Summary of WABA-UNICEF Colloquium outcomes

and way forward

Presented at the WABA Global Forum 11 Arusha, Tanzania 23rd September 2002

Compiled by the Drafting team:WABA, UNICEF, WHO, CDC, AED/SARA, AED/LINKAGES

Colloquium Background I

• Postnatal PMTCT implemented beginning in 1998• ESARO commissions 4-country study in 2000• Letters from 77 scientists and from WABA Global

Partners Meeting in 2001• WABA-UNICEF meetings in 2001-2• Often polarized debate on HIV and infant feeding

policies and required actions at field level• Inadequate support for health workers and HIV-

positive mothers

Colloquium Background II

• In 4 years we learned much through research and in particular experiences from the field. This is now being used to review / update policies and guidelines.

• There seems to be increasing consensus on how to get things right.

• First time such a wide variety of stakeholders have discussed together the way forward.

Colloquium Objectives

• Provide technical basis for consensus building through update on relevant research and field experiences.

• Build consensus among participants on general principles relating to policy and practices.

• To identify general agreements for actions.

• To inform and advise the WABA forum and other relevant meetings and stakeholders.

Context

Goal:– UNGASS for Children - reductions of child mortality and

malnutrition by at least one third by 2015.– UNGASS on HIV/AIDS - reductions in the proportion of HIV

infected infants by 20% by 2005 and 50% by 2010.

Reality 2001:– NEW INFECTIONS CHILDREN 0-14 YRS 800 000– HIV/AIDS DEATHS 0-14 YRS 580 000– AIDS ORPHANS 11 Million– CHILDREN 0-14 YRS LWHA 3 Million– HIV POSITIVE PREGNANT WOMEN 2.6 Million

Strategic Approaches to Prevent MTCT of HIV

The 4 pronged approach:• Prevention of HIV infection particularly

in women and young people• Prevention of unintended pregnancies• Reduction of the risk of MTCT of HIV• Provision of care and support to HIV

infected women, their children and families

Selected Ongoing UN Actions

• Increasing access to ANC and VCT• Development of in-country guidelines, manuals, HIV and

infant feeding (IF) counselling cards, and Question and Answer tool

• Development of a framework for priority actions for HIV and IF (draft presented at Colloquium)

• Ongoing revision of the 1998 HIV and IF guidelines • Country level support to over 45 countries (including

planning, coordination and scaling up)• Multi-centre study on HAART, breastfeeding and mother’s

health• PMTCT to become PMTCT+ to include care and support for

HIV+ mother, children and their families

Key Note Address - 1

Be reminded:• Exclusive breastfeeding for 6 months must receive

support as a social norm.• Breastfeeding is the golden standard for HIV

negative women and those of unknown status; when affordable, feasible, acceptable, sustainable and safe (AFASS), replacement feeding is recommended for HIV positive women.

• In HIV positive women, exclusive breastfeeding or exclusive replacement feeding are recommended.

• We need to enforce the International Code of Marketing of BMS and subsequent WHA resolutions to deal with commercial pressures.

Key Note Address -2

Call for action:• Improve understanding of the epidemic:

– Young women in Africa are most affected– Gender inequality is lethal

• Programs are gender insensitive--e.g., we say MOTHER-to-child transmission!

• Don’t forget the 10% of children infected due largely to predatory men.

• Need to set and support a research agenda on HIV and infant feeding, including health outcomes.

• WABA should continue provoking the establishment and getting actively involved in supporting mothers.

Draft UN Framework for HIV&IF priority actions - 1

Purpose:To propose priority actions to be considered by governments in the context of the special circumstances of HIV/AIDS to ensure an environment that encourages appropriate infant and young child feeding while reducing mother to child transmission of HIV

Draft UN Framework for HIV&IF priority actions - 2

Components:• Develop national Infant and Young Child

Feeding (IYCF) policies.• Implement the International Code of Marketing

of BMS and subsequent WHA resolutions.• Protect, promote and support IYCF in the

context of HIV.• Provide support to HIV positive women in their

chosen infant feeding method.• Promote research on HIV and infant feeding

and strengthen monitoring and evaluation.

Draft UN Framework for HIV&IF priority actions - 3

Challenges:• Communicating evidence clearly to all levels

and maintaining consensus on the way to proceed in a rapidly changing environment

• Dealing with limitations of existing evidence base on appropriate feeding for infants of HIV+ mothers: answers for some key issues will take time

• Moving rapidly with priority actions in a context of limited resources and weak health systems

Role of Breastfeeding Supportive NGOs in HIV and

Infant Feeding • Need for breastfeeding supportive NGOs to increase

their knowledge on HIV issues (science and implementation).

• Need for governments, the UN and other agencies to utilize more extensively the expertise and human resources of the BF supportive NGOs in policy, research and program implementation, including the establishment of exclusive breastfeeding as a social norm, support for training and capacity building, and lactation management programs in the context of HIV.

• Attention should be paid to the health and nutritional status of HIV positive women regardless of their infant feeding method.

Role of Breastfeeding Supportive NGOs in HIV and

Infant Feeding

• If subsidized infant formula is included as part of the PMTCT, then HIV positive women who choose to breastfeed should be provided with an equivalent subsidy to support their nutritional status.

• Develop and standardize context-specific, evidence-based risk assessment tools to be used by counselors.

• Research to measure outcomes for artificially fed infants, especially in Africa, is essential in doing so

HIV and Infant Feeding Knowledge, Gaps, and Challenges for the

future

• About 63% of untreated HIV positive mothers will NOT pass on the virus to their infants.

• On average about 15% of babies breastfed for two years acquire HIV through breast milk.

• A substantial amount of postnatal transmission occurs in the first 6 months of infancy, although this may be reduced if breastfeeding is exclusive.

• Immune depletion and high viral loads are major risk factors for transmission.

• Avoidable breast pathologies contribute significantly to transmission.

• Care and support of HIV infected women is very important.

HIV and Infant Feeding Knowledge, Gaps, and Challenges for the

futureChallenges:

What do we know about: • The advisability and feasibility of early

breastfeeding cessation• Other breastmilk based options• Commercial formula • Home prepared formula

Can the health of the baby also be protected by supporting the nutritional status and health of HIV positive women?

Lessons from PMTCT pilot sites - 1

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Lessons from PMTCT pilot sites -2

There is a need to:

• Strengthen training and capacity building in counseling on optimal infant feeding practices

• Provide job aids and educational materials to standardize and enhance the skills of counselors and service providers

• Develop strategies to maximize adherence to method of feeding chosen by mothers, including community support

• Improve support, monitoring and follow up of babies beyond six months

Lessons learned so far include:

• Community engagement is critical to support of breastfeeding and in addressing issues of stigma related to infant feeding.

Country Experiences-1Botswana, South Africa and Uganda:

• High level political commitment and support for programs has proven essential in the development of national policies and guidelines on IYCF• Both health worker training and provision of formula are resource-intensive• Participation of males, other family members and the community are key to supporting mothers’ IF choices• BFHI is still relevant; step 10, the development of community support mechanisms, needs strengthening; however assessment criteria need to be revised to reflect infant feeding choices for HIV positive women • Need for the Code to be implemented and enforced to deal with continued subtle marketing strategies of breastmilk substitute manufacturers

Country Experiences -2

Preliminary findings suggest that when mothers were advised to abruptly stop breastfeeding the following problems arose:

• engorged breasts• crying and sick babies• inadequate purchasing power for alternative feedsMothers suggested the need for:• peer counseling• partner involvement• consistent messages• income generating projects

Groupwork Summary and Way Forward - 1

• There was much consensus and few disagreements

• A foundation was laid for future collaboration between the HIV and breastfeeding “communities”

Groupwork Summary and Way Forward - 2

• The issue of infant feeding for HIV+ mothers should be addressed in the context of improved care and support for women

• The goal should be a healthy child – not just preventing HIV infection

• The UN agency draft Framework for Priority Actions received support

• Work on IYCF policies needs to be pursued at national level; WHO and partners to provide frameworks and best practices

• Improved understanding of the Code and subsequent WHA resolutions, as well as implementation in the context of HIV and AIDS is required

• Wider sharing of existing tools, guidelines, manuals is needed.

Groupwork Summary and Way Forward - 3

• Renewal/ strengthening implementation of BFHI• Capacity building of health workers and counselors on

breastfeeding support and lactation management and HIV and infant feeding counseling is imperative

• HIV&IF risk assessment should include an assessment of the mother’s health, and nutritional status, availability of nutritional support, family context and prevailing social and environmental conditions

• Strengthening community capacity to deal with all issues on infant and young child nutrition including HIV and infant feeding, stigma

• Strengthening health systems cannot continue to be neglected• Improve monitoring and evaluation, especially of outcomes for

women and children

Groupwork Summary and Way Forward - 4

• Establish a coordinating mechanism to accelerate action on the priority research agenda and to explore funding mechanisms for rapid deployment of priority research

• The working group revised and re-prioritized research priorities for postnatal HIV transmission

• Research should be independent, that is, not funded by companies with vested interests in the outcomes

• Strengthen sharing of best practices and lessons learned

• Improve advocacy with emphasis on consistency of messages

Groupwork Summary and Way Forward - 5

We recognized the need for INNOVATIVE RESOURCE MOBILISATION

• WABA, UNICEF,WHO, and UNAIDS were asked to set up a working group to monitor the follow up of the outcomes of the Colloquium

• Terminology needs to be reviewed, particularly the use of “mother to child transmission,” which the meeting agreed needs to be replaced with a less judgmental term

• Greater attention is needed to improving definitions of the components of AFASS and of exclusive breastfeeding in the context of HIV