World Health Organization. HIV and Infant Feeding: Framework for Priority Action, Guidelines and Related Tools

Transcription

1 World Health Organization HIV and Infant Feeding: Framework for Priority Action, Guidelines and Related Tools 2004

2 Timing and risks of HIV transmission in absence of interventions During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% Overall without breastfeeding 15-25% Overall with breastfeeding until 6 months 25-35% Overall with breastfeeding until 18 to 24 months 30-45% Adapted from De Cock et al., JAMA 2000

3 Relative risk of infectious disease mortality among nonbreastfed infants 5.8 Relative risk <2 2 to 3 4 to 5 6 to 8 9 to to 23 age group (months) WHO, Lancet 2000

4 UN recommendations HIV- or status unknown Exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for 2 years or beyond HIV+ When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first months of life Counselling should include information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option

5 Global Strategy for Infant and Young Child Feeding (2002) Sets context for all actions, including in exceptionally difficult circumstances The HIV pandemic and the risk of mother-to-child transmission of HIV through breastfeeding pose unique challenges to the promotion of breastfeeding, even among unaffected families.

6 The IYCF strategy and HIV Mother's milk is unsuitable only under exceptional circumstances Only health workers should demonstrate preparation of breastmilk substitutes, and only to mothers who need to use it Infants who are not breastfed constitute a risk group All HIV-infected mothers should receive counselling Adequate replacement feeding is needed for infants born to HIV-positive mothers who choose not to breastfeed

7 HIV and Infant Feeding: Framework for Priority Action (2003) Purpose: To recommend key priority actions, related to infant and young child feeding, that cover the special circumstances associated with HIV/AIDS. The aim is to create and sustain an environment that encourages appropriate feeding practices for all infants, while scaling-up interventions to reduce HIV transmission. (WHO/UNICEF/UNFPA/UNAIDS/World Bank/UNHCR/WFP/FAO/IAEA)

8 HIV and Infant Feeding Framework: Priority action areas Provide support to HIV+ women Promote research Comprehensive policy Code of Marketing Promote IYCF in context of HIV, including BFHI

9 HIV and Infant Feeding Framework: Priority Area 1 Develop a comprehensive national IYCF policy, including HIV and infant feeding Draft or revise existing policy to reflect current knowledge on appropriate feeding practices in general and in relation to HIV Build consensus among stake-holders Promote consistency with other policies Develop means for implementation

10 HIV and Infant Feeding Framework: Priority Area 2 Implement the Code of Marketing (and subsequent relevant WHA resolutions) Implement the Code at the national level Monitor compliance If the country has decided to provide replacement feeding, establish appropriate supplies/logistics systems and mechanisms in accordance with the Code and subsequent relevant WHA resolutions

11 HIV and Infant Feeding Framework: Priority Area 3 Protect, promote and support appropriate IYCF practices in the context of HIV: increase priority given to IYCF develop and implement guidelines on IYCF, including HIV build capacity for promoting primary prevention of HIV revitalize and scale-up the BFHI

12 HIV and Infant Feeding Framework: Priority Area 4 Provide support to HIV+ women in their chosen infant feeding method Expand access and demand for improved ANC and VCT Integrate counselling into MCH services Support orientation of managers and capacity development of counsellors and health workers on breastfeeding counselling and HIV and infant feeding Provide follow-up of mothers and infants, including nutritional support to mothers Strengthen follow-up and supervision of health workers Develop and implement comprehensive communications strategy

13 HIV and Infant Feeding Framework: Priority Area 5 Promote research on HIV and infant feeding, monitoring and evaluation Carry out formative research on local feeding options Promote assessment and evaluation of programmes related to HIV and Infant Feeding Disseminate results and other information Revise national guidelines in response to new knowledge

14 HIV and Infant Feeding Framework: What s New Global Strategy recognizes that HIV-positive mothers need special support Framework recognizes that support to HIV-positive mothers requires an environment in which breastfeeding is promoted, supported and protected Strategy and Framework both build on previous and ongoing efforts such as the Code, BFHI and other child health and reproductive health initiatives Prevention of HIV transmission to infants and young children should include activities outlined in Framework

15 Revised HIV and Infant Feeding tools: HIV transmission through breastfeeding: A review of available evidence (1) Audience: policy-makers, planners, researchers Purpose: provide technical background and rationale for guidance (WHO/UNICEF/UNAIDS/UNFPA, 2004)

16 Revised HIV and Infant Feeding tools: HIV transmission through breastfeeding: A review of available evidence (2) Presents available scientific evidence on transmission of HIV through breastfeeding: describes benefits of breastfeeding summarizes evidence on relative risk of MTCT during pregnancy, delivery, and breastfeeding focuses on HIV transmission through breastfeeding: rates, mechanisms, timing, risk factors and approaches for prevention

17 Revised HIV and Infant Feeding tools: Guidelines for decision-makers Audience: policy-makers, planners and senior administrators Purpose: provide guidance on key issues and highlight areas of special concern (WHO/UNICEF/UNAIDS/UNFPA, 2003)

18 Revised HIV and Infant Feeding tools: A guide for health-care managers and supervisors Audience: Mid-level managers Purpose: to help plan, implement and strengthen services (WHO/UNICEF/UNAIDS/UNFPA, 2003)

19 Major revisions: Guidelines and Guide Incorporate recommendations from 2000 Technical Consultation Within context of Global Strategy on IYCF Programmatic experience Organization around HIV and IF Framework More guidance for countries considering providing free or subsidized formula

20 Guidelines and Guide: Content - Feeding options for first six months (1) Replacement feeding: Commercial infant formula Home-modified animal milk Breastfeeding: Exclusive with early cessation Breast-milk feeding options: Expressed and heat-treated BM Wet-nursing BM banks

21 Guidelines and Guide: Content - Feeding options for first six months (2) Definitions For each option: Explanation of risks Programme experience Considerations for decision-makers and managers Breastfeeding: Early cessation Transition Safety in terms of HIV

22 Improved guidance based on programme experiences: counselling on infant feeding options (1) Formative research to determine local options Types of counsellors: health workers, lay counsellors Training of counsellors: all health workers, BFC and HIVC Integration of counselling into MCH: for all mothers Timing of counselling: at key points

23 Improved guidance based on programme experiences: counselling on infant feeding options (2) Content and process of counselling: benefits, risk and challenges of local infant feeding options whether replacement feeding is AFASS implications of feeding options for mother and child guidance on most suitable option Follow-up and support independent of mother's choice

24 Decision-makers: ART and infant feeding No evidence yet available on impact of ARV use during breastfeeding on health of mother or infant Whatever ARVs used, infant feeding recommendations in guidelines still apply Questions remaining: Can ARVs reduce postnatal transmission Drugs to infant, mother or both Health consequences for mother and baby

25 Decision-makers: Example of practical changes (1) AFASS defined, e.g. Acceptable: The mother perceives no barrier to replacement feeding. Barriers may have cultural or social reasons, or be due to fear of stigma or discrimination. This concept includes: There is no social or cultural pressure attached to using replacement feeding. The mother is supported by family and community, or the mother will be able to cope with pressure from family and friends to breastfeed and she will be able to deal with possible stigma if people see her with replacement food.

26 Decision-makers: Example of practical changes (2) Key steps and issues for decision-makers: Has a situation assessment and analysis on infant and young child feeding in the context of HIV been completed on which to base policy, strategy and guidelines? No Carry out assessment and analysis (section 3.2 and Annex 1) Yes Update the assessment as necessary over the course of the programme Use information as a baseline for national policy (section 3.1) and for monitoring and evaluation (section 7)

27 Decision-makers: Example of practical changes (3) Guidance on provision of formula (1): Free or subsidized infant formula could be provided when: Uninterrupted supply guaranteed Code respected Procured through normal channels Formula up to 6 months, and formula or milk up to 1 year needed Consider provision of equal support for women choosing other options

28 Decision-makers: Example of practical changes (4) Guidance on provision of formula (2): Pre-requisites to be in place before distribution: Trained counsellors Guidelines for distribution Practical demonstrations Monitoring of health outcomes

29 What are the options: Using formative research to adapt global recommendations on HIV and infant feeding to the local context (1) For programme managers, researchers and policy-makers Provides guidance on how to conduct local assessments of feeding options based on AFASS (WHO/UNICEF, 2004)

30 What are the options: Using formative research to adapt global recommendations on HIV and infant feeding to the local context (2) Assessment useful for developing: national policies and guidelines for health workers content for training of counsellors behaviour change communications strategies Describes 12-step process for formative research Recommends research methods Gives suggestions for: analysing findings disseminating results

31 Breastfeeding and replacement feeding practices in the context of mother-to-child transmission of HIV: an assessment tool for research For researchers Provides guidance on establishing association between infant feeding patterns and HIV transmission (WHO, 2001) Counselling and infant feeding practices of mothers in programmes to prevent mother-to-child transmission of HIV For researchers Evaluates counselling strategies (UNICEF, 2002)

32 HIV and Infant Feeding: Counselling Course For health workers/counsellors Requires background in breastfeeding counselling, or combined course Provides skills and knowledge needed to counsel and support HIV-positive mothers in feeding decisions Extensive practice in counselling and in preparing replacement feeds (WHO, 2000)

33 HIV and Infant Feeding: Counselling Tools For health workers/counsellors trained in HIV and infant feeding Tools consist of: Counselling flow chart Counselling cards to use with mothers Take-home flyers Reference guide Orientation guide Need for local adaptation (WHO, UNICEF, AED, in press)

34 Other tools (1) Guidelines for follow-up after training in breastfeeding counselling and HIV and infant feeding counselling courses (WHO and UNICEF, 2003) For supervisors For BF counselling and HIV and IF counselling BFHI Health Administrators Course (under revision) 2 versions one for countries where HIV is significant problem

35 Other tools (2) Guidance on complementary feeding of the non-breastfed child (in process) Review published as journal article Guiding Principles for Feeding the Non-breastfed Child March 2004 meeting report

36 Steps to promote use Dissemination in regional workshops, conferences, meetings in conjunction with Global Strategy dissemination and planning Build national capacity Obtain feedback on utilization