Embedded video follows On May 17, 2016, the Interagency Task Team (IATT) on Children and HIV and AIDS had a webinar on the new WHO HIV and Infant Feeding guidelines. , Key points, Key Themes:, The WHO recommends that HIV positive mothers exclusively breastfeed their infant for the first six months of life then continue to breastfeed until twelve months while introducing other foods. After the first twelve months of life, breastfeeding should only cease when a nutritionally adequate and safe diet can be provided. Health workers are a…, Challenges:, Low rates of first trimester attendance in ANC. Limited capacity for counselling infant and young child feeding. Limited data on breastfeeding status collected at health facility level. Health workers do not have the confidence to translate the current recommendation of breastfeeding to mothers on ARVs into practice for the mothers. Mixed feeding…, Successful Interventions:, Establishment of sustained government leadership from the outset. Peer to peer support such as Mentor Mothers in Kenya with strong mechanisms for monitoring and evaluation. For example, rates of exclusive breastfeeding for the first six months for HIV exposed infants (HEI) are between 63 and 92 per cent (programme data, Nyanza Province, 2012).…, Key concerns from the discussion, Does exclusive breastfeeding and prolonged breastfeeding increase the risk of HIV transmission from an HIV positive mother to her infant? , Recent studies have the transmission rate of HIV from mother to child during breastfeeding is around 5% if the mother is on ARV treatment or receiving ARV prophylaxis. The risk of acquiring HIV from breast milk remains as long as the infant is being breastfed, hence the recommendation of stopping at 12 months for HIV-exposed infants as opposed…, How can a HIV positive mother balance the risk of HIV transmission during breastfeeding and the feasibility of providing an adequate diet to the infant upon weaning? , Follow up is necessary to track a mother’s disease status and adherence to ARV regimens so as to reduce the risk of transmission from mother to child during breastfeeding. Incorporate routine viral load monitoring for HIV positive mothers who are breastfeeding as well as more intensive monitoring of HIV infection in infants. HIV positive…, Q&A sessions, Q&A Session After Linda’s Presentation: Feeding in the Context of HIV, Q: Do the Mentor Mothers get paid for the work that they do? , Linda:, Yes, they do and the community health workers have some mechanism for remuneration that is all done through the government so they get paid a minimum wage and it is part of the review at the national level. There was a best practice review and a critical look at how this keeps the staff within the health system. They make the equivalent of a…, Q: How do the Mentor Mothers differ from community health workers? , Linda:, The community health workers in Kenya have a defined package of support which is largely primary care interventions for all of the population. Some focus on mothers and children. They provide the support at the community level so they will often visit households, connect mothers with care, and screen children to identify their needs. They do…, Q: Regarding the Mentor Mothers, how many have now been employed? And do they report any resistance from community members since they work with both people living with HIV and those without? , Linda:, Fifty percent of the country is now accelerating to the Mentor Mothers program. USAID, in its support to Kenya, funds a substantial amount for strengthening HIV care and services. This has been endorsed as their model of support and will be accelerated nationally. Mentor Mothers don’t usually go to the community level. They give the support to…, Q: One slide showed an increase in infection of babies from around 4% at 8 weeks to 7% at 18 months. Is exclusive breastfeeding effective? , Linda:, We still have challenges with exclusive breastfeeding so it’s just been in the last 6-9 months where we’ve seen a lot more clarity. Mentor Mothers provide clear messages about exclusive breastfeeding but it’s sometimes health workers who still give the confusion. We have seen improvements in this area. That’s where you will still see impact with…, Q: Were the mothers of any of the babies who were infected on prophylaxis on ART? , Linda:, We don’t know at a facility level. We have not tracked those specifically. We are doing monitoring and getting anecdotal reports. , Q&A After Nigel’s Presentation: Breastfeeding, HIV & ARVs, Q: Do we have documented experiences on stopping breastfeeding around 12 months? How successful has that been and what are the challenges? , Nigel:, The simple answer to that question, and probably to most that will come in, is no. We have very little documented experience on most of the issues around post-natal transmission and the programmatic issues around implementation of the guidelines. The evidence that was available for the recommendations in 2010 were almost entirely based on…, Jessica:, Just to comment on data on breastfeeding at the health facility level – there was an interesting report released recently by the MOH in Mozambique about early infant diagnosis and it showed transmission rates increasing with age and perhaps some of that was due to breastfeeding transmission and then it showed the link to need for improvement of…, Q: Regarding the study you shared on the low level of knowledge about breastfeeding from 2008, do you think there has been improvement since then?, , Nigel:, Again, I think the answer is, I just don’t know. This is where we really want implementation-type research. But there is no reason to expect any change unless there has been good communication to health workers. One of the things I’m fearful of is that it’s very easy for a ministry to send out guidelines and in a very quick way, say “this is how…, Q: In Latin America and the Caribbean region, PAHO guidance recommends that HIV positive mothers avoid all breastfeeding. In this region, many countries are middle income countries and their governments are opting for following the example of high income countries that are discouraging HIV positive mothers from breastfeeding. Some go even further…, Nigel:, I think it’s very difficult. It all depends on the quality of the health system of the reliability of the health system to get drugs to mothers and support them at the time and to keep women in care. If you have very high confidence in that, then it is a reasonable thing to suggest that HIV positive mothers avoid all breastfeeding, especially if…, Linda:, We have struggled with that and we have a bit of variation within the country. One of the areas of the country that has achieved their MDG targets really wanted to support a formula-based approach. We would really like to see stringent research around that shows evidence of improvement and not a detrimental effect on neonatal and infant…, Karan:, Is there any update on mother to child transmission risk from exclusive breastfeeding versus mixed feeding? In your paper from November there was no evidence of a difference. Is there any update?, Nigel:, With respect, in some ways, I think this may be the wrong question. In the data that has been presented on all the ARV interventions, the research teams, including the study I was involved with, we said that women were supported to exclusively breastfeed but I think in the studies, there was a lot of mixed feeding in those research studies and in…, KK:, UNAIDS shows that as MTCT during pregnancy and delivery decreases, the amount of MTCT during breastfeeding is increasing. There is urgent need to ensure protected breastfeeding with ARVs. Following your comments on the importance of educating health care providers and increasing their confidence of promoting exclusive breastfeeding, how will the…, Nigel:, The first point is that, we need to be careful in saying that the amount of transmission in breastfeeding is increasing, it’s not. It’s not increasing. The proportion of transmission that occurs during breastfeeding is increasing. If over a two year period, there were no drugs and you had 20 children becoming infected through transmission and…, Tin Tin:, As Nigel mentioned, we had a meeting at the end of last year where we discussed some of these issues, especially how to boost healthcare workers’ capacity, knowledge and confidence about giving the appropriate messages to the affected and infected women. One of the things that UNICEF will be taking the lead on this year is to develop a…
