Update on challenges of the revised global guidance

IAS 2011 Professional Development Workshop Implementation and Operations Research Considerations for Rolling Out the 2010

WHO Guidelines on PMTCT and Infant Feeding

Hosted by the Elizabeth Glaser Pediatric AIDS Foundation

Outline

• Introduction• Review of PMTCT guidelines• Review of HIV and infant feeding guidelines• Implementation issues and challenges of the

infant feeding guidelines• Conclusion

2010 - WHO guidelines on ART, PMTCT and Infant and young child feeding & HIV

New recommendations available at: http://www.who.int/hiv/en/

July 2010

Rapid advice: Use of antiretroviral drugs for

treating pregnant women and preventing HIV infection

in infants

WHO pages: http://www.who.int/hiv/

1. Initiation of ART among pregnant women

• Mothers in need of ART for their own health should get lifelong treatment• Initiate ART in pregnant women with

CD4<350 regardless of clinical stage• Initiate ART in clinical stage 3 and 4 if

CD4 not available• Start ART as soon as feasible • Importance and critical need of CD4

for decision-making on ART eligibility

2. ARV prophylaxis to prevent MTCT

For women not eligible for ART or unknown eligibility

• Beginning as early as 14 weeks of gestation (2nd trimester) or as soon as possible thereafter

Strong recommendation

2 possible options:A) Maternal AZT, IP NVP with AZT/3TC ‘tail’ Infant NVP prophylaxis during breastfeeding B) Maternal triple ARV prophylaxis during

pregnancy and breastfeeding (if breastfeeding is best infant feeding option)

ARV prophylaxis to give to non-eligible pregnant women

WHO Recommendations for Breastfeeding - no change

As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.

(WHA55 A55/15, paragraph 10) http://www.who.int/child_adolescent_health/documents/pdfs/IYCF_brochure.pdf

March 2001

WHA54.2.

Breastfeeding benefits and practices

Benefits • Breastfeeding is the single most effective

child survival intervention (WHO Collaborative Study Team 2000)

Opportunities • BF initiation rates are high• Successes have been seen in improving EBF

in many settingsChallenges • Low rates of EBF to 6 months• Mixed feeding is normative • Messaging about BF in HIV populations has

changed many times over past 10 years

Can higher rates of EBF be achieved?

Brazil has successfully increased EBF rates through:

• Protecting mothers and babies - through employment legislation and control of marketing of substitutes for mother's milk &• Promoting breastfeeding through the use of the

mass media, professional training, brochures, verbal messages to breastfeed, implementing BFHI & other health systems approaches • Supporting breastfeeding through mothers'

groups, information material, and direct counseling, peer counsellors , & other community-based approaches

Conditions needed to safely formula feed

• Safe water and sanitation• Reliable provision of sufficient formula• Ability to safely prepare the feeds• Ability to provide exclusive formula for 6

months• Supportive family environment• Access to comprehensive child health services

WHO urges that National or sub-national health authorities need to identify the strategy that will most likely give most infants the greatest chance of HIV-free survival

Decision should be based on:socio-economic and cultural contextavailability & quality of health services local epidemiology (ANC HIV prevalence among pregnant women, main causes of infant & child mortality & maternal & child under-nutrition)

How should national authorities develop recommendations for infant feeding in the

context of HIV

WHO Recommendations for infant feeding in the context of HIV 2010

National or sub-national health authorities should decide whether health services will principally counsel and support mothers known to be HIV-positive to

– breastfeed and receive ARV interventions OR

– avoid all breastfeeding

as the strategy that will most likely give infants the greatest chance of HIV-free survival

15

Implementation context

• IMR and U5MR remain high • Quality & access to Child Health services

remains poor• Limited access to secure water, sanitation,

hygiene & cooking facilities in the home • Poor food security and high rates of

malnutrition

KEY ELEMENTS FOR SCALING-UP

National policy level

•Evidence-informed policy development

Management and Coordination •Management and planning capacity at national and sub-

national level

Service delivery level •Capacity of health care workers, counselors and

community cadres to deliver services

DATA

FO

R AC

TIO

N

SYSTEMS APPROACH

Build capacity for national and sub-national planning

• Define the ‘minimum Infant Feeding package’ closely linked

with delivery of ARVs as per new recommendations.

Identify points of service delivery for the packageRelook at opportunities for closer f/u in late infancy

(beyond 14 week EPI visit)-align Infant Feeding support with recommended visits for NVP dose changes

Service Delivery

• Service delivery model will have to be established. • Integration within MNCH and continuum of care– Longitudinal follow-up of mother baby pairs

•Systems put in place to ensure the ARV interventions are accessible and available at all levels of the health care systems • Community health systems strengthening to

support Infant and Young Child Feeding

Tools

• Resource pack to aid decision making and implementation at country levelGuidance for Policy developmentGuidance for district managersKey considerations for service providers

• Job aids to standardize counseling• Informational materials for clients and their

families

Challenges• History of changing messages given to HIV+

mothers and communities about feeding• Detrimental traditional feeding practices (i.e., early

mixed feeding), • Loss to follow-up; weak community-facility linkages; • Human resource capacity building

– Training and re-training of health workers– Task shifting/sharing– Mentoring and support supervision

• Resource mobilization for infant feeding support

Conclusion

1. Thousands of babies lives will be saved if exclusive breastfeeding rates were increased

2. Recent revised policies means that for most HIV positive women breastfeeding with ARV interventions is currently the best feeding method for the health and well being of their babies

3. Aggressive and systematic promotion & support for breastfeeding is necessary to make progress towards national and international goals & targets for child health

Questions raised at recent workshops

• How would mothers and communities respond to an approach that promotes breastfeeding and ARVs?

• How to give health workers confidence in an approach that promotes breastfeeding and ARVs?

• How can an approach that promotes breastfeeding be promoted when EBF rates are already low?

• How can the impact of PMTCT interventions best be estimated?

• Maternal health and breastfeeding

Acknowledgments

• Landry Tsague – UNICEF• Elevanie Nyankesha - UNICEF• Paula Libombos - UNICEF• Luisa Brumana – UNICEF• Corri Mazzeo - EGPAF

Thank You