Breastfeeding in the context of HIV: the South African experience

Tanya Doherty

Specialist Scientist UWC School of Public Health & Medical Research Council

Infant feeding and HIV in SA: A History • 2001: PMTCT programme launched with single dose nevirapine • Free formula provided as part of the package • Abrupt cessation of breastfeeding at four months recommended

Infant feeding and HIV in SA: A History 2008: PMTCT Guidelines revised • AZT introduced • Early cessation of breastfeeding no longer recommended • Free formula milk still provided

Infant feeding and HIV in SA: A History 2010: PMTCT guidelines revised • Maternal HAART (CD4 <350) or infant nevirapine for the breastfeeding period • Continued provision of free formula

Infant feeding practices of HIV positive women : what have we learnt?

Feeding choices, 2003

Health Systems Trust: National PMTCT Evaluation, 2003

AFASS

When replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), avoidance of all breastfeeding by HIV-infected mothers is recommended.

WHO 2000

Implementing AFASS

Infant feeding intentions according to 5 key criteria %

80 70 60 50 40 30 20 10 0 Piped water in house or yard Fuel (electricity, gas, parrafin) Main income provider regular employment Use of a fridge Disclosed HIV status* Formula feeders Breast feeders * P-value = 0.01

Doherty et al. AIDS 2007

What about AFASS?

Good Start Study, 2006

Goga et al. Good Start Study: 2011

Preliminary data 2010 national PMTCT 6 week survey: Mixed feeding amongst HIV positive women 100 80 60 40 20 19.7

22.5

14.6

13.5

30.5

29.1

19.7

21.5

6.4

0 E as te rn C ap e Fr ee S ta te G au te ng K w aZu lu -N at al Li m po po M pu m al an ga N or th er n C ap e N or th W es W t es te rn C ap e

Preliminary data: feeding practices of HIV positive women national 6 week PMTCT survey 2010 100 80 60 40 20 0 20 18 62 EBF Mixed feeding Formula feeding

South African context

100 90 80 70 60 50 40 30 20 10 0 urban rural Electricity Piped water in house Flush toilet Fridge SADHS, 2003 17% of mothers in the 2010 PMTCT survey reported running out of food in the previous 12 months

Contamination of formula

• Contamination with E-Coli – At clinic – At home – Demonstration 64% 59% 33% feeds • Contamination with Enterococci – At clinic – At home – Demonstration 26% 56% 14% feeds Andresen E, Rollins N et al J Trop Paed 2004

Why is it so critical to promote breastfeeding in SA?

How are we doing with Exclusive Breastfeeding?

%

50 40 30 20 10 0 100 90 80 70 60 Ethiopia Madagascar Tanzania Uganda Zambia Zimbabwe South Africa 1990-1999 2000-2006 Source: DHS surveys

A bleak picture

Contributing factors to poor infant feeding practices in SA • Longstanding cultural practices of early introduction of other fluids and foods • Support of formula milk through the PEM scheme • Lack of legalization of the Code of Marketing of Breastmilk Substitutes • Provision of formula milk through PMTCT • Lack of breastfeeding promotion

How can we improve feeding practices in SA?

PROMISE STUDY: EBF at 12 weeks ** p<0.01

(%) 100 40 30 20 10 0 90 80 70 60 50 Burkina Faso I 2.3** C Burkina Faso Uganda 1.9** South Africa 1.8** I Uganda C I C South Africa Tylleskar et al. Lancet 2011

Message: Community based support alone is NOT enough

PHC Re-engineering

The Good News! Preliminary data - Infant HIV Exposure and MTCT Rate Measured at 4-8 weeks Province MTCT (%) 95% CI

Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape Northwest Western Cape National

Infant HIV exposure (%)

30.0 (26.3-33.7) 31.1 (28.9-33.3) 30.2 (27.7-32.8) 43.9 (39.7-48.0) 22.6 (20.4-24.8) 36.2 (33.6-38.9) 15.6 (13.0-18.3) 30.9 (28.6-33.1) 20.8 (16.8-24.9)

31.4 (30.1-32.6)

3.5 (1.2-5.8)* 5.7 (3.5-7.9) 2.3 (1.3-3.3) 2.8 (1.7-4.0) 3.4 (1.0-5.8) 6.2 (4.5-7.9) 1.9 (0.1-4.5)* 4.6 (3.0-6.1) 3.3 (1.3-5.2)

3.5 (2.9-4.1)

No more mixed messages!

National or sub-national health authorities should decide whether health services will principally counsel and support mothers known to be HIV-infected to either: » breastfeed and receive ARV interventions »

Or

avoid all breastfeeding Taking into account: •socio-economic and cultural •availability and quality of health services, •main context causes of maternal and child undernutrition •main causes of infant and child mortality WHO 2010

What is needed Health System Actions • Implement a national media and communication campaign for health workers and the general public promoting breastfeeding as a key intervention to reduce child mortality • Train all health workers in the above, including doctors, nurses, dieticians and community health workers during initial training and reinforced during in service training.

• Rapidly increase the proportion of hospitals with Baby Friendly status • Employ breastfeeding counsellors in health facilities and at community level • Train existing community health workers to support breastfeeding and establish a system of home visits to women postpartum for lactation support

Formula withdrawal – what are the cost savings?

274,539 HIV exposed infants born/ year 62% are formula fed ( 170,214 ) Conservative cost of R1200/infant for 6 months formula supply Annual cost of formula provision = R204 million Number of CHWs that could be employed with the cost saving from formula = 6800 (based on annual package of R30,000 planned for PHC outreach teams)

AFASS defined, WHO 2010

• safe water and sanitation are assured at the household level and in the community,

and

• the mother, or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant,

and

• the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition,

and

• the mother or caregiver can, in the first six months, exclusively give infant formula milk,

and

• the family is supportive of this practice,

and

• the mother or caregiver can access health care that offers comprehensive child health services.

What is needed: Policy Actions • Legally enforce the Code of Marketing of Breastmilk Substitutes • Avoid using formula milk in health facilities • No advertising of formula in health facilities.

• Restrict advertising/promotion of formula, including at professional conferences.

• Review the current policy of provision of free formula milk to HIV-positive women

Conclusion

• Under 5 mortality rate is unacceptable • We know that breastfeeding is the most potent intervention to reduce mortality • Peri partum MTCT has been dramatically reduced = postnatal now the greatest proportion of infections • Mixed messages = mixed feeding!

• South Africa needs one default feeding option breastfeeding.

Acknowledgements

• Professor David Sanders • Dr Ameena Goga