HIV and Infant Feeding: A Programme Challenge

Among the greatest programme challenges of recent years for United Nations agencies working in child health and nutrition, especially in sub-Saharan Africa, has been the prevention of transmission of the deadly HIV virus from mother to infant. The majority of that transmission occurs during childbirth, but breastfeeding is also a mechanism for mother-to-child transmission (MTCT). The co-sponsor agencies of UNAIDS, including UNICEF and WHO, have not retreated in their commitment to support, protect and promote breastfeeding - in fact, they recognise that the HIV pandemic makes support to breastfeeding more important than ever. But they have also recognised that HIV-positive women have a right to be supported in trying to minimise the chances of passing HIV to their infants.

Before 1998, it was virtually impossible to design a feasible programme for MTCT reduction for low-income countries. It was known that the risk of transmission in utero and during childbirth could be reduced by a long and expensive course of the drug zidovudine (AZT) - costing about $1000 for the drug alone - but this was unaffordable in many countries. In February 1998, however, it was shown in a study in Thailand that a much shorter course of AZT during the last weeks of pregnancy could significantly reduce the risk of MTCT with no adverse side effects for the woman or child. The cost of the drug for the short-course regimen is ENN Team $50-80, and the manufacturer of the drug has since made a limited quantity of AZT available free through UNICEF for UN-supported start-up programmes in certain countries. The manufacturer has also indicated its willingness to negotiate further with UNICEF and with national authorities to make this drug treatment widely available. With these developments, it became possible to talk about affordable programmes for MTCT reduction.

The results of the Thailand trial relate to transmission up to the time of childbirth. There is as yet no evidence that continuing a course of AZT post-partum period would reduce the risk of transmission during breastfeeding. In order to allow women to take best advantage of the risk reduction associated with the AZT, something needs to be done about the infant feeding options of HIV-positive women. WHO and UNICEF working with UNAIDS have published guidelines for health workers and policy-makers to support HIV-positive women in making the best-informed decision possible on whether to breastfeed. That decision depends on a host of factors, many of which only the woman herself can weigh. For HIV-positive women who cannot be sure of having regular access to adequate water (and time) even if they can get access to infant formula in adequate quantities, breastfeeding may still be the best option. For other women, it may be possible to minimise the risks of artificial feeding and thereby come up with a better alternative than being forced to face the risk of passing a fatal illness to their infants. There is also good evidence to suggest that the risk of transmission increases with duration of breastfeeding, so early cessation of breastfeeding may be a useful measure in some cases, though the UN agencies have not recommended a particular cut-off point.
The UN agencies working on HIV/AIDS have decided collectively that there is a moral imperative at least to try to support HIV-positive women in finding alternatives to breastfeeding in cases where they choose this option. WHO and UNICEF working with UNAIDS have supported several countries over the last ten months to design integrated programmes for the reduction of MTCT. Such programmes already exist in Latin America, Thailand and South Africa, but these programmes are of course more challenging in poorer countries in Africa, where health services are often inadequate and access to breastmilk substitutes is difficult. In spite of the programme challenges, eight countries in Eastern and Southern Africa have worked hard to design such programmes in selected health facilities where pregnant women can benefit from a range of services to reduce the likelihood of MTCT. These services include:

• HIV testing and counselling, a prerequisite for access to the AZT short course.
• Well informed and sensitive post-test counselling, including on infant feeding choices.
• A well adminstered AZT regimen
• Obstetric services that include best practices for minimising the risk of MTCT
• Nutritional support for women.
• Support for ensuring access to adequate breastmilk substitutes where women decide not to breastfeed. (UNICEF is ready to assist countries with the acquisition of a good quality generic infant formula at a price well below the lowest commercial formula prices where government partners deem it necessary.)

Funding is available from several sources, and additional funds are being sought to move these programmes forward in 1999. One of the most difficult aspects of this kind of programme in Africa is likely to be having adequate capacity for counselling and testing. The co-sponsor agencies of UNAIDS have designed training materials to create an army of HIV counsellors who can also provide well informed counselling on infant feeding issues. In addition, communication strategies are needed to improve community-level acceptance of persons living with HIV.
It may be possible to provide some of the services related to reduction of MTCT risk in emergency situations, particularly in situations where provision of clean water may help reduce risks associated with not breastfeeding. These risks may also soon be reduced in emergency and other situations by the use of the new rotavirus vaccine, which is likely to reduce transmission of a significant portion of diarrhoeal disease.

Programmes to reduce MTCT under any circumstances require great vigilance to ensure that the life-saving practice of breastfeeding for the great majority of children is not compromised.

For further information contact Joanne Csete at jcsete@unicef.org