Update on challenges of the revised global guidance

1. 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

2. Outline • Introduction • Review of PMTCT guidelines • Review of HIV and infant feeding guidelines • Implementation issues and challenges of the infant feeding guidelines • Conclusion

3. 2010 - WHO guidelines on ART, PMTCT and Infant and young child feeding & HIV New recommendations available at: http://www.who.int/hiv/en/

4. Rapid advice: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants July 2010 WHO pages: http://www.who.int/hiv/

5. 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

6. 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

7. ARV prophylaxis to give to non-eligible pregnant women 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)

8. 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.

9. 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 settings Challenges • 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

10. 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 throughmothers' groups, information material, and direct counseling, peer counsellors , & other community-based approaches

11. 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

12. How should national authorities develop recommendations for infant feeding in the context of HIV 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 survivalDecision should be based on:socio-economic and cultural context availability & quality of health services local epidemiology (ANC HIV prevalence among pregnant women, main causes of infant & child mortality & maternal & child under-nutrition)

13. 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

14. 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

15. KEY ELEMENTS FOR SCALING-UP DATA FOR ACTION SYSTEMS APPROACH

16. 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 package • Relook 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

17. 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

18. Tools • Resource pack to aid decision making and implementation at country level • Guidance for Policy development • Guidance for district managers • Key considerations for service providers • Job aids to standardize counseling • Informational materials for clients and their families

19. 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

20. Conclusion • Thousands of babies lives will be saved if exclusive breastfeeding rates were increased • 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 • Aggressive and systematic promotion & support for breastfeeding is necessary to make progress towards national and international goals & targets for child health

21. 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

22. Acknowledgments • Landry Tsague – UNICEF • ElevanieNyankesha - UNICEF • Paula Libombos - UNICEF • Luisa Brumana – UNICEF • CorriMazzeo - EGPAF

23. Thank You