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[pronut-hiv] HIV and infant feeding - are we in confusion?

  • From: "Neil Pakenham-Walsh, UK" <>
  • Date: Sun, 05 Feb 2012 09:27:25 +0000

Dear Miriam, Kate, Pamela and ProNUT-HIV colleagues,

(I stress that I am not an expert in this field - my comments are
observational, seeking better to understand the issues and how they
can be better translated to policymakers and health workers. As one
nurse-counsellor in Tanzania said: "I'm really in a dilemma and confused.")

Miriam said: "Yes there is confusion, and yes, I do think the 2010
guidelines could benefit from some 'translation' into simple clear
language. I have been working on this with the folks I work with in
Africa and Asia."

Further to discussions on HIFA2015 ( I am interested
to locate clear practical guidance on HIV and infant feeding and
would be very grateful to hear more about your work on translating
the 2010 Guidelines into clear language. It would be valuable,
indeed, to see this translated into multiple languages.

Meanwhile, I have found that UNICEF has produced a set of Counselling
Cards based on the 2010 Guidelines:

I would be interested to learn whether people have used these and
what their experience has been.

Also, there is another WHO publication (published in 2009, but on the
WHO website, so presumably still current) that is a lot shorter and
(in my opinion) easier to read than the 2010 publication:

'HIV and infant feeding: Revised Principles and Recommendations.
Rapid Advice. 2009'

As the 2009 publication notes:

'Infant feeding in the context of HIV is complex because of the major
influence that feeding practices exerts on child survival. The
dilemma is to balance the risk of infants acquiring HIV through
breast milk with the higher risk of death from causes other than HIV,
in particular malnutrition and serious illnesses such as diarrhoea
among non-breastfed infants.'

The UNICEF website points out: 'The recommendation that replacement
feeding should not be used unless is it acceptable, feasible,
affordable, sustainable and safe (AFASS) remains, but the acronym is
replaced by more common, everyday language and terms. It was believed
that more carefully defining the environmental conditions that make
replacement feeding a safe or unsafe option for HIV-exposed infants
will enhance mothers' understanding and practices and improve
HIV-free survival of infants. It was considered that such language
would better guide health workers regarding what to assess and
communicate to mothers who were considering if their home conditions
would support replacement feeding. The concept of AFASS had proven
difficult to translate into practical counseling messages.'

Miriam, I'm also really interested in what you say about national
decision making on HIV and breastfeeding:

"The questions I often get are around the national or sub-national
body that is to make a recommendation on Option A [breastfeed and
receive ARV interventions] or B [avoid all breastfeeding]. In many
places this decision has not been made, or has not been communicated,"

For me, it is quite shocking that governments appear not to have made
a decision on this, which must be causing further confusion among
health workers.

Even where governments _have_ made a decision, I remain confused that
such decisions can or should be made for whole countries. I would be
very interested to hear how countries make such decisions. Most
importantly, the danger of replacement feeding varies according to
the _individual's_ circumstances and socioeconomic status. Is it
appropriate to make a blanket decision across a whole country, or
indeed is this blanket decision in practice only applied to
government health services, perhaps in the assumption that everyone
who uses such services are poor and therefore a blanket decision can
be made for all?

Like the nurse-counsellor in Tanzania, I too would be in a dilemma if
I were advising on HIV and infant nutrition.

With best wishes,

Dr Neil Pakenham-Walsh MB,BS, DCH, DRCOG
Coordinator, HIFA2015 and CHILD2015
Co-director, Global Healthcare Information Network
Corner House (John Kibble Room)
Charlbury, Oxfordshire OX7 3PN, UK
Tel: +44 (0)1608 811899
Email: <>
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