Updates to IYCF Training Materials

1. Updates to IYCF Training Materials By Monica Muti National Nutrition Coordination and Technical Update Meeting 5-6 August 2013 Kadoma

2. HIV and infant feeding: What is new? Significant programmatic experience and research evidence regarding HIV and infant feeding have accumulated since 2006. In particular: Evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding 17/2 3

3. PREGNANCY 5% LABOUR & DELIVERY15% BREASTFEEDING15% NEVER HIV-INFECTED 65% LABOUR AND DELIVERY Total ~35% BREASTFEEDING 0-24m PREGNANCY 5-8% 10-20% 5-20% Total~35% 17/5 Risk of Mother-to-Child Transmission in pregnancy, labour and delivery, and breastfeeding for 2 years:withoutARV interventions

4. No ARVs 5-8% 10-20% 5-20% Total~35% With ARVs LABOUR AND DELIVERY BREASTFEEDING 0-24m PREGNANCY BREASTFEEDING 0-12m with ARVs 2-3% PREGNANCY 0-1% Total~5% LABOUR AND DELIVERY 1-2% 17/6 Risk of Mother-to-Child Transmission in pregnancy, labour and delivery, and breastfeeding for 2 years:without and withARV interventions

5. BREASTFEEDING Risk of: HIV transmission through breastfeeding REPLACEMENT FEEDING Risk of: Mortality from infectious diseases Risk of: Malnutrition from not breastfeeding 17/8 HIV- free survival: avoiding HIV transmission and remaining alive Source: WHO slide 2007

6. 17/9 The Key Principles • National authorities to make strong recommendations about infant feeding • Breastfeeding and ARV interventions, OR • Avoid all breastfeeding • Balancing HIV prevention with protection from other causes of child mortality • When antiretroviral drugs are not immediately available breastfeeding may still provide infants born in HIV-infected mothers with a greater chance of HIV-free survival • Informing mothers known to be HIV-infected about infant feeding alternatives • Providing services to specifically support mothers to appropriately feed their infants

7. 17/11 Conditions needed to safely formula feed (R5) • HIV-infected mothers should only give commercial infant formula milk as a replacement feed to their HIV-negative infants or infants who are of unknown HIV status, when specific conditions are met: • Safe water and sanitation are assured at household level and In the community • The mother or other care giver can reliably provide sufficient infant formula milk to support normal growth and development • The mother or care giver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition • The mother or care giver can in the first 6 months, exclusively give infant formula milk • The family is supportive of this practice • The mother or caregiver can access health care that offers comprehensive child health services.

8. 17/12 When the infant is HIV-infected (7) • If Infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first six months of life and continue breastfeeding as per the recommendations for the general population that is up to two years or beyond

9. 17/13 Policy of supporting breastfeeding • “As a general principle, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported.” HIV and Infant Feeding: a policy statement, developed collaboratively by UNAIDS, WHO and UNICEF, 1997.

10. 17/15 New PMTCT ARV recommendationsare based on these two key areas • Lifelong ARTfor HIV-positive women in need of treatment for their own health, which is also safe and effective in reducing MTCT • ARV prophylaxis (short term) to prevent MTCT during pregnancy, delivery and breastfeeding for HIV-infected women who do not need treatment for their own health

11. Three options for PMTCT Programmes Source: Programmatic Update ARVs for treating pregnant women and preventing HIV in infants. Executive Summary, WHO Geneva April 2012

12. 17/15 Main infant feeding recommendations for HIV-positive women • Mothers known to be HIV-infected should be provided with lifelong ARV therapy or ARV prophylaxis to reduce HIV transmission through breastfeeding • These mothers should exclusively breastfeed their infants for the first 6 months of life, introduce appropriate complementary foods thereafter, and continue breastfeeding until 24months or beyond

13. Heat-treated expressed breast milk • Mothers known to be HIV-infected may consider expressing and heat-treating breast milk as an interim feeding strategy • In special circumstances such as: • when the infant is low birth weight at birth or is ill in the neonatal period and unable to breastfeed; • When the mother is unwell and temporarily unable to breastfeed or has a temporary breast problem such as mastitis; • to assist mothers to stop breastfeeding; • if antiretroviral drugs are temporarily not available

14. What to feed infants when mothers stop breastfeeding When HIV +ve mothers stop breastfeeding at anytime, provide infants with safe, adequate replacement feeds to enable normal growth and development. • For infants less than 6 months: • Commercial infant formula milk if home conditions as outlined in Rec 5 • Expressed heat treated breastmilk Home-modified animal milk not recommended as replacement food in first 6 months • For children over 6 months of age: • Commercial infant formula milk if home conditions as outlined in Rec 5 • Animal milk as part of diet providing adequate micronutrient intake -boil for infants under 12 months • Meals, including milk-only, other foods and combination of milk and other foods, should be provided 4 or 5 times per day. • All children need complementary foods from six months of age

15. cIYCF Training Programme • IYCF covered in 3days • One day for screening and anthropometry • One day for practical exercises