Counselling on infant feeding choice: Some practical realities from South Africa

By Tanya Doherty (pictured), Mickey Chopra and Mike Colvin

Tanya is currently a senior scientist at the Health Systems Trust and Medical Research Council in Capetown, South Africa. For the past five years, her research has focused on PMTCT of HIV involving national evaluations of programme coverage, qualitative investigation of infant feeding, and a multi-site cohort study assessing HIV transmission. Her main area of interest is implementation of infant feeding recommendations in operational settings.

Mickey Chopra is Director of the Health Systems Research Group of the South Africa Medical Research Council.

Mark Colvin is a Director of the Centre for Aids Development, Research and Evaluation (CADRE), and is based in Durban, South Africa.

A health worker interviewing a mother on a home visit

Avoiding transmission of HIV from mother to child after birth has become one of the greatest challenges in HIV prevention. Approaches to date to reduce or prevent postnatal transmission through breastfeeding have included the avoidance of all breastfeeding through the use of exclusive replacement feeds, or exclusive breastfeeding for a limited duration with early and rapid cessation of breastfeeding as soon as it is feasible (see box).

Implications of infant feeding choice

Programmes for prevention of mother to child transmission (MTCT) need to focus not only on preventing HIV transmission but also on improving child survival. Exclusive breastfeeding has been identified as the single most effective way of saving the lives of millions of young children in developing countries¹, a fact that is supported by international policy² and operational guidance for emergency contexts³. Although most infants in sub-Saharan Africa are breastfed, rates of exclusive breastfeeding are low as early introduction of liquids is a common practice. It is against this background that infant feeding recommendations for women with HIV are being implemented. If women with HIV are to succeed in practising exclusive infant feeding, then improvements in infant feeding practices in the general population are necessary to ensure that exclusive breastfeeding is the norm rather than an exception.

A recent study⁴ from South Africa has confirmed earlier findings⁵ that exclusive breastfeeding results in a lower rate of postnatal HIV transmission compared to mixed feeding. This study, undertaken in a rural area in KwaZulu- Natal province, found a cumulative postnatal HIV transmission risk of 4.04% after five months of exclusive breastfeeding. Infants who were fed both breast and formula milk at age twelve weeks were twice as likely as exclusively breastfed infants to be infected (HR 1.82, 95% CI: 0.98-3.36).

Recent data from Mozambique⁶ and the ZVITAMBO study in Zimbabwe⁷ have highlighted the dangers of early cessation of breastfeeding under conditions of underlying poor socio-economic status and food insecurity. In Mozambique, commonly consumed, locally available foods would not meet the nutritional needs of non-breastfed infants between 6-12 months of age and replacing breastmilk with local foods would double the estimated daily cost of feeding a 6-12 month infant. In Zimbabwe, most of the infant diets only met 58% of the infant's energy needs and were insufficient in animal milks or formula.

Replacement feeding means feeding an infant a diet that provides the necessary nutrients while receiving no breastmilk. Recent research and experiences from Botswana (see research summaries in this issue of Field Exchange) highlight the risks of formula feeding and reinforce the importance of individual assessments of home and environmental circumstances in the process of decision-making. In low and middle income countries and in emergency contexts, replacement feeding is unlikely to be the most appropriate choice for HIV positive women due to socio-economic environments that are not conducive to safe replacement feeding.

The importance of counselling

Given the implications that infant feeding choice may have for child survival, infant feeding counselling and support is one of the most important components of PMTCT programmes.

In many countries, shortcomings in the implementation of the WHO guidelines have been found. Inadequate training of health workers, particularly infant feeding counsellors, about the relative risks associated with infant feeding in the context of HIV, lack of culturally sensitive counselling tools, and the stigma associated with replacement feeding, all make appropriate and effective infant feeding counselling difficult.

Within the context of busy antenatal clinics, it is not surprising that the quality of infant feeding counselling has generally been found to be poor.

One intervention that has been shown in a variety of settings to increase exclusive breastfeeding is peer counselling. Peer counselling is a proven cost-effective approach for changing behaviour. Community-based interventions using local women's groups have also been shown to change behaviour in relation to infant feeding and birth outcomes.

Investigation of Infant feeding choice and practices in South Africa

Due to the poor follow up of HIV positive women through routine public health services in South Africa, very little is known about the actual infant feeding practices of this group. In order to describe these practices, the national Department of Health of South Africa (DoH) commissioned a group of research institutions to conduct a prospective cohort study known as the 'Good Start' study in three PMTCT sites; Paarl (rural/peri-urban Western Cape), Umlazi (peri-urban KwaZulu- Natal) and Rietvlei (rural Eastern Cape) in South Africa.

Context

Paarl is situated 60 km from Cape Town in the heart of the Winelands region. The approximate total population for the district is 198 546. Paarl East Hospital currently renders 97% of antenatal care services in the district with an average of 210 - 381 new bookings per month. All deliveries are done at Paarl Regional Hospital. The antenatal HIV prevalence is 9% and the infant mortality rate is 30 per 1000 live births.

Umlazi is a peri-urban formal township with interspersed informal settlements situated roughly 20km southwest of Durban, in the Durban-Ilembe health district in KwaZulu- Natal Province. There is one regional hospital, Prince Mshiyeni Memorial Hospital that serves as a referral hospital for the surrounding feeder clinics. Maternity services (including a 40-bed antenatal ward and 40-bed labour ward) and paediatric services (including a neonatal unit and paediatric outpatient services) are available at the hospital. The antenatal HIV prevalence is 47% and the infant mortality rate is 68 per 1000 live births.

Rietvlei is situated in one of the poorest sub-district of South Africa. The infant mortality rate is 99/1000 live births. Diarrhoea, malnutrition and lower respiratory tract infections are the major causes of infant mortality. A community survey in the neighbouring Mount Frere district found out that 40% of mothers reported delivering their last child at home. The antenatal HIV prevalence is 28%.

Study findings

This study recruited 665 HIV positive women and followed them until their infants were 36 weeks of age through regular home-based interviews and assessments of infant feeding practices and HIV transmission.

The infant feeding intentions (i.e. how they planned to feed their infant following counselling) of women enrolled in the study differed greatly between the sites (Figure 1) and did not reflect what would be expected for the socio-economic or geographic region, i.e. more women in the rural Rietvlei site chose to formula feed. Qualitative research⁸ has shown that women rely heavily on the advice of health workers in guiding their feeding choices. The power and influence of health workers over mothers feeding choices was also found to have increased with the new knowledge that they possessed regarding HIV and infant feeding.

The home circumstances of women choosing to breastfeed and women choosing to formula feed were similar in terms of access to piped water, a sustainable source of cooking fuel, household income and use of a fridge. There were, however, higher rates of disclosure of HIV status amongst women who chose to formula feed (figure 2). This clearly indicates that the WHO/ UNICEF guidelines are not being utilised in counselling resulting in poor infant feeding decisions being made on both sides, i.e. inappropriate choices to breastfeed and to formula feed.

Given the finding that many women in this observational study did not appear to be making appropriate infant feeding choices, we sought to identify key individual and environmental criteria that could be used to guide appropriate infant feeding choices in operational settings, and to assess the effect of inappropriate feeding choices on infant HIV-free survival.

Criteria to guide infant feeding choice

Criteria deemed to constitute appropriateness of formula use based on the WHO/UNICEF guidelines (acceptable, feasible, affordable, sustainable and safe) were identified as piped water in the house or yard; electricity, gas or paraffin for cooking fuel; disclosure of HIV status by three weeks postpartum; having someone in the household employed; and access to a fridge for storage of prepared formula. Further analysis was undertaken to determine which of these criteria best predicted infant HIV-free survival.

Children playing in the Paarl informal settlement, one of the survey sites

Implications of inappropriate choice on HIVfree survival

An assessment score with piped water in the house or yard, electricity, gas or paraffin for cooking fuel and HIV status disclosure, was deemed to be the best measure of appropriateness in terms of yielding the greatest benefit for HIV free survival. Based on this score, amongst women who intended to formula feed, 67.4% made an inappropriate choice and amongst women who intended to breastfeed, 30.5% met the defined criteria for appropriate formula feeding. Infants of women who were classified as inappropriate formula feeders (i.e. not meeting the criteria in the score) had a three times greater risk of HIV transmission or death compared to women who chose to formula feed who did meet the three criteria. This finding highlights the importance of adequate assessment of individual and environmental circumstances during infant feeding counselling.

These infant feeding choices and practices lead to different rates of late HIV transmission across the three sites (figure 3). Only the Paarl rate was similar to a previous Breastfeeding and HIV International Transmission Study (BHITS) meta-analysis⁹. In Umlazi, the late transmission (3-36 weeks) accounted for almost half of the overall transmission and in Rietvlei it accounted for over half of total transmission and almost triple the rate at 36 weeks found in the BHITS meta-analysis.

Recommendations

Dried blood spot method for mother's viral load testing

Based on our research we make the following recommendations;

• Exclusive breastfeeding for six months is recommended as the preferred infant feeding method for HIV positive women in the first 6 months until replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) for them and their infants
• All HIV exposed infants should receive regular follow up care and periodic reassessment of infant feeding choices based on individual and environmental circumstances.
• At six months, if AFASS criteria are not met, HIV-infected women should continue to breastfeed their infants and give complementary foods in addition, and return for regular follow-up assessments. As soon as AFASS criteria are met all breastfeeding should stop.
• Breastfed infants who are HIV-infected should continue to be breastfed according to the infant feeding recommendations for the general population.
• Protection, promotion and support for optimalbreastfeeding practices in the general population should be re-vitalized in order to help HIV-infected and other women who choose exclusive breastfeeding to practise their choice without stigma or discrimination.
• All HIV-exposed infants and their mothers should receive the full package of maternal health and child survival interventions with strong linkages to HIV prevention, treatment and care services.

For further information, contact Tanya Doherty, email: Tanya@hst.org.za For more details on related work, see online at: CADRE: http://www.cadre.org.za Health Systems Trust: http://www.hst.org.za MRC South Africa: http://www.mrc.ac.za

¹Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361(9376):2226-34. and Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study G. How many child deaths can we prevent this year? Lancet 2003;362(9377):65-71.

²UNICEF/WHO. Global strategy for infant and young child feeding. Geneva: World Health Organisation, 2003.

³Operational Guidance on Infant and Young Child Feeding in Emergencies. For Emergency Relief Staff and Programme Managers. Version 2.0, May 2006. Avaialble from the ENN and at http://www.ennonline.net

⁴Rollins N. HIV transmission and mortality associated with exclusive breastfeeding: implications for counselling HIVinfected women. International AIDS Conference. Toronto: PATH Satellite Session, 2006

⁵Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet 1999;354(9177):471-6. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005;19(7):699-708.

⁶Johnson W, Alons C, Fidalgo L, Piwoz E, Kahn S, Macombe A, et al. The challenge of providing adequate infant nutrition following early breastfeeding cessation by HIV-positive, food insecure Mozambican mothers. International AIDS Conference. Toronto, 2006.

⁷Humphrey J. Why consider breastfeeding cessation at six months for HIV positive mothers? International AIDS Conference. Toronto: PATH, 2006

⁸Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: "When they see me coming with the tins they laugh at me". Bull World Health Organ 2006;84(2):90-96.

⁹Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, et al. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis 2004;189(12):2154-66.