INFANT FEEDING AND HIV Towards a new policy and implementation plan for minimising postnatal HIV transmission and maximising infant HIV-free survival

Recent studies on antiretroviral prophylaxis during breastfeeding show that maternal highly active antiretroviral therapy (HAART) (alone or with 1, 4 or 24 weeks' infant prophylaxis) or infant prophylaxis alone for 6, 14 or 24 weeks (with limited maternal prophylaxis) reduces HIV transmission through breastmilk (postnatal transmission). Maternal postnatal regimens appear to be as efficacious as infant postnatal regimens, although one study shows a trend favouring infant nevirapine over maternal HAART (both used from 1 week to 6 months after delivery). These new findings necessitate a review of existing interventions to prevent mother-to-child transmission of HIV (PMTCT), and the immediate implementation of regimens that reduce postnatal transmission - where this is feasible - to save children's lives. In the public sector, while stakeholders engage in discussions about which is the best regimen to minimise postnatal transmission, SSSUPPORT should be given to all HIV-positive women to improve infant outcomes and reduce postnatal transmission, as follows: Screen all women for HIV, Send off CD4 cell counts on all HIV-positive women, Screen all HIV-positive women for AFASS using a standardised tool (e.g. Table II/Fig. 2 below); Understand the woman's personal and socio-cultural context; Promote exclusive or predominant breastfeeding if all AFASS criteria are not met,- Promote exclusive formula feeding if all AFASS criteria are met; Organise supplies of formula milk and co-trimoxazole; Review mothers and infants in the first 3 days after delivery, in the first 2 weeks postnatally, and monthly thereafter, and review health and feeding practices, regardless of feeding choice, at every visit; lastly Treat all pregnant women with HAART if they meet national criteria for HAART initiation.