NUTRITION AND HIV/AIDS

Estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) indicate that by the beginning of 1998 over 30 million people were infected with HIV, the virus that causes AIDS, and that 11.7 million people around the world had already lost their lives to the disease. The virus continues to spread, causing nearly 16,000 new infections per day. During 1997 alone that meant 5.8 million new HIV infections, despite the fact that more is known now than ever before about what works to prevent the spread of the epidemic

OVERVIEW TO THE FEATURE

A body of literature is accumulating on the role of nutrition in decreasing not only the wasting that accompanies advanced HIV infection but also in preventing the progression of the disease. It is also possible that specific nutrients affect the transmission of the HIV virus. The first report in this feature outlines some of the key statements from the WHO/UNICEF/UNAIDS newly-released manuals on HIV and Infant Feeding. Citing firm evidence that HIV can be transmitted through breast milk, the manuals respond to the urgent need for guidance when advising infected mothers as well as formulating sound public health policies. With this in mind, the manuals identify the wide range of precautions and policy options needed to reduce the risk of HIV transmission through breastfeeding while insuring that the nutritional requirements of infants born to HIV-infected mothers are adequately met.

Breastfeeding and HIV infection are explored further on page 5. Citing the work in Durban, South Africa, the authors suggest that safe alternatives to breastfeeding should be considered in countries where infant mortality rates are considered moderate or low.

A description of possible alternatives to breastfeeding taken from the WHO/UNICEF/UNAIDS manual “A Guide for Health Care Managers and Supervisors” is also included. Although no global survey of alternative feeding choices has been completed, this paper outlines some of the possibilities that could be considered should a mother choose not to breast feed.

The role of micronutrients in the transmission and progression of HIV infection is summarised in the article by Henrik Friis. UNAIDS, UNICEF and WHO agree that there is insufficient evidence to promote improved micro-nutrient intake to slow HIV disease progression or transmission. However, improving micronutrient status of undernourished people is highly desirable for many reasons and should be actively promoted.

A description of the impact of HIV/AIDS in Kenya is given on page 13. The importance of a coordinated effort to control this disease, including the provision of adequate nutrition, is emphasised.

The evolution of the UN policy on infant feeding and HIV transmission is traced by Lida Lhotska, page 15. This article describes how the 1992 approach was inadequate. The new policy is committed to promoting a mother’s right to choose the best methods for feeding her child.

An example of a study to assess the need to fully inform HIV positive women of the risk of breastfeeding is outlined on page 17. This research is part of the larger Zvitambo project which has been previously described (SCN News #14).

A woman’s decision to breast feed must be balanced against an infant’s right to be breastfed. From a human rights perspective, the major issue is one of protecting the woman-infant unit from outside interference. This issue is briefly discussed by George Kent on page 18.

Issues of food security are highlighted on page 20. The loss of able-bodied men and women to HIV/AIDS leads to labour shortages and a decline in productive capacity with a subsequent decline in income. More needs to be done to protect these vulnerable households from food insecurity.

Finally, the UN pilot projects are presented on page 22. This initiative is aimed at assessing the feasibility of prevention of mother-to-child transmission of HIV in some of the worst-affected countries suffering from the highest rates of HIV infection.

HIV AND INFANT FEEDING WHO/UNICEF/UNAIDS¹

In a concerted effort to stop the spread of HIV/AIDS among young children and mothers, WHO, UNICEF and UNAIDS support the right for HIV-infected women to choose safe alternatives to breastfeeding based on full information. Key statements from the two manuals developed to provide guidelines to decision makers are outlined below.

à Worldwide, an estimated three million children under the age of 15 years have been infected with HIV to date, mother-to-child transmission - during pregnancy, delivery or breastfeeding - is responsible for more than 90% of HIV infection in children. The remaining 10% are infected through contaminated blood or sexual abuse.

à Mother-to-child transmission rates vary considerably. In the industrialised world, the risk of an infant acquiring HIV from an infected mother ranges from 15-25%, compared with 25-45% in developing countries. Differences in breastfeeding rates may account for much of this variation.

à Research shows that the risk of transmission is significantly higher if the mother becomes infected with HIV during pregnancy or while breastfeeding, and when the mother is in an advanced stage of the disease.

à Breastfeeding is thus a significant preventable mode of HIV transmission to infants, creating an urgent need to educate, counsel and support women and families so that they can decide how best to feed infants in the context of HIV.

à Faced with this need, health services should strive to prevent transmission through breastfeeding, for women known to be HIV-positive, while continuing to protect, promote, and support breastfeeding as the best infant feeding choice for HIV-negative women and those of unknown status.

à The most widely available antibody tests cannot determine whether an infant is infected with HIV until after the age of about 18 months. Feeding decisions must thus be made without firm knowledge of the infant’s HIV status at birth.

à In many situations it is necessary to act on the assumption that infants of HIV-infected mothers are not infected at birth - which will be true in 80% of cases. When mothers receive antiretroviral therapy during late pregnancy, it can be assumed that over 90% of infants will be born uninfected.

à Early cessation of breastfeeding reduces the risk of transmission by reducing the length of time that an infant is exposed to HIV through breast-milk. There is at present no agreed cut off point.

à Breastfeeding is normally the best way to feed an infant. However, when the mother is infected with HIV, it may be preferable to replace breast milk to reduce the risk of transmission to her infant.

à The risk of illness and death from replacement feeding should be less than the risk of HIV transmission through breastfeeding. Otherwise there is no advantage to replacement feeding.

à In some settings, consideration could be given to providing HIV-positive mothers with free or subsidized infant formula and supporting its safe use.

à If free or subsidized breast-milk substitutes are to be offered, efficient distribution is essential to ensure they reach eligible mothers, but do not “spill over” to mothers who are HIV-negative or of unknown status. Distribution should be in compliance with the International Code.

à Where breastfeeding is the norm, women who do not breast-feed may be labeled as HIV-infected and stigmatized, resulting in a range of additional problems. Measures are thus required to provide social support to HIV-positive mothers who use replacement feeding.

à A woman’s decision to breast-feed, and, if she opts not to breast-feed, her choice of breast-milk substitute, should not be influenced by commercial pressures. Once she has made a decision about the method that she feels is best for her and her infant, she needs support to carry out her decision as safely as possible.

à Prevention of mother-to-child transmission requires a complete package of care including strengthened maternity and family planning services, with increased antenatal care, counseling and testing for HIV, possible use of antiretroviral drugs, and altertives to breastfeeding.

1. Guidelines for Decision-Makers. 1998, 36 pages. WHO/FRH/NUT/CHD 98.1; A Guide for Health Care Managers and Supervisors 1998, 36 pages. WHO/FRH/NUT/CHD 98.2; A Review of HIV Transmission through Breastfeeding. 1998, 28 pages. WHO/FRH/NUT/CHD 98.3 The three documents listed above are available upon request from Randa Saadeh, WHO/NHD Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: [email protected]

BREASTFEEDING AND HIV-1 INFECTION
by Hoosen Coovadia and Raziya Bobat

Recent reviews of the available published data on the subject of breastfeeding consistently show that breastfeeding protects against infections and reduces infant mortality, both in developing and developed countries. With the increasing spread of HIV infection the role of breastfeeding has however recently drawn more attention. Mother-to-child transmission (MTCT) of HIV, partly through breastfeeding, is thought to be an important factor in the increased infant mortality rates recently observed in countries like Zimbabwe. This led the UN steering group on MTCT to recommend that HIV-infected women be counselled about the various infant feeding options, and to the recommendation that those women who in due consideration of all alternatives opted not to breastfeed or limit the duration of their breastfeeding be supported in their choice. The recommendations carry the potential of compromising the universal practice of this method of infant feeding.

Most studies on breastfeeding were undertaken in the pre-HIV era. There is little information on whether breast-milk from HIV seropositive women is as protective against common infections and malnutrition in infants as that of HIV-uninfected women. However, a difficult problem with conducting studies to determine the benefits of breastmilk of HIV-infected women, is the ethical difficulty of randomising such women to either breastfeeding or formula feeding. One trial, based on a randomised design, is being done by Dr. Ruth Nduati’s group in Kenya but results are not yet available. In the meantime a number of observational studies do have data on the impact of breastfeeding but also significant design problems that limit generalisation of their results.

Soon after the HIV epidemic resulted in sick infants appearing in our hospitals in Durban, South Africa, we started an observational cohort study of the short term natural history of HIV infection and the influence of feeding on infant outcomes. This was not a randomised study because the mothers self-selected their feeding methods. We categorised feeding as exclusive breastfeeding, exclusive formula and mixed feeding. The study found that the HIV transmission in those exclusively breastfed was increased by 15% compared to those on exclusive formula (Table 1). These data must be interpreted with caution because the study was not randomised, and the number of infants in the exclusively formula fed group was small (n=21). Therefore the number of HIV infected infants in this group was small (n=5). A further limitation is the relatively short follow-up period, which averaged 21 months, in our study.

Table 1. The association between method of feeding and HIV transmission in the infant.

Feeding Method	Total	HIV-infected		Non-HIV-infected
	n	n	(%)	n
Breast milk only	36	14	(39)	22
Breast milk and formula	76	24	(32)	52
Formula only	21	5	(24)	16
Total	131	43		90

Modified from AIDS 1997;11:1627-1633.

There was a non-significant stepwise increase in the transmission rate with duration of exclusive breastfeeding of one, two, and three months. Although the exclusively breastfed infants had a higher frequency of developing AIDS, they had a slower rate of progression from HIV to AIDS. These apparently opposing effects were probably the result of a balance between transmission of virus through breastmilk and protective effects of breastfeeding. Mortality occurred in the infected infants only. While breastfeeding might have postponed the development of AIDS in infants who became HIV-infected, it is to be expected that HIV-infected infants would have worse survival than those without, a finding our study could not capture.

Table 2 shows the relationship between feeding method and morbidity. The frequency of failure to thrive and episodes of diarrhoea and pneumonia were not significantly different among the three feeding groups, in both the HIV-infected and uninfected infants.

Table 2. Morbidity according to feeding practice and HIV-1 status in infants born to HIV-1-seropositive women.

Morbidity	Breastfed	Mixed Feeding	Formula Fed
Infected Infants
Number§	14	22	1
Follow-up (months)	287	437	24
Pneumonia*	6.3	8.7	0
Diarrhoea*	10.5	13.5	0
Otitis media*	3.8	3.6	0
Failure to Thrive (%)	57.1	68.2	0
Uninfected Infants
Number§	22	52	16
Follow-up (months)	537	1246	393
Pneumonia*	4.7	4.0	3.1
Diarrhoea*	4.1	6.6	2.3
Otitis media*	3.8	0.8	1.8
Failure to Thrive (%)	13.6	15.4	11.1

Modified from AIDS 1997;11:1627-1633.
^§ Number of children on whom adequate morbidity data were available.
* Figures are given per 100 child months of follow-up.

Results from an Italian study among perinatally HIV-infected children (see Bobat et al (1) and WHO/UNAIDS/UNICEF(2) for a complete list of references) indicated that breastfeeding was of short term advantage; progression to AIDS was slower and survival longer in breastfed as opposed to formula fed HIV-infected children. This advantage of breastfeeding was lost by the time children reached 5 years of age. However, the interpretation of these data are limited since the data were retrospectively collected and the duration of breastfeeding was not known. In a study of relatively privileged Zairian women, presumably unrepresentative of the majority of women in Africa, breastfeeding was found to protect infants from common childhood illnesses, in those born to both HIV-infected and HIV negative women. In a prospective study from Nairobi, breastfeeding by HIV-infected women, for longer than 15 months, was more often associated with growth retardation than breastfeeding for shorter periods. An increased HIV transmission rate and an increased mortality in exclusively breastfed HIV-infected infants was reported from Soweto, South Africa. The mortality rates in the breastfed infants have to be carefully interpreted as the sample size was insufficient to detect significant differences between breastfed and formula fed infants. Moreover, there were no adverse effects on growth or morbidity, and no increase in hospital admissions among breastfed over non-breastfed infants born to HIV seropositive women. It must be remembered that Soweto is also unlike most of Africa; socio-economic conditions are typical of those of a middle-income country with an infant mortality rate less than 30.

From an extensive review of the literature (2) it has been estimated that MTCT rates are from less than 15% to 40% or more. Little information is available on the association between duration of breastfeeding and risk of transmission. Although about 70% of all postnatal transmission occurs within the first 4-6 months, MTCT can occur as long as breastfeeding continues. In a recent analysis of international data (3), the risk of breastfeeding transmission was estimated to be 3% per year among infants who were documented to be HIV uninfected in the first 3 to 6 months of life.

The recent statement on “Infant Feeding and HIV’ by WHO/UNAIDS/UNICEF(4) has supported “the use of safe alternatives for infants born to HIV positive women”. While the findings from Durban and Soweto would support this policy, one should also realise that they were obtained in countries with an intermediate economy and an under five mortality rate between high and moderate. In such a setting it would be safe to assume that HIV-infected women can choose safe alternatives to breastfeeding, and it would make public health sense to offer all pregnant women counselling and HIV testing, and to advise those found to be positive that breastfeeding may not provide the anticipated degree of protection against common infections and growth failure, and is associated with a higher risk of transmission (1).

However in less well developed countries there are to date insufficient data to suggest that the same would apply to their population, and a more cautious individual approach is needed. In many developing countries there will be many HIV-infected women who cannot afford to formula-feed or who will choose to breastfeed after the risks and benefits are presented to them. In these societies HIV-infected women who deviate from the cultural norm of breastfeeding also risk exposing their HIV status and becoming prey to the attendant negative social implications. It is important that these problems be dealt with to enable women in such settings to make informed choices regarding infant feeding.

In a simulation exercise on infant survival, HIV infection and feeding alternatives in developing countries, Kuhn and Stein(5) conclude that “avoidance of all breastfeeding by the whole population always produces the worst outcome”. While simulation models are limited in their predictive power by the quality of the data that feeds the assumptions used in it, the model outcomes should at least lead to caution.

Child care practitioners consider breastfeeding to be one of the principal elements in maternal and child health, preserved through long standing campaigns to protect mother-infant well-being, particularly in developing countries. However recent trends suggest that initiation and duration of breastfeeding is on the decrease in some developing countries. In Durban, breastfeeding initiation rates which were 82% in 1996/1997 are now 71%.

Breastfeeding is believed to be so pre-eminent in human nutrition because of its well recognised nutritional, immunological, social and nurturing benefits. Given these benefits, it is important that breastfeeding should continue to be promoted as the standard of infant feeding. In developing countries the recommendations encouraging that HIV-infected women be informed about the risks and benefits of the different feeding options should be implemented cautiously, in well controlled settings, and their effects should be monitored thoroughly prior to exposing the general public to health programmes that might be well meant, but hold the potential of serious adverse outcomes. Last, while most data on the importance of HIV transmission through breastmilk were obtained by comparison of populations that either formula fed or breastfed, it should be recognised that there are alternatives to formula feeding (Table 3). It will be important to assess their feasibility and impact of HIV transmission, infant outcom and mother well-being, especially in developing countries where formula feeding is problematic.

Table 3. Possible alternatives to formula feeding.

	Efficacy against HIV	Feasibility
Heat treatment of breast milk	Good	Difficult
Exposure of breastmilk to room temperature	Not well known	Difficult
Wet nursing by known HIV-negative wet nurse	Good	Difficult; also there is risk that HIV infected infant infects nurse
Shortened breastfeeding period and supplemental feeds with e.g. modified animal milk	Should be reasonable	Should be reasonable
Use of antiretrovirals by mother	Unknown	Cost and level of development of health service problematic
Use of antiretrovirals by infant	Unknown	Cost and level of development of health service problematic
Modified animal milk from birth (home made for-	Good	Should be reasonable

References

1. Bobat RA, Moodley D, Coutsoudis A, Coovadia HM. Breastfeeding by HIV-1 infected women and outcome in their infants: a cohort study from Durban, South Africa.. AIDS 1997; 11:1627-1633.

2. HIV and Infant Feeding. A review of HIV transmission through breastfeeding. UNICEF, UNAIDS, WHO, Geneva, 1998.

3. Leroy V, Newell ML, Dabis F. International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV infection. Lancet 1998; 352:597-600.

4. HIV and Infant Feeding. A Guide for Health Care Managers and Supervisors. UNICEF, UNAIDS, WHO, Geneva, 1998.

5. Kuhn L, Stein Z. Infant survival, HIV infection and feeding alternatives in less developed countries. American Journal of Public Health 1997; 87:926-931.

Hoosen Coovadia, Head, Department of Paediatrics and Child Health, Faculty of Medicine, University of Natal, Private Bag 7, Congella, 4013 South Africa. Tel: +27 31 260 4345 Fax: +27 31 260 4388 Email: [email protected] and Raziya Bobat, Principal Specialist/Senior Lecturer, Department of Paediatrics and Child Health, University of Natal, Private Bag 7, Congella, 4013. South Africa. Tel: +27 31 260 4348 Fax: +27 31 260 4388 Email: [email protected]

FEEDING OPTIONS FOR HIV-POSITIVE MOTHERS

The following is adapted from “HIV and Infant Feeding: A guide for health care managers and supervisors”¹

From birth to six months, milk in some form is necessary for an infant. If not breastfed, an infant needs about 150 ml of milk per kg of body weight a day. So, for example, an infant weighing 5 kg needs about 750 ml per day, which can be given as five 150 ml feeds a day.

Breast-milk substitutes

1. Home-prepared formula

Home-prepared formula can be made with fresh animal milks, with dried milk powder or with evaporated milk. Safe use of formula with any of these types of milk involves modification of the protein and salt content to make it suitable for infants. Care is needed during preparation to avoid over-concentration or over-dilution. Micro-nutrient supplements are recommended, because animal milks may provide insufficient iron and zinc and may contain less vitamin A, C and folic acid. If micronutrient supplements are unavailable, complementary foods rich in iron, zinc, vitamin A and C and folic acid should be introduced at four months of age. However, it is unlikely that they will provide sufficient amounts of the required nutrients.

Modified animal milks

Cow milk has more protein and a greater concentration of sodium, phosphorous and other salts than breast milk. Modification involves dilution with boiled water to reduce the concentration. Dilution reduces the energy concentration so sugar must be added. The milk, water and sugar should be used in the following proportions and then boiled to make up 150 ml of home-prepared formula: 100 ml of cow milk with 50 ml of boiled water and 10 g (2 teaspoons) of sugar.

Feeding an infant for six months requires, on average, 92 litres of animal milk (500 ml per day).

Goat milk is similar in composition to cow milk and so needs to be modified in the same way. It is deficient in folic acid which infants need to be given as a micronutrient supplement. Camel milk is very similar in composition to goat milk and should be modified and supplemented in the same way.

Both sheep and buffalo milk have more fat and energy than cow milk and the protein content of sheep milk is very high. Using either of these milks for infants would therefore require more dilution than cow milk. The following proportions are appropriate: 50 ml of milk with 50 ml of water and 5 g sugar.

Dried milk power and evaporated milk

The full cream variety of dried milk powder or evaporated milk should be used. Normally, reconstitution involves adding a volume of boiled water to a measure of powdered or evaporated milk, as instructed on the container or packet. To make up a milk formula that is suitable for infants, however, the volume of water added needs to be increased by 50 per cent relative to the amount recommended for general consumption, and 10 g of sugar added for each 150 ml of the feed. This is the equivalent of the recipe for the modification of cow milk.

Home-prepared formula could be considered as an option by HIV-positive women when:

* The supply of animal milk or other milk is reliable and the family can afford it for at least six months

* The family has the resources to prepare it hygienically and can make the required modifications accurately

* Micronutrient supplementation is possible.

* Commercial infant formula is not available or is too expensive for the family to buy and prepare

2. Unmodified cow milk

During the first few months of life, feeding with unmodified cow milk can cause serious problems leading to dehydration and death. Infants need to be offered extra water (that has been boiled and cooled) and monitored carefully for dehydration if they have fever, respiratory infection or diarrhoea. To ensure that the infant gets enough milk and that water does not displace milk, drinks of water should be offered after feeds.

Unmodified cow milk could be considered as an exceptional option by HIV-positive women when:

* The supply of cow milk is reliable and the family can afford it for at least six months

* The family lacks the resources, time and fuel to modify cow milk to make home-prepared formula

* The family will be able to offer extra water and monitor for dehydration

* Micronutrient supplementation is possible

* Commercial infant formula is not available or is too expensive for the family to buy and prepare

3. Commercial infant formula

Commercial infant formula, based on modified cow milk or soy protein, is closest in nutrient composition to breast milk, though it may lack some substances such as long-chain essential fatty acids present in breast milk. It is usually adequately fortified with micronutrients, including iron.

Formula is usually available as a powder to be reconstituted with water. The instructions on the tin for mixing the formula should be followed exactly to ensure that it is not too concentrated or diluted. Over-concentration can overload the infant with salts and protein, which can be dangerous, and over-dilution can lead to malnutrition.

Feeding an infant for six months requires on average 40 × 500 g tins (44 × 450g tins) of formula. Up to at least four and usually six, months of age, infants who are fed on commercial infant formula do not need complementary foods if they are gaining weight adequately.

Commercial infant formula could be considered as an option by HIV-positive women when:

* The family has reliable access to sufficient formula for at least six months

* The family has the resources - clean water, fuel, utensils, skills and time - to prepare it accurately and hygienically.

Modified Breastfeeding

1. Early cessation of breastfeeding

Early cessation of breastfeeding reduces the risk of HIV transmission by reducing the length of time during which an infant is exposed to HIV through breast milk. The optimum time for early cessation of breastfeeding is not known. However, it is advisable for an HIV-positive woman to stop breastfeeding as soon as she is able to prepare and give her infant adequate and hygienic replacement feeding. The most risky time for artificial feeding in environments with poor hygienic conditions is the first two months of life, and family circumstances will therefore determine when the mother is able to stop breastfeeding and start replacement feeding.

Early cessation of breastfeeding is also advisable if an HIV-positive mother develops symptoms of AIDS.

Early cessation of breastfeeding could be considered as an option by HIV-positive women who:

* Find it difficult for social or cultural reasons to avoid breastfeeding completely
* Develop symptoms of AIDS during the breastfeeding period
* Can provide adequate replacement feeds, and can prepare and give these hygienically, only after their infants are a few months old.

2. Expressed and heat-treated breast milk

Heat treatment of expressed breast milk from an HIV-positive mother kills the virus in the breast milk. Heat-treated breast milk is nutritionally superior to other milks but heat treatment reduces the levels of the anti-infective factors.

To pasteurise the milk in hospital, it should be heated to 62.5C for 30 minutes (the Holder pasteurisation method). At home, it can be boiled and then cooled immediately by putting it in a refrigerator or standing the container in cold water.

To minimise contamination, heat-treated breast milk should be put in a sterilised or very clean container and kept in a refrigerator or in a cool place before and after heat treatment.

Expressing and heat-treating breast milk is time consuming and women may not find it a practical option for long-term infant feeding at home. However, if they are motivated and have the time, resources, and support, they may wish to consider this option. It may be most useful for sick and low-birth-weight babies in a hospital setting.

Other breast milk

1. Breast-milk banks

In some settings, milk is available from breast-milk banks. Breast-milk banks are generally used as a source of breast milk for a short time, for example, for sick and low-birth-weight newborns. They are not usually an option for meeting the nutritional needs of infants for a long period.

Given the risk of HIV transmission through unpasteurised pooled breast milk from unscreened donors, breast-milk banks should be considered as an option when:

* They are already established and functioning in accordance with standard procedures and safety precautions

* It is certain that donors are screened for HIV and that the donated milk is correctly pasteurised (using the Holder method.)

2. Wet-nursing

In some settings there is a tradition of wet-nursing in the family context, where a relative breastfeeds an infant. However, there is a risk of HIV transmission to the infant through breastfeeding if the wet-nurse is HIV-infected. There is also a potential risk of transmission of HIV from the infant to the wet-nurse, especially if she has cracked nipples.

Wet-nursing should be considered only when:

* A potential wet-nurse is informed of her risk of acquiring HIV from an infant of an HIV-positive mother

* The wet-nurse has been offered HIV counselling and testing, voluntarily takes a test and is found to be HIV-negative

* The wet-nurse is provided with the information and is able to practise safe sex to ensure that she remains HIV-negative while she is breastfeeding the infant

* Wet-nursing takes place in a family context and there is no payment involved

* The wet-nurse can breastfeed the infant as frequently and for as long as needed

* The wet-nurse has access to breastfeeding support to prevent and treat breastfeeding problems such as cracked nipples.

Unsuitable breast-milk substitutes

Skimmed and sweetened condensed milk are not recommended for feeding infants under six months of age. Skimmed milk has had all of the fat removed and does not provide enough energy.

Fruit juices, sugar-water and dilute cereal gruels are sometimes mistakenly given instead of milk feeds, but these and milk products such as yoghurt, are not recommended for replacement feeding for infants under six months of age.

Editor’s note: The SCN Secretariat would like to hear from researchers in developing countries who have conducted studies to assess the feasibility of alternative infant feeding methods for babies of HIV infected mothers who are not breastfed.

SIX MONTHS TO TWO YEARS

After the age of six months, breast milk should normally be an important component of the diet, providing up to half or more of nutritional requirements between the age of 6 and 12 months and up to one-third between the age of 12 and 24 months. An infant who is not breastfed needs replacement feeding which provides all the required nutrients.

After six months of age, replacement feeding should preferably continue to include a suitable breast-milk substitute. In addition, complementary foods made from appropriately prepared and nutrient-enriched family foods should be given three times a day. If suitable breast-milk substitutes are no longer available, replacement feeding should be with appropriately prepared family foods which are further enriched with protein, energy and micronutrients and given five times a day. If possible other milk products, such as unmodified animal, dried skimmed milk, or yoghurt should be included as a source of protein and calcium; other animal products such as meat, liver and fish should be given as a source of iron and zinc; and fruit and vegetables should be given to provide vitamins, especially vitamin A and C. Micronutrient supplements should be given if available. Health workers need to discuss with families how to prepare an adequate diet from local foods and how to make sure that the infant eats enough.

1. UNICEF/UNAIDS/WHO HIV and Infant Feeding. A Guide for health care managers and supervisors. 1998. For further information, please contact from Randa Saadeh, WHO Nutrition in Health and Development.. Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: [email protected]

BREASTFEEDING AND PERINATAL HIV TRANSMISSION IN THAILAND by Usa Thisyakorn The HIV epidemic in Thailand, has caused a large and growing pediatric AIDS epidemic due almost entirely to perinatal transmission. The rate of perinatal HIV transmission studied at the beginning of the epidemic in Thailand varied between 25-42%. The higher transmission rate (42%) was observed in the northern part of Thailand where the majority of HIV-infected mothers breast-fed their babies. The transmission rate in the same area dropped to 21-28% after breastfeeding had been discouraged in HIV-infected mothers, and once difficulties in supplying breastmilk substitutes had been solved through the Thai Government’s longstanding commitment. Breastfeeding by mothers known to be HIV-infected is actively discouraged in Thailand. Child mortality caused by infectious diseases is comparatively low in Thailand, consequently the discontinuation of breastfeeding is unlikely to result in substantial increases in infant disease-related mortality. However, most children who are at risk of acquiring HIV come from areas of the world where finding safe and economically feasible alternatives to breast milk is difficult. Strategies of infant feeding for HIV-infected mothers in these areas are urgently needed. Usa Thisyakorn is Deputy Director, The Thai Red Cross AIDS Research Centre, 1871 Rama IV Road, Bangkok, Thailand. Tel. 662-256-4107 to 9 Fax: 662-254-7577

THE POSSIBLE ROLE OF MICRONUTRIENTS IN HIV INFECTION
by Henrik Friis

Wasting and failure to thrive have long been known to be important features of HIV infection: for example, wasting is one of 3 major symptoms that define AIDS in the WHO clinical case definition of AIDS. However, in recent years the role played by nutritional deficiencies in early stages of HIV infection has also been investigated, and it has become clear that early HIV infection is accompanied by a range of micronutrient deficiencies. These deficiencies may contribute to the impairment of immune function seen in HIV infection, and may also affect viral replication and pathogenicity.

The potential for micronutrient deficiencies to act as cofactors in HIV transmission and progression is most obvious in poor populations with inadequate dietary intake and a high infectious disease burden. But since micronutrient deficiencies may be precipitated by HIV infection per se, a role for micronutrients is likely even in affluent populations (see Friis and Michaelsen (1) for a complete list of references). Micronutrient deficiencies could be co-factors in the progression of HIV infection to AIDS and death, in the sexual transmission of HIV, and in mother-to-child transmission of HIV.

HIV progression

The time from HIV infection to AIDS varies within as well as between populations, and has been reported to be shorter in developing than in industralized countries, even prior to the antiretroviral era. These differences in rate of progression may be due to a number of factors, such as genetic and virological characteristics, concurrent infections, standards of health care, as well as micronutrient intake and status. The fact that many factors may contribute to disease progression makes the identification of single causes difficult. However, there is evidence from longitudinal studies that micronutrirents play a role in HIV disease progression. In the USA, HIV-infected men with high intakes of vitamins A, thiamin, riboflavin, niacin, B₆, and possibly C, had less disease progression and/or mortality. However, very high intakes of vitamin A (more than 4 times RDA) and zinc were associated with increased progression and mortality. In another similar study, high intakes of riboflavin, vitamin E and iron, and possibly vitamin A, C and thiamin were associated with reduced disease progression. These studies were performed in populations with high dietary and supplemental intakes of micronutrients, and their results therefore do not permit inferences about the effects of micronutrient deficiencies. Unfortunately, no studies on the effects of dietary or supplemental micronutrient intake on the progression of HIV infection have been reported among adults in developing countries. However, data from a randomised, controlled vitamin A trial among pre-school children with acute pneumonia in Tanzania have just been presented at the recent Third International Symposium on Global Strategies to Prevent Perinatal HIV Transmission (Valencia, 9-10 November 1998). Although there was no effect of vitamin A on morbidity or mortality in the acute phase, it prolonged life expectancy among those with HIV infection, suggesting that vitamin A may play a role in slowing the course of HIV infection in children.

In a study from Malawi, serum retinol among pregnant HIV-infected women was found to be inversely related to maternal mortality. Similarly, the mortality among their infants before 12 months was 93% in infants of women with very low serum retinol, compared to 14% in infants of vitamin A replete women. It is worth noting that a proportion of these infants probably died because of other infections induced by vitamin A deficiency, but also that low retinol levels have been associated with advanced HIV infection in the mother, and increased HIV transmission to their infants. More serious HIV infections in the infants of retinol deficient mothers is therefore a likely contributing factor to the high infant mortality rate seen in their offspring, and among the mothers themselves.

Recently, low serum selenium - but none of a number of other micronutrients - was shown to be associated with approximately 10 times increased risk of mortality in three different USA cohort studies involving HIV-infected men. The association between host selenium deficiency and HIV progression could reflect impairment of immune functions and increased viral replication due to selenium deficiency.

HIV transmission

Like their possible role in the progression of HIV infection, the role of micronutrient deficiencies in sexual HIV transmission is difficult to study. Just like the progression of HIV infection, HIV transmission is determined by a complex of cultural, socio-economic, behavioural and biological factors. However, some data suggest that micronutrient deficiencies may affect the infectiousness of HIV-infected individuals: in a recent study from Kenya HIV-infected women with low serum vitamin A were more likely to shed HIV in vaginal secretions. There are as yet no epidemiological data to support the hypothesis that uninfected individuals with deficiencies of vitamin A (known to be essential to epithelial integrity) and other micronutrients are more susceptible to HIV, or to genital infections that are known risk factors for HIV.

The rates of mother-to-child HIV transmission were higher in developing (25-30%) than in industralized countries (14-25%) prior to the routine use of antiretrovirals. Although differences in breastfeeding practices and antenatal care are important contributors to this difference in transmission rate, micronutrient deficiencies in women of reproductive age in developing countries, exacerbated by the nutritional stress of pregnancy and lactation, may play a role. Studies from Kenya have shown that tow serum vitamin A in pregnant and lactating women was associated with the presence of HIV in vaginal secretions and breast milk. This suggests that maternal vitamin A deficiency increases the HIV exposure of the infant as it passes through the birth canal and during breastfeeding. Additionally, maternal micronutrient deficiencies may reduce the micronutrient status of the foetus or infant, thereby affecting immune functions and susceptibility of the unborn or young breastfed child to HIV. In accordance with these rests, a study from Malawi showed that women with tow compared to normal serum vitamin A at the first visit to the antenatal clinic had a four-fold increased risk of having an HIV-infected child. However, the association between vitamin A deficiency and HIV progression or transmission could be due to the confounding effect of either advanced disease or a co-existing micronutrient deficiency.

Randomised, controlled trials are ongoing to assess the cause and effect relationship between micronutrient deficiency and mother-to-child HIV transmission. Data from trials using vitamin A atone or in combination with vitamins and minerals are now emerging. A study on daily vitamin A supplementation to pregnant HIV-infected women in Malawi was recently presented in Valencia: however, no effect on mother-to-child transmission was found. Whether the lack of effect was due to co-existing deficiency of zinc, considered to be essential for mobilization of vitamin A from the liver, is not clear, but seems unlikely as there was a significant effect on birthweight.

A study among HIV-infected women in Tanzania using multi-vitamins (six B vitamins and C and E at approximately 10 times the RDA - but no vitamin A) showed reduced risk of abortion, stillbirth, prematurity, small-for-gestational age, and an increase in the T-helper cell count and haemoglobin concentration of the mother (2). Data on the effect of mother-to-child transmission are expected soon. However, the question of the effect of other deficiencies, and the role of interactions between multiple deficiencies which usually co-exist, will remain unanswered by these trials, and single nutrient interventions may fail in the presence of another deficiency. Multiple nutrient interventions or factorial designs may therefore be required to define whether nutritional intervention can reduce HIV transmission.

Potential public health measures

Data from observational studies suggest that several vitamins and selenium may decrease the progression of HIV infection or its transmission. On the other hand, the role of micronutrients is complex, and excess intake - particularly vitamin A - could be harmful. Randomised, controlled supplementation trials are urgently needed to clarify the relationship between potentially beneficial micronutrients and HIV progression and transmission. If supplementation with one or a combination of micronutrients can be proven, then developing countries could have affordable, cost-effective and safe public health interventions at hand.

References

1. Friis H and Michaelsen KF (1998). Micronutrients and HIV infection: a review. European Journal of Clinical Nutrition 52:157-63.

2. Fawzi WW, Msamanga GI, Spiegelman D, Urassa EJN, McGrath N, Mwakagile D, Antelman G, Mbise R, Herrera G, Kapiga S, Willet W, Hunter DJ (1998). Randomised trial of effects of vitamin supplements on pregnancy outcomes and T-cell counts in HIV-1-infected women in Tanzania. Lancet 351:1477-82.

Henrik Friis, Associate Research Professor, Research Department of Human Nutrition, The Royal Veterinary and Agricultural University, Rolighedsvej 30, DK-1958 Frederiksberg C. Denmark and Danish Bilharziasis Laboratory, Denmark Tel: +45 35 28 24 85 Fax: +45 35 28 24 83 Email: [email protected]

HIV/AIDS: THE KENYAN CASE
by Ruth Oniang’o and Agnes Kimokoti

The first report of Acquired Immune Deficiency Syndrome (AIDS) in Kenya was in 1984. The AIDS epidemic has continued to expand and by September 1997 over 76,000 AIDS cases had been reported. About 1.3 million Kenyans are estimated to be infected with human immunodeficiency Virus (HIV). Of these, 77,950 are estimated to be children. One of the major impacts of AIDS in Kenya is the reduction in life expectancy and increased child morbidity and mortality which threatens child survival. Other impacts include the effect of AIDS on women as traditional primary care providers (1).

For various reasons not all AIDS cases in Kenya are reported:

* Some people never seek hospital care for AIDS;

* Doctors may not want to record a diagnosis of AIDS because of the stigma attached to it;

* Individuals with HIV infection may die of other diseases before they are ever diagnosed as having AIDS;

* Some rural health care facilities may not have the capability to test for HIV infection.

The Economic Impact of AIDS

The loss of young adults in their most productive years of life affects overall economic output. AIDS is more prevalent among the economic elite, the best-educated people with the highest-paying jobs. Also, the private cost of AIDS is high and includes expenditures for medical care, drugs and funerals. Since most of these extra expenditures are financed out of savings, the reduction in investment could lead to a significant reduction in economic growth. The result is that families become poorer and their standard of living declines.

Secondly, the impacts on agriculture are likely to vary by agricultural system. In rainy areas, where a variety of crops are planted throughout the year, families can cope relatively well with the loss of a few labourers. They may reduce the area cultivated and cut back on the number of crops planted, but may still be able to produce an adequate amount of food. In dry areas, where farming depends on one or two crops that must be planted and harvested at specific times of the year the impacts are likely to be more severe. In such areas the loss of a few workers at the crucial periods of planting and harvesting can significantly reduce the size of the harvest and food security may be compromised. The aspect that is most devastating to agricultural production is, however, the diversion of available labour to caring for those who stay ill for long periods of time. Where the deceased was the most productive member of the family, coping with the aftermath and shock takes considerable time and energy Also, a los of agricultural labour is likely to cause farmers to switch to less labour-intensive crops. In many cases, this may mean switching from export crops to food crops. Thus, AIDS is affecting production of cash crops as well as food crops.

HIV/AIDS Related Morbidity and Mortality

Once a person is infected with HIV, survival depends on how long the body’s immune system is able to fight the virus. Poor nutrition and infections such as sexually transmitted diseases (STDs), tuberculosis (TB) and other opportunistic infections may accelerate progression to AIDS. Additionally, distance from health facilities, unavailability of diagnostic equipment, high cost of drugs, limited health worker skills, and poor attitudes towards AIDS patients may also contribute to the accelerated AIDS mortality.

The above observations suggest that good nutrition and prompt treatment of infections in HIV infected individuals may delay the onset of AIDS. This is particularly relevant to Kenya where expensive treatments of AIDS are unaffordable. Promoting the survival of HIV infected individuals is one of the ways to prevent children from becoming orphans at a very young age (1).

Control Programme of AIDS and STDs in Kenya

The government has tried to control AIDS and STDs nationally by creating the National AIDS and STDs Control Programme (NASCOP) within the Ministry of Health. The programme adopts a multi-sectoral approach to mobilise a widespread effort against AIDS. The plan calls for action in six primary areas: prevention of sexual transmission of HIV, prevention of HIV transmission through blood and blood products, mitigation of the socio-economic impacts of HIV/AIDS, epidemiological surveillance, co-ordination of research, and management and co-ordination of the multi-sectoral AIDS control programme. In addition to these government efforts, a number of NGOs and private sector programmes also contribute to the fight against AIDS (2,3).

What Needs to be Done

Much is being done today in Kenya to care for HIV/AIDS patients and to educate people about the dangers of AIDS. However, HIV is still spreading rapidly in most parts of Kenya. Early initiation of sexual activity among adolescents has been observed in Kenya as reported in studies by the Centre of Adolescent Studies (CAS) and the African Medical and Research Foundation (AMREF). The situation is quite worrisome since there is little evidence of behavioural change towards safe sex approaches (1)

Women are increasingly finding themselves as single parents with the dual responsibility of care provider and income generator for the family. Rehabilitation programmes and training in income generating activities for such women, especially in rural areas, will need to be expanded to cover a wider population. The number of young widows is increasing at an alarming rate as a result of deaths of young productive spouses (4). These young widows may enter new sexual relationships with serious implications regarding the expansion of the epidemic if they are infected with HIV.

One of the worst impacts of AIDS deaths of young adults is an increase in the number of orphans. These children lack the proper care and supervision that they need at this critical period of their lives. In fact, there is a tremendous strain on social systems to cope with such a large number of orphans. At the family level there is increased burden and stress for the extended family that has the traditional mandate to care for these orphans. Many grandparents are left to care for young children. Some families are headed by children as young as 10-12 years old. At the community and national level there is an increased burden on society to provide services for these children, including orphanages, health care and school fees. Many children go without adequate health care and schooling, increasing the burden on society in future years. There is an increase in the number of street children, particularly in urban areas (1).

In order for prevention efforts to succeed, a number of changes are required. Among the most important:

* Strong political commitment by all leaders

* Adoption of a multi-sectoral approach to AIDS interventions. All sectors of society must be involved in the solution to this problem including government, NGOs, private sector organisations, religious organisations, unions, professional societies and others.

* Strengthening of STD treatment at all levels as a strategy to decrease progression of HIV to AIDS. This is quite important because at the moment, government hospitals are inadequately stocked with drugs of almost every kind.

* Establishment of an effective national co-ordinating body with strong leadership and the backing of the Office of the President, international donor agencies, NGOs and all Kenyans. This is necessary in order to effectively co-ordinate a multi-sectoral approach to AIDS prevention.

* Introduction of AIDS education into school curricula in order to inform adolescents on how to stop the spread of AIDS. In this regard, religious leaders should be sensitised to see the seriousness of this issue so that they can co-operate in accepting AIDS education to be taught in schools. This has been quite a serious bone of contention in this country.

* Proper and timely counselling for HIV-infected pregnant women regarding infant feeding options.

* Provision of adequate nutrition to strengthen the immune system and delay the progression of AIDS

* Strengthening of HIV/AIDS/STDs surveillance and research programmes.

* Increased AIDS education and advocacy for behaviour change. Existing multi-media networks and interpersonal communication should be utilised to disseminate messages on positive behaviour change. Women and children should be involved in the design and dissemination of AIDS messages. Participatory advocacy and inter-personal communication should be utilised to enhance discussion of sensitive issues. The rural people should be reached by increased use of electronic and folk media as well as outdoor messages.

Nutrition as a factor in HIV/AIDS cannot be considered in isolation. It needs to be considered as part of a comprehensive package of approaches to control and prevent HIV infections. This is a difficult request in a country such as Kenya which is experiencing serious deterioration to the economic status.

References

1. GoK/UNICEF Situational Analysis of Women and Children in Kenya, (Draft-unpublished) 1998.

2. NASCOP, AIDS in Kenya. Background, Projections, Impact, Interventions. Fourth Edition, Nairobi, 1998.

3. GoK, Kenya Development Plan 1997-2001, Nairobi: The Government Printer, 1997.

4. Ndolo, MH A Comparative Review of the Epidemilogical Trends of HIV/AIDS and Tuberculosis in Kenya and the Implications for the Control of Tuberculosis, (MPH thesis, University of Wales College of Medicine. Welsh Combined Centre for Public Health), 1996.

Ruth Oniang’o, Food Science and Nutrition, Jomo Kenyatta University College of Agriculture and Technology, P.O. Box 62000, Nairobi, Kenya. Tel: 254 151 22646/9 Fax: 254 151 21764 Email: [email protected] Agnes Kimokoti, Senior Lecturer, University of Nairobi, P.O. Box 30197, Nairobi c/o Email: [email protected]

INFANT FEEDING IN THE AGE OF AIDS:
A DECADE-LONG EVOLUTION OF POLICY AND PRACTICE
by Lida Lhotska

The possibility that HIV could be transmitted from mother to child has been known for more than a decade. But even now, with so many questions still unanswered, it is a terribly difficult issue for health care professionals and policy makers. Transmission can occur at any stage: in utero, during birth and after birth through breastfeeding. Recently, trials in Thailand using the anti-retroviral drug AZT have shown a dramatic reduction in vertical transmission before and during birth. These reductions only increase the need to ensure that a newborn who has escaped infection thus far will avoid infection through breastfeeding.

In 1985, early evidence that HIV could be transmitted through breastfeeding came as a shock, though it really shouldn’t have. It was already known that HIV is passed through bodily fluids, and breastmilk is one of them. However, breastmilk has always been seen as an extremely healthy and natural substance, and breastfeeding as a way to provide irreplaceable benefits for both mothers and babies. To learn that breastfeeding could actually pose a danger was profoundly disconcerting.

I don’t think that in those early days many people immediately began to rethink strategies because the evidence was still anecdotal. It was not yet clear how - or when - transmission occurred.

But as the number of HIV-positive babies increased, the need to establish a policy and guidance for mothers grew. In 1992, WHO and UNICEF had a technical consultation that established the fact that HIV could be transmitted through breastfeeding. Aside from the science proving such transmission, there were other hard facts to face: Most of the women in the world had no access to HIV testing; the overwhelming majority of women who tested positive could not afford breastmilk substitutes; and the combination of fear and lack of information could easily lead to panic. Moreover, if people reacted by abandoning breastfeeding, the resulting deaths of children from diarrhoea, malnutrition and other diseases would certainly number in the thousands daily. And to complicate matters even further, it was known that in certain settings and circumstances, the risks posed by artificial feeding, even when a mother tested positive for HIV, could outweigh the still uncertain risk of transmitting the virus.

It was certainly not possible to change circumstances in poor countries rapidly enough to make artificial feeding safe for infants who needed it. So the expert group on HIV and infant feeding established by WHO and UNICEF was careful in choosing the settings in which they advised alternatives to breastfeeding. The group considered such criteria as infant mortality and malnutrition rates, as well as access to adequate hygiene. Yet, in retrospect, the 1992 approach was inadequate, with an implicit, though unintended, double standard, suggesting that in poor countries, mothers should continue to breastfeed. Population-wide recommendations gave way to policies and strategies that enabled health workers to counsel mothers.

In 1997, the UNAIDS Secretariat issued a policy statement promoting a mother’s right to choose the best method for feeding her child. The statement was followed in 1998 by guidelines for policy makers and health care managers who deal with the issue of HIV and infant feeding, highlighting the need to respect and fulfil women’s rights.

The current policy has been greatly influenced by actions over the past five years to integrate into programming two important human rights conventions - the Convention on the Rights of the Child and the Convention on Elimination of All Forms of Discrimination against Women. It is one thing to read the documents, however; another to internalize the ideas; and still another to turn principles into practice. Throughout the 1990’s people have increasingly sought to ensure that all the rights outlined by the two conventions are protected, respected and fulfilled. So too in the area of HIV and infant feeding have we come to insist that individual rights be considered. These rights cover voluntary and confidential counselling and testing, informed choice about infant feeding and personal decision-making about reproductive health.

This rights approach needs to be supported by concrete measures. For example, once we recognize that women have the right to informed choice, we have to provide the information. And if we value a child’s right to the highest attainable standard of health, we have to specify what that means in the case of HIV and infant feeding. One enormous difficulty we face is the limitations of current tests. Those most widely available do not always establish whether a child is infected at the time of birth, because the infant carries the mother’s antibodies for up to 18 months. Mothers, therefore, cannot base their decisions about infant feeding on sure knowledge of the child’s HIV status.

HIV poses special challenges to health workers, who have traditionally been trained to dispense advice. If a person comes in with the flu, it’s easy. You simply say, take this aspirin, get some rest, you’ll get better. With HIV, there is no straightforward, consistent advice that works for everyone. Determining what is best requires an individual assessment of various risks, as well as crucial information often known only by the mother. Suddenly, health workers find themselves in the unfamiliar role of counsellors. I hope that, with appropriate training, they can help a woman to consider all aspects of the situation, to understand her options, and to assess the potential dangers posed by artificial feeding. Most of all, I hope that health workers will understand that the woman receiving their counselling and care is going through a very traumatising experience.

Ultimately, the decision of what to do must be in the hands of mothers, who want more than anything to do what is best for their babies. Feeding is one area that mothers can control. Each mother will struggle to make the best feeding choice possible and to minimise the risk to her baby - even as she considers a whole range of circumstances, such as the effect of using commercial formula on other children in the family and on household food security.

It’s a painful choice: By breastfeeding, she might be introducing a risk that could lead to her baby’s death; by not breastfeeding, she could be causing harm to that very child while also endangering the rest of the family. Whichever choice she makes, the mother must be supported.

This support may entail providing what she needs to carry out her decision - including, in some cases, uninterrupted access to adequate replacement feeding for the baby. It has long been known that the ideal nutrition for babies is exclusive breastfeeding for about the first six months followed by the addition of complementary foods, but we now recognise that for babies of HIV-positive mothers, avoidance of breastfeeding may save the child’s live. We need to ensure that such mothers have access to a suitable breastmilk substitute for the first six months and to additional nutrients later on.

In the process, UNICEF would like to see two ‘safety catches’: one, that adequate supplies of substitutes be available to all the women who need them; and two, that provision of these supplies not cause ‘spillover’, or the unnecessary use of artificial feeding by HIV-negative mothers and those of unknown status. It is difficult to strike a balance between reaching everyone in need with replacement feeding and ensuring that the rapidly implemented programme does no unintended harm. We are working with governments that are ready to try this approach carefully and whose experiences may lead to an effective global response.

Even before the HIV-breastfeeding connection was established, we acknowledged that there might be a limited number of children who may need breastmilk substitutes to protect their own or their mothers’ health. But particular caution must be exercised in cases where manufacturers donate infant formula. The International Code of Marketing of Breastmilk Substitutes and subsequent resolutions by the World Health Assembly clearly state that supplies are not to be donated through the health care system. Each nation needs to develop distribution channels that comply with the Code.

The Code is even more crucial in the face of HIV/AIDS because it is the only agreed-upon way to fight inappropriate promotion of breastmilk substitutes and supplies to the general public or through the health care system. We would, therefore, like to see an acceleration of Code implementation and enforcement in all countries to protect against such promotion, and to ensure that governments meet their obligations under the Convention on the Rights of the Child, which calls for correct information to the public - especially parents.

As research and thinking evolve, so will policy guidance. But its basis and purpose, to help parents and governments ensure that the best interests of every child is protected, remain unchanged.

Lida Lhotska is Project Officer, Infant Feeding and Care, UNICEF Nutrition Section.

This article is reprinted, with permission, from the Baby-Friendly Hospital Initiative Newsletter. Sept/Oct 1998, pp 4-5.

INFORMING ZIMBABWEAN WOMEN ABOUT THE TRANSMISSION OF HIV THROUGH BREASTFEEDING - THE ZVITAMBO SUB-STUDY
by Lorrie Gavin and Jean Humphrey

Investigators from the ZVITAMBO project in Zimbabwe (see SCN Newsletter #14, July 1997) are undertaking a new sub-study in an attempt to operationalise recently revised UN policy about informing women in developing countries on the risk of transmitting HIV to their children through breastfeeding. Until recently, global policy was to encourage HIV-positive women living in developing countries to continue to breastfeed. With the acknowledgement that approximately one-third of HIV-infected infants acquired HIV while breast feeding, HIV-infected women in developing countries have the right to be ‘fully informed’ through counselling about the risks of transmitting HIV through breastfeeding so that they can make their own choice about how to feed their children (UNAIDS/UNICEF/WHO 1998). This is likely to be new information for many women in developing countries; among ZVITAMBO mothers, approximately one-half report that before joining ZVITAMBO they did not know that HIV can be transmitted through breast feeding.

This new study must address a wide range of social, cultural and economic issues in two complex behavioral areas: infant feeding practices and social response to HIV/AIDS. It will be targeted at African women, a population which frequently lacks decision-making autonomy and may be at risk of negative consequences if found to be HIV-positive. Counselling a woman about HIV and breastfeeding may pose unique challenges because an HIV-positive mother who chooses replacement feeding1 must consider the impact of HIV infection on her child as well as herself; weigh the risks of replacement feeding against the risks of breastfeeding; consider nearly-immediate disclosure of her HIV status to her husband and/or other family members; risk social stigmatisation and/or other negative consequences; and acquire a new set of infant feeding skills that will enable her to safely provide replacement feeding to her child for a prolonged period of time. Since replacement feeding can also pose a significant threat to child helth, there is concern that the dissemination of information about HIV and breastfeeding will lead to a shift away from breastfeeding among HIV-negative women or women who do not know their HIV status. Thus, the project has three objectives:

* Develop an intervention to educate and counsel women about HIV and breast feeding. Ethnographic research will be conducted to better understand the context within which women decide how to feed their child. In Zimbabwe, breastfeeding is a nearly universal practice with 93% of children receiving breast milk at 6 months of age (UNICEF 1998). Breastfeeding also has important social meaning, for example; it has traditionally been used as a ‘yard stick’ to measure a married woman’s chastity and fidelity (Cosminsky 1993). We will consider various counselling modalities to determine how to best structure the intervention.

* Monitor the impact of the intervention. The project will assess the intervention by determining whether there is a change in women’s knowledge of the risk of transmitting HIV by breast feeding. It will also monitor the actual infant feeding practices of HIV-positive and HIV-negative women at 3-monthly intervals over the first year postpartum. (The infant feeding practices of HIV-negative women will be monitored so that any shift away from breastfeeding can be quickly identified.) Other consequences of the intervention (e.g., negative life events) will also be monitored, while a qualitative component will provide in-depth information about the process by which infant feeding decisions were made among women who received the intervention.

* Disseminate results and provide guidance to the Government of Zimbabwe. The project will be implemented in close collaboration with government health officials in Zimbabwe, and results will be disseminated widely among health care providers throughout the country.

We expect to offer the counselling to at least 5000 of the 14,000 mother-baby dyads recruited into ZVITAMBO over the next year. We hope that lessons learned from this effort will be useful to others as they attempt to implement the revised UN guidelines on HIV and breastfeeding.

The United Nations (1998) defines ‘replacement feeding’ as the process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients the child needs. Feeding options for an HIV-positive mother include providing breastmilk substitutes (commercial or home-prepared infant formula) and modified breastfeeding (early cessation or express and heat-treated breastmilk).

References:

1. Cosminsky S, Mhloyi M & Ewbank D (1993). Child feeding practices in a rural area of Zimbabwe, Social Science and Medicine. Vol. 36(7): 937-947.

2. UNAIDS/UNICEF/WHO (1998). HIV and Infant Feeding: Guidelines for decision-makers. Draft WHO/FRH/NUT/CHD/98.1.

3. UNICEF (1998). The State of the World’s Children 1998. Oxford University Press, NY, NY.

Jean Humphrey, Principal Investigator, The ZVITAMBO Project 21 Van Praagh Avenue, Harare, Zimbabwe Tel: 263-4-781-532

Email: [email protected]

WOMEN’S RIGHTS TO BREASTFEED vs. INFANTS’ RIGHTS TO BE BREASTFED
by George Kent

What is the relationship between the mother’s interest in breastfeeding and the infant’s interest in being breastfed? How do the mother’s rights relate to the infant’s rights?

Infant care and feeding are affected by many different parties, including the infant, the parents, siblings, the extended family, the community, health professionals, employers, infant formula manufacturers and sellers, local government, national government, and others. Each party has its own interests and its own capacities to press for outcomes preferable to itself. At times infants are not nurtured properly because of the pull of others’ interests. They are all concerned, more or less, with the infant’s health, but they also have other interests such as profits, increased leisure time, and having opportunities to do other things. Where these parties do not all have preferred outcomes that are consistent with one another, there is conflict among them.

At times the mother and the infant may have conflicting interests. The conflict is raised in clear relief when it is argued that the infant has a right not only to be well nourished but, more specifically, that the infant has a right to be breastfed. Such a right could clash with the woman’s right to choose how to feed her infant.

Article 3 of the Convention on the Rights of the Child says that “In all actions concerning children... the best interests of the child shall be a primary consideration”. Combining this with the observation that breastfeeding is better than alternative methods of feeding, some breastfeeding advocates argue that infants have a right to be breastfed. However, this appears to be a minority view.

While it is true that actions must be based on consideration of the best interests of the child, that is not the only consideration. Moreover, it is assumed that normally the parents judge what is in the child’s best interests. The state should interfere in the parent-child relationship only in extraordinary situations, when there is extremely compelling evidence that the parents are acting contrary to the best interests of the child.

The infant has great interests at stake, but few resources to be used to press for preferred outcomes. Given the infant’s powerlessness, it is sensible to use the law to help assure that the best interests of the infant are served. However, while it is surely appropriate to use the law to protect the infant from outsiders with conflicting interests, it is not reasonable to use the law to compel an unwilling mother to breastfeed. Thus, for the purposes of framing appropriate law, the woman and infant can be viewed as generally having a shared interest in the infant’s well being. From the human rights perspective, the major concern is with protecting the woman-infant unit from outside interference.

The prevailing view is that women must remain free to feed their infants as they wish, presumably in consultation with other family members, and that outsiders are obligated to refrain from doing anything that might interfere with a freely made, informed decision. It is assumed that they have appropriate and accurate information available to them. This is the approach taken in the International Code of Marketing of Breastmilk Substitutes. The code is not designed to prevent the marketing or use of formula, but to assure that parents can make a fully and fairly informed choice on how to feed their infants.

Rather than have the state make decisions for them, citizens in a democracy prefer assurances that nothing impedes them from making good decisions. To the extent possible we should be free to choose, and that includes being free to make what others might regard as unwise decisions.

Fundamental Principles

In my view, the human rights of infants with regard to nutrition may be summarised in a few fundamental principles:

(1) Infants have the right to be free from hunger, and to enjoy the highest attainable standard of health.

(2) Infants are entitled to good food, good health services, and good care.

(3) Mothers have a right to breastfeed.

(4) Infants have the right to be breastfed if their mothers choose to breastfeed.

(5) A reluctant mother cannot be legally compelled to breastfeed.

(6) Human rights law requires respect, protection, and facilitation by outsiders - and particularly by the state - of the nurturing relationship between mother and child.

(7) Infants are entitled to assurance that their parents are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition and the advantages of breastfeeding.

(8) Infants are entitled to expect that their mothers have good prenatal care.

(9) Infants are entitled to baby-friendly health facilities.

(10) Infants are entitled to assurances that, through appropriate maternity legislation, their mothers have adequate opportunities to nurture them.

Recommendations

The idea that parents should be able to make informed decisions remains valid in the context of HIV/AIDS. However, its application depends on the decision-makers, primarily mothers, being aware of and having real access to a range of feeding alternatives, and it depends on their having good information about these available alternatives. Where commercial interests are represented, the presentation of options and the information about them are likely to be sharply skewed.

The ten principles regarding the human rights of infants with regard to nutrition apply in the context of HIV/AIDS; they are not to be suspended. This means, for example, that even HIV-positive mothers have a right to breastfeed. If any country were to prohibit HIV-positive mothers from breastfeeding, that would violate their human rights, and also violate their infants’ human rights.

Particular attention should be given to Principle 7 which focuses on the obligation to assure that the infants’ parents are well informed with regard to their infant feeding choices. This is the major idea underlying the International Code of Marketing of Breastmilk Substitutes. The code does not prohibit marketing or use of formula, but insists that promotion activities for the products must be conducted in ways that are fair rather than being skewed to favour commercial products. Article 24, paragraph 2e of the Convention on the Rights of the Child goes directly to the point. It calls upon States Parties “To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breast-feeding, hygiene and environmental sanitation and the prevention of accidents.” This is a legally binding obligation on all States Parties to the convention (all countries except the Unite States and Somalia), and a strong moral obligation on those that are not. From the debate relating to HIV, it is now increasingly clear that the full array of feeding options should be presented to the parents, and better research is needed about the advantages and disadvantages of each option in particular local circumstances.

In addition, there is a need to enable the mother to learn whether she is HIV-positive through voluntary counseling and testing so that she can make an informed decision regarding the feeding of her infant in relation to her own condition. This counseling should include factual information on the limitations, validity, and meaning of the test.

These points can be formulated as Fundamental Principles on the human rights of infants with regard to nutrition where there is significant risk of HIV infection through breastfeeding. These principles, to be added to the ten listed earlier, might be stated as follows:

(11) Regardless of the mother’s HIV status, infants are entitled to assurance that their parents are informed of the full range of feeding alternatives and their advantages and disadvantages in the local circumstances.

(12) Women in their child-bearing years are entitled to accessible voluntary testing and counseling regarding HIV/AIDS. This counseling must include information about the limitations, validity, and meaning of the test and the benefits and risks of various feeding alternatives in the local circumstances.

(13) Infants are entitled to expect that their governments will help to make quality feeding alternatives available, including expressed and heated breastmilk, or breastmilk from others obtained through wet nurses, milk banks, or other comparable arrangements.

(14) Infants are entitled to expect that their governments will seek to obtain and provide the unbiased information needed by their parents regarding HIV/AIDS and feeding alternatives.

In other words, as a consequence of the infant’s human right to nutrition, parents are entitled to good information about a broad range of feeding alternatives.

These are tentative formulations, offered to stimulate discussion. Principles of this sort should be considered in preparing policy at the global level, and also in the drafting of national legislation and national policies relating to HIV/AIDS.

1. Convention on the Rights of the Child.
http://www.unhchr.ch/html/menu3/b/k2crc.htm

George Kent is Professor and Chair, Department of Political Science, University of Hawaii, Honolulu, Hawaii 96822-2231, USA. Email: [email protected] He serves as Coordinator of the Task Force on Children’s Nutrition Rights for both the World Alliance on Nutrition and Human Rights and the World Alliance for Breastfeeding Action. Although he has consulted with others on the views offered here, these views are his own and do not represent those of any other individuals or organisations.

THE IMPACT OF HIV&/AIDS ON RURAL FOOD SECURITY
by Daphne Topouzis

Access to an adequate amount of food is the most basic of human needs and rights. Food security, as defined by the Food and Agriculture Organisation of the United Nations (FAO), is “enough nutritious and safe food being available and accessible for a healthy and active life by all people at all times.”¹ Food security is thus dependent on four factors: availability, stability and accessibility of food, and good health. To achieve national food security, a country must be able to grow sufficient food or have enough foreign exchange to enable it to import food. As many as 44 countries in Africa today are classified by FAO as low-income and food-deficit. At the household level, food security is “the capacity of a household to procure a stable and sustainable basket of adequate food,”¹ according to the United Nations International Fund for Agricultural Development. Households must have sufficient income to purchase the food they are unable to grow for themselves.

¹ FAO, The Effects of HIV/AIDS on the Farming System in Eastern Africa, 1995, p.93

The main causes of food insecurity are low productivity in agriculture combined with fluctuations in food supply, low incomes, insecure livelihoods and shocks, such as asset loss (for example the death of livestock), war, theft and civil conflict, and more recently the onset of HIV/AIDS.² HIV/AIDS-related morbidity and mortality affects household food security through:

à the loss of prime-age adult on- or off-farm labour; labour shortages lead to a decline in the productive capacity of a household;

à a decline in household income and loss of assets, savings and remittances;

à an increase in household expenditures (for medical treatment and transport, special foods for the infirm); and

à a rise in the number of dependants relying on a smaller number of productive family members.

² FAO, Implications of Economic Policy for Food Security, FAO, 1997.

These factors may result in any of the following scenarios:

à they may trigger food insecurity in previously unaffected households;

à they may render some households chronically food insecure and their members chronically undernourished with severe consequences for infants, young children, pregnant/lactating women and the elderly; and

à they may increase the frequency and extent of food insecurity among households previously only suffering from seasonal food insecurity.

Food-insecure household members are susceptible and vulnerable to HIV/AIDS: malnutrition contributes to poor health status, and by extension, to low labour productivity, low incomes and livelihood insecurity. People with low incomes are less likely to get treatment for sexually transmitted diseases (which can facilitate HIV transmission) or opportunistic infections associated with HIV/AIDS. People living with AIDS are particularly vulnerable as, without a good diet, they cannot prolong good health and live a longer life to provide for their children.

FAO research in East and West Africa³ shows that the most immediate problem for many AIDS-affected rural households is not medical treatment and drugs but a lack of food and poor nutrition (see Box). In case of adult deaths, survivors (especially widows and their families) often have few assets to dispose of in time of need. Household food security coping mechanisms may disintegrate soon after adult death and food consumption may decline sharply amongst remaining family members.

³ D. Topouzis and G. Hemrich, The Socio-Economic Impact of HIV/AIDS on Rural Families in Uganda, UNDP Discussion Paper No. 6, 1996, and A. Michaud, Impact du VIH/SIDA sur les systs d’exploitations agricoles en Afrique de l’Ouest, FAO, 1997.

Rural household coping mechanisms weaken under the impact of HIV/AIDS and may even inadvertently facilitate the spread of the epidemic. For example, rural-to-urban migration, which has traditionally acted as a livelihood security coping strategy and mechanism for rural accumulation (through remittances and savings for investments in technology and inputs) may contribute to the spread of HIV and the impoverishment of rural areas. The epidemic is eroding the savings capacity of rural households as youths that migrate to urban areas and contract HIV return to their villages when they fall sick. Rural households (and especially women) provide most of the care for people with AIDS and bear most of the food and medical costs, and funeral expenses. Little is known about the effects of the epidemic on savings flows and other remittances to rural areas and the ramifications for food security. A key question is whether coping mechanisms of rural households using migration as a strategy for accumulation are changing in the face of HIV and, if so, how.

Issues to be Addressed

At the programme level, the sharp increase in young adult morbidity and mortality means that the viability and sustainability of food security may be undermined by the HIV epidemic. For example, the impact of morbidity and mortality on agriculture may result in labour shortages forcing farm households to shift from cash to subsistence crops when food security is being threatened. Cash crops requiring an extended investment period may not be suitable for families affected by AIDS that need quick returns to cover immediate medical, funeral or orphan-related expenses. Crops requiring intensive labour or high external inputs may not be suitable as a result of labour or cash shortages.

Labour shortages also raise the issue of the sustainability of traditional agricultural production methods. In Kagera, Tanzania, for instance, bananas are not being mulched or replanted in heavily HIV affected areas, resulting in falling yields and reduced soil fertility. Usual practices entail clearing new areas every few years, but as labour is no longer readily available, there is overcropping. What will be the impact on yields and on food security in the medium term? How can traditional coping strategies be maintained given the increasing pressures on subsistence agriculture?⁴

⁴ Personal communication, Desmond Cohen, UNDP, 28 April 1998.

Given the labour shortages experienced by many rural households as a result of HIV/AIDS as well as other factors (migration, shifting employment patterns), a review of labour-intensive food production strategies, upon which food security policies and programmes are often based, may be necessary. In particular, it is important to re-assess labour-intensive food production strategies in areas heavily affected by the epidemic. There is a need for:

à research, dissemination and promotion of labour-saving technologies and improved farming practices for men and women farmers (including the youth and the elderly);

à promotion of drought- or disease-resistant crop varieties (both being labour-saving measures which enhance food security);

à adjustment of post-harvest protection measures to account for the loss of knowledge on storage of particular crops; and

à information, education and communication campaigns on nutrition, diet and health.

HIV/AIDS, Gender and Food Security Josephine, a widow in her late 30s, has seven children. Her husband has died of AIDS. She also has AIDS and is at times bedridden. Josephine, who lives with her 19-year-old daughter and 12-year old son in a village in Eastern Uganda, is severely malnourished. Her biggest problem is that she does not grow enough food. The family diet consists of cassava, millet and a few greens. Josephine’s daughter tries to prepare two meals a day but they often have only one. Eating the same food-boiled cassava without sauce (they have no money to buy oil with which to prepare the sauce)-has made Josephine loose her appetite, she said. She had not eaten fruit for a month. Josephine has not received moral or material support from her late husband’s family or from the community. No one comes to see her. Attitudes toward her and her family were very negative, she said. She does not want to ask for help from her husband’s brothers because she fears their wives will suspect that she is sexually involved with them. When she is not bedridden, Josephine works as a casual labourer from 5:00am to 9:00pm for about 1,000 Ugandan Shillings (about US$.80). This long workday exhausts her, but she cannot afford to rest or she and her daughter would not have enough food. She described this as a vicious circle: on the one hand, she cannot grow enough food to feed herself and her family because she is too weak and hungry, while on the other hand she needs to eat properly in order to work in the fields. Source: Topouzis & Hemrich, The Socio-Economic Impact of HIV/AIDS on Rural Families in Uganda, UNDP Discussion Paper, op. cit, p. 15.

Agricultural research programmes need to investigate farmers’ supply response to AIDS in terms of output or labour inputs and the special needs of farm households with fewer working adults and higher dependency ratios (i.e. for appropriate technology). Agricultural extension programmes need to ensure that strategies for labour-substitution, technical advice and credit services are made available to enhance food and livelihood security. They may also need to review the impact of HIV/AIDS in terms of increased morbidity and mortality among agricultural extension staff and of the reduction of the work week as a result of the rise in funeral attendance. In some parts of Uganda, for instance, the six-day work week is often informally reduced as a result of HIV/AIDS mortality and morbidity.

Food security coping mechanisms of key informal rural institutions⁵ particularly cooperative production and marketing arrangements, need to be better understood and strengthened. For instance, how do communities cope with labour shortages in AIDS versus non-AIDS scenarios? Do traditional labour-sharing arrangements (communal/individual) continue to function under the impact of HIV/AIDS, and if so, with what adjustments? How does the principle of reciprocity continue to operate in areas heavily affected by the epidemic? What happens when AIDS-affected households cannot contribute labour and thus do not receive assistance when they need it most? How vulnerable are traditional labour-sharing coping mechanisms to HIV and how can these be strengthened? Are there relief-oriented mechanisms in place (i.e. by church groups) when other reciprocal mechanisms fail?

⁵ These include the extended family system, the kinship system, non-registered CBOs (women’s groups, mutual assistance associations, traditional savings groups, etc.), cooperative production and marketing arrangements and traditional political structures.

Other key issues to be addressed when assessing the impact of HIV/AIDS on rural households and their coping mechanisms include the following:

What is the impact of the epidemic on the nutritional status of infants, children, pregnant women and the elderly? Is there evidence of gender-based and/or age-based differentiation?

If food is the most immediate problem for many HIV/AIDS-affected households, how can food security programmes provide relief to such households when needed and what is the most effective way of delivering it?

What are the key food security coping strategies adopted by male- versus female-headed households affected by HIV/AIDS?

How can the livelihoods of the poorest be strengthened through self-help mechanisms (savings and funeral societies/groups)?

Nutrition can be used as an entry point for a more comprehensive understanding of the inter-relationships between HIV/AIDS and food/livelihood insecurity, as well as of the changing dynamics of food and nutrition coping mechanisms at the household level. Given that nutritional assessments are location-specific (being dependent on the agro-ecological, socio-economic and cultural environments), they can also serve as the basis for AIDS mitigation measures, where appropriate.

Daphne Topouzis, a consultant on HIV/AIDS and Agriculture/Rural Development, is the author of “The Socio-Economic Impact of HIV/AIDS on Rural Families in Uganda,” UNDP Discussion Paper No. 5, 1996; “The Implications of HIV/AIDS for Agricultural Investment Projects,” FAO Investment Centre, Rome, 1995; and “Rural Ugandans Close Ranks Against AIDS,” The African Farmer, July 1994. This article is based on the forthcoming The Implications of HIV/AIDS for Rural Development Policy and Programming: Focus on Sub-Saharan Africa, to be published by UNDP, New York. The author would like to thank Desmond Cohen, Senior Adviser to UNDP’s HIV and Development Programme, Jacques du Guerny, FAO AIDS focal point and Emmanuel Chengu, FAO Rural Development Analysis Officer for their contribution, e-mail: [email protected].

UN INITIATIVE FOR THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION: SUPPORT FOR IMPLEMENTATION OF PILOT PROJECTS

Unchecked, HIV/AIDS in children will undo much of the progress made in the last 20 years in improving child survival and development in low-income countries. In much of sub-Saharan Africa HIV/AIDS is, or will soon become, the leading cause of death in young children. In some of the worst-affected cities, infant mortality rates have doubled in recent years.

A combination of effective interventions now exist which have already been used to dramatically reduce the number of children born with HIV in industralized countries. But no large-scale efforts are presently being made to prevent mother-to-child transmission of HIV in low-income countries Recent research has enabled a drastic reduction in the cost of the drug intervention that prevents mother-to-child HIV transmission by shortening the duration of treatment while maintaining a good level of effectiveness. UNICEF, in close collaboration with the UNAIDS Secretariat, has been able to obtain a donation from the Glaxo Wellcome Company, the producer of AZT, for 30,000 pregnant women. It is likely that the total cost of reducing the risk of transmission of HIV from a mother to her child will be reduced to about $200 per treated HIV-infected mother, making HIV treatment as cost-effective in preventing child death as other child survival interventions, such as immunisation.

The overall goal of this UN initiative is to assess the feasibility of prevention of mother-to-child transmission (MTCT) of HIV in a variety of situations in some of the worst-affected countries in Africa and South East Asia, thus reducing the infection rate in infants and young children.

Specific objectives:

à To make available good quality voluntary confidential counselling and testing to 10,000 pregnant women and their partners in each pilot country.

à To integrate interventions to prevent MTCT into a comprehensive package of on-going antenatal, maternity and nutrition services in the participating countries. The comprehensive package will include voluntary and confidential counselling and testing, provision of AZT to HIV¦ women, modified delivery practices, provision of information on infant feeding options, and where necessary, a supply of breast-milk substitutes.

à To sensitize health service managers and policy-makers on the scope of the problem and possible solutions.

à To carefully monitor implementation and document experiences in order to facilitate replication in other facilities within countries and to other affected countries.

Two major outcomes are expected:

à Through a better understanding of the conditions for the intervention to be feasible and cost-effective in saving children’s lives and preventing suffering, governments and the donor community will expand efforts to reach more HIV-infected mothers.

à Voluntary and confidential counselling and testing for HIV will become more acceptable and accessible, contributing to the reduction of all forms of HIV transmission.

Other anticipated outputs include:

à Reduced number of infected infants born to HIV-positive mothers.
à Changed attitudes of families and communities to the problem.
à Improvement in the quality of maternal-child health services.

Beneficiaries

The primary beneficiaries of the project are the infants of HIV-positive women in the pilot sites, up to one-half more of whom will be born and remain uninfected as a result of the interventions. In addition, all pregnant women in the pilot sites will benefit from improved antenatal and maternity services and voluntary and confidential counselling and testing.

Monitoring and Evaluation

The monitoring and evaluation arrangements for this project are critical, because it is aimed at establishing the feasibility of the intervention, and the conditions necessary for it to succeed in low-income countries with varying types and levels of services. Close monitoring will be necessary in order to modify site-specific approaches if problems are identified and/or a particular strategy is shown to be successful and warrants adaptation in other areas.

At the global level, the project will be monitored by UNICEF, the UNAIDS Secretariat and other partners. Data from the countries will be periodically reviewed at this level, and site visits undertaken as and when necessary.

At the onset of the project in each country, a monitoring and evaluation plan will be agreed between the local UN Cosponsors, the Government, managers of the pilot sites and other relevant partners, such as local research institutes. The most likely scenario will be the setting up of a local Task Force which will meet regularly and act upon its own Terms of Reference.

The results of the evaluation will be presented as case studies in various international fora, (Lusaka 1999 Africa Regional Conference and Durban 2000 XIII International AIDS Conference). UNICEF and the UNAIDS Secretariat are supporting HIV networks in Eastern Africa and South East Asia which will be used to disseminate the information among the countries. Finally, as this intervention is part of a combined effort of the UNAIDS Secretariat, WHO, UNFPA and UNICEF, the results and lessons learned will be compiled and disseminated as part of the UNAIDS best practice collection of materials.

More detail on the pilot projects can be obtained from Isabelle De Vincenzi, UNAIDS, Room 309, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland Tel: +41 22 791 4610 Email: [email protected]

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HIV AND INFANT FEEDING: A CHRONOLOGY OF RESEARCH AND POLICY ADVANCES AND THEIR IMPLICATIONS FOR PROGRAMS
by Elizabeth Preble and Ellen G. Piwoz

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This report reviews the literature on HIV and Infant Feeding and supports the general consensus that HIV can be transmitted to infants through breastfeeding and that mothers who themselves become infected while breastfeeding are at heightened risk of transmitting the virus to their infants. However, the authors believe that there are still many unanswered questions surrounding HIV and infant feeding.

This paper addresses five major areas. It reviews:

à the major advances in the study of HIV and infant feeding;
à criteria to consider when evaluating research studies;
à findings of several major studies;
à limitations of our current knowledge; and
à areas requiring further research.

Accompanying the report, is a fact sheet “Frequently asked questions on: Breastfeeding and HIV/AIDS” This address issues such as:

à how mother-to-child transmission occurs,
à how many infants are at risk,
à should mothers be advised not to breastfeed,
à can use of anti-retroviral drugs help reduce mother-to-child transmission of HIV, and
à what advice can health workers give mothers.

Particularly useful is a table summarising the major studies on HIV and breastfeeding in developing countries which gives country of study, sample size, type of study and major findings.

This is a joint publication of the Linkages (Breastfeeding, Complementary Feeding, and Maternal Nutrition Program) Project and the SARA (Support for Analysis and Research in Africa) Project. Reports can be ordered from: Sara Project, Academy for Educational Development, 1255 23^rd Street, N. W., Washington, D.C. 20037. Tel: 202-884-8701, Fax: 202-884-8701, E-mail: [email protected]

MEDICAL NUTRITION THERAPY ACROSS THE CONTINUUM OF CARE (2^ND EDITION, 1998) CLIENT PROTOCOLS FOR HIV/AIDS CHILDREN/ADOLESCENTS/ADULTS
by The American Dietetic Association and Morrison Health Care

The Medical Nutrition Therapy Protocol for HIV/AIDS is part of the revised manual on client protocols on all major medical nutrition therapies. Two sections are devoted to HIV/AIDS - one for children and adolescents, the other for adults. Clinical, functional and behavioural assessment factors are given along with the expected outcome and the ideal goal. For example, assessment factors would be height, weight and BMI percentile; expected outcomes would be to meet growth velocity goals and maintain or improve lean body mass and fat stores based on age and gender; the ideal goal would be to achieve at least the 50 percentile based on growth grids for age and gender. Clinical parameters to be assessed include albumin, prealbumin, viral load, cholesterol and triglycerides, BMI, body composition, diarrhoea, nausea/vomiting and dysphagia. Behavioural assessment includes using safe food and water handling procedures; consuming adequate food and nutrients to maintain weight; including or avoiding foods based on side effects of medication or symptoms of infection; and participating in regular physical activity.

Three categories of care are given for children/adolescents:

à no sign/symptoms or mild signs/symptoms
à moderate signs/symptoms
à severe signs/symptoms

For adults four categories are listed:

à HIV asymptomatic
à HIV/AIDS symptomatic but stable
à HIV/AIDS acute
à Palliative

Protocols for assessment and measurement of each stage are elaborated. Expected outcomes, follow-up and guidelines for communication are given. Appropriate bibliographic references are included.

Editor’s note: These client protocols would most likely be implemented in large teaching hospitals in developed countries where there is a high level of resources to accommodate the various tests and procedures. This 3-ring binder contains client protocols for 15 major medical nutrition therapies. The binder contains reproducible masters of disease-specific protocols and is accompanied by two IBM discs with all protocols and key master documents in Word 7.0 ISBN: 0-88091-168-9 US$90.00 Email: http://www.eatright.org/catalog

A HEALTHY DIET FOR BETTER NUTRITION FOR PEOPLE LIVING WITH HIV/AIDS
By Nap+, Network Of African People Living With Hiv/Aids

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This booklet was developed for people living with HIV/AIDS, their families, health care providers and social workers. Its purpose is to provide people living with HIV/AIDS the basic information that will allow them to maintain the best nutritional status possible, prolong their survival, live more comfortably and avoid passing the disease to others.

The booklet, comprising 40 pages, is organised in a series of questions:

à Why does a person living with HIV/AIDS suffer from malnutrition?
à What foods are necessary to satisfy nutritional requirements?
à What foods should be eaten in order to maintain a balanced diet?
à What kind of diet is recommended for a person living with HIV (or seropositive)?
à What should a person with advanced AIDS do in order to endure the illness better?
à How can a diet be used to fight opportunistic infections?
à How can food-borne infections be avoided?
à What is the risk of HIV transmission from a seropositive mother to her baby?
à What are other recommendations for a healthy lifestyle for people living with HIV/AIDS?

Suggestions are given on how to improve one’s appetite, how to deal with oral candidiases, how to treat diarrhoea and how to feed a baby born to a HIV infected woman. The booklet concludes with some recipes from Sub-Saharan Africa which have been taken from the manual “Marvels of the African Cuisine”. It is the authors’ intention to have the booklet updated at regular intervals.

Research, production and print costs for the booklet were supported by a grant from the United Nations Development Programme (UNDP) Regional Project on HIV and Development, Dakar, Senegal for the Network of African People living with HIV//AIDS Inquires can be addressed to NAP+ Secretariat, POBox 30218, Nairobi, Kenya. Tel/Fax: (254 2) 81 - 1350

KEY EVENTS IN EVOLUTION OF FEEDING POLICY

1985: First indications

Reports show evidence of HIV transmission through breastfeeding. (See the list of selected studies below.) One study estimates a breastfeeding transmission rate of 14 per cent from mothers who were seropositive at the time of delivery and 29 per cent from mothers who became infected during the post-partum period.

Research provides proof.

* ‘Risk of human immunodeficiency type 1 transmission through breastfeeding’, Dunn, D.T., Newell, M.L., Ades, A.E. and Peckham, C.S., The Lancet, 1992,340:585-588.

Other research papers include:

* ‘Postnatal transmissions of AIDS-associated retrovirus from mother to infant’, Ziegler, J.B., Cooper, D.A., Johnson, R.O., The Lancet, 1985, 1:896-897.

* ‘Isolation of AIDS virus from cell-free breastmilk of three healthy virus carriers’, Thiry, L, Sprecher-Goldberger, S., Jonckheer, T., et al, The Lancet, 1985, 2:891-892.

* ‘Human immunodeficiency virus and other viruses in human milk: placing the issues in broader perspective’, Oxtoby, M.J., Pediatric Infectious Disease Journal, 1990, 9:825-835.

* ‘International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-I infection’, Leroy, V., et. al, The Lancet, 1998, 352:597-600.

1992: Policy seen as reflecting double standard

The ‘Consensus statement from the WHO/UNICEF consultation on HIV transmission and breastfeeding’ (Geneva, April/May 1992) upholds breastfeeding as a choice for HIV-positive women in areas showing high rates of infectious diseases and child malnutrition. But the statement is not endorsed by the UNICEF Executive Board, as it appears to embody a double standard. It states: “Where the primary causes of infant deaths are infectious diseases and malnutrition, infants who are not breastfed run a particularly high risk of dying from these conditions. In these settings, breastfeeding should remain the standard advice to pregnant women.” The statement also emphasizes the need for countries to maintain a strong Code, and for information about family planning and HIV prevention to be available to all.

1995: UNAIDS established

The Joint United Nations Programme on HIV/AIDS (UNAIDS) is established in Geneva (Switzerland). UN-AIDS is an unprecedented collaboration that pools the experience, efforts and resources of six United Nations organizations: UNICEF, the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization(WHO and the World Bank.

1990s: Rights conventions influence approach

Throughout the 1990s, human rights conventions began to influence policy.

The convention on the Elimination of All Forms of Discrimination against Women was adopted in 1979 and today has been ratified by 162 countries. Article 10(h) outlines every woman’s right to have access to information to help assure the health and well being of her family. This information would include her HIV status and infant feeding options.

The Convention on the Rights of the Child was adopted by the General Assembly in 1989. It includes several key provisions relating to health and nutrition: “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health...States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures...to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents...”

1997: Joint statement from UNAIDS, WHO and UNICEF

HIV and Infant Feeding, the joint statement developed by UNAIDS, WHO and UNICEF, outlines key elements to be considered in formulating policies and upholds the fulfilment of women’s rights as paramount.

1997: AZT trials in Thailand show success

Clinical trials in Thailand show that a short course of AZT given late in pregnancy and at delivery can halve HIV transmission in non-breastfeeding women (US Centers for Disease Control and Prevention, 1998). Findings suggest that women receiving this treatment should also be provided with safe breastmilk substitutes. The Thai Government takes steps to crease a programme to satisfy this recommendation.

1998: UNAIDS establishes steering group

UNAIDS establishes a steering group on vertical transmission following two international meetings, in March and April 1998, that discussed mother-to-child transmission of HIV and infant feeding. The group, with representatives from WHO, UNICEF and UNFPA, holds regular meetings to discuss guidelines, strategies for implementation of pilot projects, and monitoring and evaluation. In addition, the steering group convenes regional meetings with government counterparts.

1998: Pilot AZT programmes designed for low-income countries

UNAIDS supports the development of pilot programmes using anti-retroviral drugs in some low-income countries in Africa, Asia and Latin America to help reduce mother-to-child transmission of HIV. Actions aim to include early access to antenatal care, voluntary and confidential testing and counselling, AZT use during pregnancy and delivery for HIV-positive women, improvements in care during labour and delivery, and counselling to HIV-positive women on a range of infant feeding choices. Activities are designed to eventually reach 30,000 HIV-infected women in 11 countries.

1998: UNAIDS issues feeding policy guidelines

UNAIDS issues two sets of guidelines entitled HIV and Infant Feeding - one for decision-makers and the other for health care managers and supervisors. The documents offer advice and practical recommendations in programme planning and policy.

Reprinted here with permission of UNICEF. The Baby Friendly Hospital Initiative Newsletter. Sept/Oct 1998 p. 6

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