adults in 2003AIDS orphans 890,000HIV Prevalence (women 15-49) in Urban 12.3%HIV Prevalence (women 15-49) in Rural 7.5%HIV Prevalence (men 15-49) In Urban 7.6%HIV Prevalence (men 15-49) In Rural 3.5%HIV Prevalence (women 15-49) Total 8.7%HIV Prevalence (men 15-49) Total 4.5%HIV Prevalence Total 6.7%It is estimated that 2.2 million Kenyans are now living with HIV, but few of them know thatthey are infected or show symptoms of the disease, and only about 200,000 have AIDS(Government of Kenya, 2001). Results of the Kenya Demographic and Health Survey(KDHS) in 2003 indicated that the national prevalence rate derived from women participatingin a 2003 sentinel surveillance program was 9.4%. Gender differences were most striking inyoung people. In the 15-19 age group, 3.5% of women and only 0.5% of men were infected,while in the 20-24 year age group, 8.7% of women and 2.4% of men were infected (KDHS,2003). It is projected that AIDS will increase the death rate at all ages. However, the impactwill be most severe among young adults and children under the age of five. This rapidincrease in young adult deaths will have serious consequences for economic and socialdevelopment.Kenya has a severe, generalized HIV epidemic, with approximately 1.25 million adults andover 100,000 children infected. The KDHS 2003 found a prevalence of 9% in adult womenand 5% in adult men. Surveillance of HIV in pregnant women has been conducted annuallysince 1990, with prevalence rising to 16% in urban areas and 8% in rural areas in the late1990s, but now showing signs of decline in some regions. Only 14% of Kenyan adults knowtheir HIV status, limiting their access to care.The seroprevalence rate of HIV among pregnant women in Africa exceeds 20% in manyareas. In Kenya, the HIV prevalence in urban areas was reported to range between 4-10% inlow seroprevalence sites and 35% in high seroprevalence sites.With the observed trends, the percentage of pregnant women who are HIV-infected isincreasing at an alarming rate. Up to 90% of HIV infections in pregnant women are due toheterosexual contact.Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org4

More than five million children worldwide have been infected with HIV, almost all throughmother-to-child transmission. The figures are sobering: in 2002 alone, for example, morethan 800,000 children became infected with HIV. Ninety percent of these infections occur insub-Saharan Africa, where AIDS has increased infant mortality in the most severely affectedcountries. Kenya is counted among one of the countries that are most severely affected byHIV/AIDS pandemic in Africa.There was an increase in both the infant mortality rate and under-five mortality rates betweenthe KDHS of 1989 and 2003. For example, the infant mortality rate increased by 30%, from60 deaths per 1000 live births in 1989, to 78 in 2003. Similarly, the under-five mortality rateshowed an increase of 30% during the same period. The trend depicts continued deteriorationin the quality of life amongst the Kenyan population over the last 20 years. Some of thesedeaths can be attributed to HIV-related infections. This same trend is likely to be found inpoor African countries with similar burdens of HIV/AIDS infections.Five Key Gains in Breastfeeding and PMTCT in KenyaThe Global AIDS Program has initiated the following:1. Provision of financial and technical support for the development of a 5-year (2001-2005) national PMTCT strategy that provides guidelines and a framework forcoordinated program implementation2. Support for PMTCT services in 18 facilities (including one offering PMTCT+)3. Integration of voluntary counselling and testing (VCT) and PMTCT into maternal andchild clinics in most hospitals and rural health centres.4. Campaigns on breastfeeding promotion5. Provision of mobile VCT services by the Ministry of Health for hard-to-reachpopulations.Five Key Challenges to Infant feeding and MTCT1. Culturally, every mother is expected to breastfeed her baby, and any deviation fromthis practice raises many questions in the family, subjecting the mother to stigma.2. Lack of appropriate and nutritionally adequate complementary foods for infants.3. Lack of safe water and poor hygienic practices making the preparation ofcomplementary foods unsafe.4. Poor infrastructure at health facilities hindering accessibility to most areas wherethere is need for VCT and PMTCT initiatives.5. Lack of knowledge of HIV status by pregnant women (many women, even whentested, are afraid to check the test results).Five Key Factors Increasing MTCT1. Widespread poverty2. Low literacy among rural women3. Home deliveries by traditional birth attendants (TBAs)4. High rate of HIV infection among women5. Religious groups that discourage the use of contraceptives, especially condomsWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org5

Infant Feeding Patterns among Kenyan WomenBreastfeeding and the introduction of supplemental foods are important determinants of thenutritional status of children, especially those under two years.Supplementation of breast milk starts quite early in Kenya. Exclusive breastfeeding (breastmilk only) is not common, as only 29% of children under two months and 9% of those underfour months of age are exclusively breastfed. Most of the supplements given are plain water,water-based liquids, juice, or other milks.Fifteen percent of babies under two months and 45% of those aged 2-3 months are givencomplementary food, presumably mushy or semi-solid food. By the age of 4-5 months, twothirdsof the children are given complementary foods (KDHS).Since most mothers in the rural areas are poor and lack safe drinking water and adequatenutritious complementary foods for the infants, such infants are often fed with nutritionallyinadequate complementary foods prepared in unhygienic conditions. This predisposes suchinfants to diarrhoeal illnesses and other infections, increasing both their morbidity and theirmortality.In 1999, 10% of reported AIDS cases in children were in those under 5 years of age, out ofwhich 90% of the HIV infections were due to MTCT. It is estimated that the number ofinfants infected with HIV per year in Kenya is 100,000. Transmission of HIV from infectedmothers to their babies can occur during the antenatal period (10-20%), labour and delivery(35-50%), and breastfeeding (14-22%). In order to reduce MTCT, these key HIVtransmission areas must be targeted.MTCT Prevention ComponentsEfforts to prevent MTCT should relate to and be considered within the entire spectrum ofHIV/AIDS primary prevention, care and support activities as shown in Table 1.Table 1: MTCT and the Prevention to Care ContinuumPrimary Prevention ofHIV/AIDS in Adults• Promotion and provision ofcondoms• Behaviour changecommunication (includingeducation and involvementof partners, families andcommunities; life skills andother programs targeted toyouths)• Prevention and treatment ofsexually transmitteddiseases• Voluntary counselling andTesting (VCT)Core interventions for thePrevention of MTCT• Comprehensive MCHservices (antennal,postnatal, and child health).• VCT• Improved breastfeeding andalternative infant feedingcounselling and practices• Optimal Obstetric care• Short-course antiretroviral(ARV) prophylaxis• Family planningCare and support• Postpartum care formothers (including familyplanning)• Postpartum care for infants(including identification,treatment of and palliativecare for AIDS-relatedconditions)• Social support for familiesand communities affectedby HIV/AIDS, especiallyorphans and vulnerablechildren• Support to carry out infantfeeding decisionsWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org6

Mechanisms, Timing and Risk Factors of MTCTMTCT in Africa is the tragic result of a chain of events that most often involves an HIVpositiveman infecting his female partner through unprotected sexual activity, and the partnerinfecting her next baby, and potentially several more babies, during the remainder of herreproductive life. To reflect the important role that men play in this chain of transmission,some organisations have replaced the biologically precise terminology of “mother-to-childtransmission” with the behaviourally-sensitive term “parent-to-child-transmission.”Infants who acquire HIV infection from their mothers do so during pregnancy (5-10%),during labour and delivery (10-20%), or after birth through breastfeeding (10-20%). Infectioncan also occur after birth through contact with infected blood, blood products, or unsterilemedical equipment, though this is extremely rare even in Africa. Efforts to improve the safetyof the blood supply, to avoid unnecessary delivery-related blood transfusions, and to improveinfection control practices have probably further reduced the incidence of non-MTCTtransmission in infants.HIV Transmission during pregnancyIn most HIV-infected women, HIV does not cross the placenta from mother to the foetus, andthe placenta actually shields the foetus from HIV. This protection from the placenta maybreak down if:• The mother has a viral, bacterial, or parasitic placental infection• The mother becomes infected with HIV during the pregnancy, and hence develops ahigh level of HIV for a short time• The mother has severe immune deficiency associated with AIDSThus, maternal conditions including untreated placental infections (particularly malaria),recent HIV infection, and advanced HIV disease have all been cited as risk factors forMTCT. In addition, malnutrition during pregnancy may directly contribute to MTCT.HIV transmission during labour and deliveryInfants of infected mothers are at great risk of becoming infected with HIV during childbirth.During this event, 10-20% of such infants will become infected if no steps are taken toprevent transmission. Most infants who acquire HIV during labour and delivery do so bysucking, imbibing or aspirating maternal blood or cervical secretions that contain HIV. Theduration of membrane rupture (deliberately performed to augment or induce labour), acutechorioamnionitis (resulting from untreated sexually transmitted infections (STIs) or otherinfections) and invasive delivery techniques that increase the baby’s contact with themother’s blood have been associated with higher risks of MTCT during labour and delivery.HIV Transmission through breastfeedingHIV is present in breast milk, although the viral concentrations in breast milk aresignificantly lower than those found in blood. On average about 15% of babies born to HIVpositivemothers will become infected through sustained breastfeeding (24 months or more).Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org7

Transmission of HIV during breastfeeding is a multi-factorial process. Studies suggest thatthe risk of MTCT through breastfeeding depends on a number of factors:• Pattern of breastfeeding (babies who are exclusively breastfed may have lower risk ofbecoming infected than those who also consume other liquids, milks, or solid foods inthe first months of life)• Breast health (mastitis, cracked and bloody nipples, and other indications of breastinflammations are associated with higher risks of transmission)• Breastfeeding duration• Maternal viral load (which is higher with recent infections or advanced disease of themother)• Maternal immune status• Maternal nutritional statusThe risk of MTCT is believed to double (to about 30%) if the mother becomes infected withthe virus while still breastfeeding. This highlights the importance of primary prevention ofHIV in lactating women.The risk of HIV transmission through breastfeeding is higher if infants are given both breastmilk and formula (mixed feeding). According to WHO recommendations, HIV- positivewomen should be encouraged either to exclusively breastfeed or exclusively formula feed,but not both.Primary prevention of HIV infection in infantsStrengthening and scaling up primary prevention of HIV/AIDS to keep men and women ofproductive age from becoming HIV-infected themselves must be a priority strategy forpreventing MTCT worldwide. Primary prevention efforts have shown success in stabilisingor reducing HIV infection rates in countries such as Senegal, Uganda, and Thailand, wherethey were introduced early in the epidemic and there was strong political commitment,funding and broad coverage. Considerably more is known now about lessons learnt and bestpractices related to achieving primary prevention than in early years of the epidemic.Primary prevention at the community level traditionally relies on three major components,each of which can include prevention of mother-to-child transmission.Promotion and provision of free, subsidised, and/or commercially marketed condomsCondoms are effective against HIV transmission when used correctly and consistently, butthis is not always understood or accepted by people at risk. Condoms are not always availableat high-risk sites such as brothels and discos (youth dancing places). Hence, both promotionand provision are important. Programs that promote condom use for HIV prevention shouldemphasise their role in prevention of MTCT as well as prevention of disease in sexuallyactive adults.Behaviour change communication (BCC) effortsBCC aims at reducing behaviours that place individuals at risk of becoming HIV-infected orspreading the virus to uninfected partners by providing accurate information about individualWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org8

isks, modes of transmission of HIV, and effective means to avoid transmission. It also seeksto motivate individuals to use information consistently and appropriately. BCC programsneed to include information about MTCT in their strategies. These messages should includeinformation about risks of MTCT during pregnancy and delivery and through breastfeeding,and should encourage people to see VCT counsellors or health providers for moreinformation on how to prevent HIV/AIDS among infants and young children.Prevention, diagnosis and treatment of STIsSTI prevention and treatment programs are important because the presence of untreated STIsis now known to increase the risk of transmitting and acquiring HIV. Men and women whoare at risk or have contracted an STI are sexually active and are therefore an appropriatetarget audience for information on MTCT risks and prevention. STI services should includeinformation on the risk of MTCT, modes of transmission, and encouragement to see a VCTcounsellor or health provider for more information on how to prevent HIV/AIDS amonginfants and young children.In addition to the three components described above, MTCT messages should be integratedinto all HIV/AIDS education including life skills curricula, adolescent outreach programs,programs to reach men and school- and faith-based AIDS education programs.Activities for primary prevention of MTCT• Develop social marketing programs for condoms and provide free, subsidised and/orcommercially marketed condoms• Condom quality assurance• Promote condom use during pregnancy to prevent infection with HIV and other STIs• Provide training and technical assistance in BCC best practices• Use BCC for primary prevention, including messages and materials development thattarget pregnant women and couples.• Identify and promote effective sex negotiation skills• Empower women to negotiate for safer sex with their partners• Support educational printing, radio or TV program development and air time• Provide training in STI prevention, diagnosis and treatment• Provide STI medications• Develop STI syndromic management guidelines• Secure funding for surveys of community knowledge, attitudes and practices relatedto HIV/AIDS• Conduct activities to promote political will and support by community leaders• Implement educational and outreach efforts aimed at community members, especiallyrelated to MTCT• Support community-based voluntary counselling and testing (VCT) services• Promote VCT before marriage and before pregnancy• Conduct research in factors influencing mother-to-child transmission of HIV• Prevent vertical transmission through screening, family planning, and healtheducationWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org9

• Intensify efforts to prevent HIV infection in young women• Ensure that HIV-positive women have access to family planning counselling andservicesActivities to promote safe infant feeding• Review and update national breastfeeding and related infant feeding practices• Review status of the national code for marketing of breast milk substitutes andsupport efforts to enforce it.• Support and expand Baby Friendly Hospital Initiatives (BFHI) and ensure that allinfant feeding training include updated information on MTCT• Conduct formative research to adapt United Nations guidelines on infant feeding andHIV at local settings and ascertain locally available replacement feeding options• Adapt Integrated Management of Childhood Illness (IMCI) and other feedingguidelines to local settings as needed• Support training on counselling about HIV and infant feeding options (using oradapting the WHO/UNICEF training package)• Strengthen training in lactation management• Strengthen efforts to promote and support exclusive breastfeeding for six months forall breastfeeding mothers, including mother-to-mother support in the first months oflife• Strengthen nutrition and health support for mothers, especially HIV-infected motherswho choose replacement feeding• Explore ways to make replacement feeding safer for HIV-infected mothers, includingclean water, food hygiene and sanitation improvement• Review and update pre-service training curricula for nurses, midwives, nutritionists,social workers and all other medical/health personnel regarding MTCT issues andbreastfeeding• Strengthen growth monitoring and promotion programs for early identification ofgrowth faltering• Monitor breastfeeding/infant feeding trends in areas of high HIV prevalence• Monitor media reporting on HIV, MTCT and breastfeeding issues and disseminateappropriate informationWays to prevent breast milk transmission of HIV• Provide breastfeeding assistance and counselling, including information on HIV andbreastfeeding in areas with high HIV prevalence.• Avoid breastfeeding completely, or if the woman opts to breastfeed:‣ Encourage exclusive breastfeeding with abrupt weaning, and avoid mixed feeding‣ Reduce the duration of breastfeeding to six months, and ensure that thisbreastfeeding is exclusive‣ Avoid breastfeeding when the mother has a breast disease such as mastitis orcracked nipples‣ Aggressively treat oral thrush or ulcers in the babyWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org10

women therefore need to be educated about HIV transmission through breast milk and aboutoptions to protect their children.Promotion of exclusive breastfeeding as the best possible nutrition for infants has been thecornerstone of child health and survival strategies for the past two decades, and has played amajor part in lowering infant mortality in many regions of the world.It has been reported that the risk of HIV transmission may be lower when exclusivebreastfeeding is practised. This is because HIV is more likely to pass through the infant’s gutwall when the wall is disturbed (as happens when solids are introduced prematurely or whenpathogens are introduced through unhygienic preparation of formula or other foods).Exclusive breastfeeding of infants is generally recommended for the first six months of theirlives, and breastfeeding with complementary foods thereafter, preferably up to twenty-fourmonths. Breastfeeding has many physical and psychological benefits for infants and mothers,as well as economic benefits to households and communities.Benefits of breastfeeding to the infant• Provides a nutritionally complete food• Strengthens the infant’s immune system, thus preventing many infections• Reduces the infant’s exposure to infections• Safely rehydrates and provides essential nutrients to a sick child, especially thosesuffering from diarrhoeal diseases• Contributes to birth spacing and thus increases the child’s chances of survivalBenefits of breastfeeding to the mother• Reduces the woman’s risk of excessive blood loss after delivery• Provides natural method of delaying pregnancy through the lactational amenorrheamethod (LAM)• Reduces the risk of ovarian cancer, breast cancer, and osteoporosis (bone disease)Benefits to the household and community• Conserves the funds that otherwise would have been spent on breast milk substitutes,supplies, and fuel to prepare the substitutes• Saves medical costs to families and governments by preventing illness and byproviding postpartum contraceptionThe emergence of HIV/AIDS has negatively affected the gains made by breastfeedingcampaigns in the 1990s. This valuable infant food and nutrient source and its many benefitsare now threatened by the HIV/AIDS pandemic. When alternative complementary feeds aregiven to infants, all the benefits of breast milk are compromised or lost.The World Health Organisation (WHO) recommends that Voluntary Counselling and Testing(VCT) be provided to all pregnant women to allow for informed decision-making aboutbreastfeeding. For women who are HIV positive, the WHO in 1999 outlined breastfeedingguidelines, giving four options:Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org12

1. Give suitable a replacement for breast milk, provided it is affordable for six monthsand can be prepared accurately and hygienically. The risk of HIV infection by breastmilk is thereby eliminated.2. Where suitable replacement feeding is not possible, exclusively breastfeed for 3-6months followed by abrupt cessation, thus largely reducing the risk of HIVtransmission.3. Manually express and heat-treat breast milk, or use a breast milk bank.4. Use a wet nurse who is documented HIV-negative and accepts the risk of beinginfected by the baby.Infant Feeding PracticesThe WHO/UNIAIDS/UNICEF guidelines on HIV and infant feeding (WHO 1998)recommend that HIV-positive mothers should be counselled on the advantages anddisadvantages of different infant feeding options and should be assisted to select the bestoption given their specific circumstances. It is the mother who makes the final choice on howto feed her child, and she should be supported in whatever method she chooses.In resource-limited settings, HIV-positive mothers have been faced with a dilemma overfeeding options, given that they cannot afford formula feeding, and moreover lack safe water,adequate fuel, and good sanitation with which to prepare the formula.Their situation is made worse by cultural child feeding practices and the stigma associatedwith HIV/AIDS.Studies from the south Saharan region indicate that although breastfeeding is the mostprevalent form of infant feeding, exclusive breastfeeding rates are extremely low. A study oninfant feeding practices in Tanzania and Uganda showed that the average breastfeedingperiods were 24.0 and 18.3 months respectively. But in Tanzania, half the study participantshad introduced liquids by 4 months while Uganda participants reported introducing liquids by6 months. Water and other liquids are given to infants very early in life by most sub-SaharanAfrican mothers.Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org13

REFERENCESAnderson VA (1997). The placental barrier to maternal HIV infection. Obstetrics andGynaecology Clinical North America 24 (2): 797-820.Dabis F, Newell ML, Fransen L, et al. (2000). Preventing mother-to-child transmission ofHIV in Developing countries: Recommended Practice. Health Policy Plan 15 (1): 39-42.Central Bureau of Statistics (2003). Kenya Demographic and Health Survey (KDHS).Coutsoudis A, Pillay K, Kuhn L, Spooner E, Coovadia HM (1999). Influence of infantfeeding pattern on early mother-to-child transmission of HIV-1 in Durban, South Africa: aprospective cohort study. South African vitamin A study group. Lancet 354 (9177): 471-6.Coutsoudis A, Pillay K, Kuhn L, Spooner E, Coovadia HM (2001). Method of infant-feedingand transmission of HIV=1 from mothers to children by 15 months of age: A prospectivecohort study from Durban, South Africa. AIDS 15:379-87deCock K, Fowler MG, Mercier E, et al. (2000b). Prevention of mother-to-child HIVtransmission in resource-poor countries. Journal of American Medical Association. 283:1175-82.Dunn DT, Newell ML, Ades AE, et al. (1992). Risk of human immunodeficiency virus type 1transmission through breastfeeding. Lancet 340:585-88.Government of Kenya (2004) Ministry of Health, CDC and UNAIDS, Published in UNAIDSReport, July 2004.Latham MC, Preble EA (2000). Appropriate Feeding Methods for Infants of HIV-InfectedMothers in Sub-Saharan Africa. British Medical Journal 320: 1656-1660.Linkages (2001). Breastfeeding and HIV/AIDS: Frequently asked QuestionsLinkages (2000). Facts for Feeding; Recommended Practices to Improve Infant Nutritionduring the First Six Months. Washington DC.Linkages (2000). Facts for Feeding; guidelines for Appropriate Complementary Feeding ofBreastfed Children 6-24 Months of Age. Washington DC..Mofenson LM, Mcintyre JA (2000). Advances and research directions in the prevention ofmother-to-child HIV-1 transmission. Lancet 355:2237-44.National Council for Population and Development (NCPD) (2005). Kenpop News: Improvingthe Quality of our Population ICPD +10 Lessons Learnt. Vol 1 No. 2Preble EA, Piwoz EG (2001). Prevention of Mother-To-Child Transmission of HIV in Africa.A Practical Guidance for Programs.Poggensee Gabriele, K.Schuidze, I. Moneta, P. Mbezi, C. Baryomunsi and Harma.G. (2004).Infant feeding practices in western Tanzania and Uganda: implication for infant feedingWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org14

Nyblade L, Field ML (2000). Women, Communities, and the Prevention of Mother-to-Child Transmission of HIV: Issues and Findings from Community Research in Botswanaand Zambia. International Center for Research on Women. Available at:http://www.icrw.org/docs/finalsynthesis.docSaba J (1999); The results of the PETRA intervention trial to prevent perinatal transmissionin sub-Saharan Africa. Abstract S6. Paper presented at the 6 th Conference on Retrovirusesand opportunistic infections, Chicago, February.Semba RD (1997); Overview of the potential role of vitamin A in mother-to-childtransmissionof HIV-1. Acta Paediatrics Supplement 421: 107-12.South Africa Department of Health (2000). Prevention of. mother-to-child HIV transmissionand management of HIV positive pregnant women. HIV/AIDS and STD Directorate,Department of Health, South Africa. Available at:http://www.cadre.org.za/BAC/BACpdf/search='MTCT'Witkor SZ, Leroy V, Ekpini ER. (2000): 24-month efficacy of short course maternalzidovudine for the prevention of mother-to-child HIV-1 transmission in a breastfeedingpopulation: A pooled analysis of two randomised clinical trials in West Africa. AbstractTuOrB354. A Paper presented at XIII International AIDS Conference, Durban, South Africa.WHO/UNICEF (2000). Children with HIV/AIDS. In Management of the Child with a Seriousinfection or severe malnutrition.RECOMMENDED WEBSITESThe MTCT-Plus Initiativewww.mtctplus.orgAvert.org – Preventing Mother-to-Child Transmission of HIVhttp://www.avert.org/motherchild.htmWorld Health Organization – Mother-to-Child Transmission of HIV (MTCT)http://www.who.int/reproductive-health/stis/mtct/index.htmWorld Health Organization – MTCT Nevirapinehttp://www.who.int/reproductive-health/publications/archive/nevirapine.htmWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.org16

Case Studies – Student GuideDear students,These tutorial problems will be done in two sessions led by a tutor. Your tutor will provideyour group with ample opportunities to be self-directing and active in your own quest forknowledge and reflection by working through the case study in a discussion session. Thismeans that you will need to participate actively in the discussion and queries on the casestudy presented.The stories of Rukia, Auma and Jennifer were specifically selected to introduce the breadthand scope of women’s health from sociocultural, geopolitical, educational, and humanrelations perspectives. The three case studies given in this module highlight the plight ofwomen as people and as mothers, and explore the factors which adversely affect theirphysical, social, emotional, and mental well-being (the WHO definition of health).Breastfeeding is the lifeline of an infant’s health. This great source of nutrition and health forinfants has been adversely affected by the onset of HIV/AIDS. Most societies expect mothersto breastfeed their newborns, and deviant behaviour can be treated harshly, especially in thedeveloping world. This has left mothers in a dilemma over whether or not to feed theirnewborns. In resource-limited situations, it is even more difficult for mothers to practice safeinfant feeding due to their inability to provide adequate supplementary or replacementfeedings. Stigma for PLWHA is yet another compounding factor affecting infant feeding inthis era of HIV/AIDS.The case studies are purposely designed to be brief and poignant. The objective of eachdiscussion is not to concentrate on a solution (diagnosis) to the problem. Rather, the focus isto understand and reflect on the underlying issues and mechanisms involved, and theirrelationship to the symptoms and signs which are presented.You are thus encouraged to explore the wider meaning of women’s health outside the scopeof diagnosis and management of disease states specific to women. As such, an open-ended,less structured approach to the discussion is proposed.Questions related to the case studies are included as a guideline and not as a compulsory orstrict protocol for the group discussion. Ideally, these questions should be raised by studentsthemselves in the course of working through the case study.Each tutorial problem will be carried out in two sessions as described below:Session 1: Raising ObjectivesThe students should do the following before handling each case study:• The group consisting of 6-8 students will elect a chairman and a secretary.• The chairman will lead the group and request one of the members to read the casestudy aloud.• After this, each member will read the case study quietly and comprehend it well.• The chairman will lead the group and ask members to list all the important terms, newwords/terms and give the theme and learning objectives of the case study. Thesecretary will record all points during each session.• The group will be given time within one week to carry out the assignment.Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Studies – Student Guide

Session 2: DiscussionThis session will follow self-study by each member of the group.• The group will convene and report their findings on the assignment:• The group will give definitions of the new terms/words, explain the important pointsin the case study, and give the appropriate theme and learning objectives of the casestudy.• The tutor will then discuss with the group members any points they missed aboutlearning objectives and theme of the case study.Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Studies – Student Guide

Case Study: RukiaRukia is a semi-illiterate 17-year-old married woman living with her mother-in-law inMalindi, Kenya. Her husband, Baraza, has been ill for some time and has lost a lot of weight.When Baraza visited voluntary counselling and testing (VCT), he was found to be HIVpositive.He has not disclosed his HIV status to his wife Rukia.Rukia is expecting her first baby and is in her seventh month of pregnancy. She is sickly andmalnourished. This has made her feel very weak.Whenever she complains of any pain, her mother-in-law boils some herbs (roots and leaves)and gives them to her to drink. Rukia has no money to pay hospital bills, or to go to theantenatal clinic. Consequently, her mother-in-law has made arrangements with the traditionalbirth attendant to help her during delivery. Rukia does not know her HIV status since she hasnot been to any VCT.Questions for students1. What are the risks that Rukia is most likely to expose the foetus to?2. Suppose that Rukia is HIV- infected, and she is delivered by the traditional birthattendant. What steps should she take to protect her infant from an HIV infection?3. What advice would you give Rukia to improve her nutritional status and health?Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Study: Rukia

Case Study: AumaAuma is a 28-year-old woman who last year lost her first husband and two children, aged 6and 20 months respectively. She thought the children died as a result of protein-energymalnutrition (PEM). Both children had long diarrhoeal illnesses, fever, and severe wasting.Auma has frequent fever and diarrhoea that has resulted in weight loss.Auma has recently remarried and had another baby. She experiences a lot pain whilebreastfeeding due to her cracked nipples. She also says that she doesn’t have sufficient breastmilk to satisfy the baby, and she is already considering introducing complementary foods asshe continues to breastfeed.The community health worker who visited her recently advised her go to the nearby healthcentre for a medical examination. She went and was referred to the VCT section. When testedshe was found to be HIV-positive.She was advised on options of safe breastfeeding. She is not willing to follow the instructionsgiven to her on safe infant feeding because that may make her husband suspect her of beingHIV-positive.Questions for students1. What disease conditions can cause cracked nipples?2. What are the risks of breastfeeding when the nipples are cracked?3. What options of safe breastfeeding would you advise Auma to follow?Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Study: Auma

Case Study: JenniferJennifer is a 30-year-old woman with a three-month-old infant. Her boyfriend died fromAIDS-related infections before she had the baby. She then left Nairobi and is now living inKisumu. She has married another man. Her husband doesn’t know about her late boyfriend’scause of death. Jennifer has gone for VCT and knows her HIV status.She is HIV-positive. She has not disclosed her HIV status to her husband or any member ofher family. She was counselled on proper breastfeeding practices at the postnatal clinic, andwas advised to practice exclusive breastfeeding and avoid mixed feeding.But she insisted that she would breastfeed her baby like everyone else to avoid arousing anysuspicions about her health. Now she has started feeding the baby on diluted porridgebecause she does not have sufficient breast milk. The baby has had a few bouts of diarrhoeaand does not seem to gain weight.Questions for students1. Outline the reasons that would make Jennifer hide her HIV status from her husband.2. What are the dangers of mixed feeding to infants?3. What are the possible causes of weight loss in Jennifer’s infant?Women and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Study: Jennifer

Case Studies – Tutor’s NotesAs a tutor you should provide ample opportunities for students to be self-directing and activein their own quest for knowledge and reflection by working through this case study in adiscussion session. This means that you will need to be patient and refrain as much aspossible from providing all the necessary answers to the students. It also means that you willneed to draw out the quiet and shy members of the small group to share their views andqueries on the case study presented.The stories in this module were specifically selected to introduce the breadth and scope ofwomen’s health from sociocultural, geopolitical, educational, and human relationsperspectives. The case studies highlight the plight of women, the reality of domestic violence,and other factors which adversely affect women’s physical, social, emotional, and mentalwell-being (the WHO definition for health).The case studies were purposely designed to be brief and poignant. The objective of thediscussion session is not to concentrate on a solution (diagnosis) to the problem. Rather thefocus is to understand and reflect on the underlying issues and mechanisms which areinvolved and their relationship to the symptoms and signs which are presented.The tutor is thus encouraged to invite students to explore the wider meaning of women’shealth outside the scope of diagnosis and management of disease states specific to women.As such, an open-ended, less structured approach to the discussion is encouraged.Questions related to the case studies are included as a guideline and not as a compulsory orstrict protocol for the group discussion. Ideally, these questions should be raised by studentsthemselves in the course of working through the case study in the discussion. You are thusrequested to hold on to the question sheets and distribute them at the end of the discussionsession.To assist you in preparing for your tutor role (and not as a resource expert), a number ofreading materials on the topic of women and health and the specific passages which relate tothe case studies and questions are provided. Please do not at any time pass these materials tothe students in your group.Case Study: Rukia – Tutor’s NotesRukia’s story is a typical case of ignorance and poverty among many young women.She cannot attend antenatal clinic, and she will therefore miss out on VCT and any remedialmeasurers and advice on breastfeeding. She relies on her mother-in-law for financial supportand medication. She may need ARVs, and she lacks knowledge of opportunistic infections inAIDS.Points for discussion• Rukia’s lack of knowledge of her HIV status• She will have her baby with a traditional birth attendant• Her husband could be HIV-positive• She has missed counselling on infant feeding• Infant will not be given any ARVs such as nevirapine syrupWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Studies – Tutor’s Notes

• Rukia may not be able to afford complementary or replacement baby foods• Women’s economic empowermentCase Study: Auma – Tutor’s NotesAuma’s case can be seen to represent many widows who lose their husbands and children tocauses they do not understand and do not associate with HIV/AIDS. They also often becomeinfected with HIV.Such women often remarry and have more children who get infected with HIV.Even if they know their HIV status, they practice risky infant feeding practices due to fear ofstigma, and in Auma’s case loss of marriage should the husband suspect her. She at least hashad exposure to the health facilities where VCT and advice on infant feeding are offered.Auma may have mastitis, which will predispose her infant to HIV infection as she continuesto breastfeed.Points for Discussion• Lack of knowledge of causes of breast infections and their dangers in lactation• Practice of mixed feeding and its dangers to the baby• Safe breastfeeding options• Similarities between AIDS and PEMCase Study: Jennifer – Tutor’s NotesJennifer has done what most women do when they have lost their partners to AIDS:they often move to new places where people don’t know their past and remarry. They cannotstop breastfeeding because this raises suspicions about their health. Jennifer cannot declareher status due to stigma of people with HIV/AIDS and fear of losing her marriage. As a resultthe infant’s health and growth are affected.Points for Discussion• Stigma when one is known to be HIV-positive• Cultures that stress breastfeeding by all women• Practice of mixed feeding against advice of proper infant feeding• Use of inadequate and non-nutritious feeds for babies• Effect of poor feeding on infants’ health and growthWomen and Health Learning Package: MTCT of HIV/AIDSwww.the-networktufh.orgCase Studies – Tutor’s Notes