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Infant feeding in the time of HIV: Assessment of infant feeding policy and programs in four African countries scaling up prevention of mother to child transmission programs
Global Health Sciences Literature Digest
Published October 1, 2007
Journal Article

Chopra M, Rollins N. Infant feeding in the time of HIV: Assessment of infant feeding policy and programs in four African countries scaling up prevention of mother to child transmission programs. Arch Dis Child 2007 Aug 8;Epub ahead of print.


To assess the infant-feeding components of prevention of mother-to-child HIV transmission (PMTCT) programs.

Study Design

Descriptive cross sectional study. A total of 29 of 49 districts offering PMTCT were selected by stratified random sampling with rural and urban strata. All health facilities in the selected PMTCT districts were assessed. Senior policy makers and program managers for PMTCT, child health, and nutrition were interviewed using a semi-structured questionnaire. Facility-level managers and senior nurses in charge of maternal care were also interviewed, and all health workers who were identified by the facility manager as being involved in the PMTCT program were requested to complete a self-administered questionnaire. Observations of PMTCT counseling sessions were conducted at all facilities. Between five and seven counselors who provided PMTCT counseling were selected per site for observation; they constituted nearly all the counselors at the sites. Four post-HIV-test observations were conducted per counselor. Reliability was assured through the training of the observers until there was over 90% inter-rater reliability for at least two joint observations consecutively between observers. In at least three sites per country, focus group discussions were held both with women attending antenatal clinic and separately with men in the community. The interview guides explored general perception of HIV and modes of transmission and included a specific section on HIV and breastfeeding.


Four African countries - Botswana, Kenya, Malawi and Uganda - in which the national governments were in the process of scaling up their national PMTCT programs. Data collection occurred between July and November 2003.


See the Study Design section above. No additional data provided.


There was no intervention for this policy analysis.

Primary Outcomes

Support for infant feeding, training of health workers in HIV and infant feeding, knowledge of risks associated with breastfeeding, quality of infant-feeding counseling, supplies of infant formula, and community perceptions were all measured through observations, interviews, and focus group discussions.


Completed questionnaires were returned by 334 (90%) health workers (27/35 in Botswana, 151/170 in Kenya, 82/85 in Malawi and 74/79 in Uganda). A total of 640 PMTCT counseling observations were conducted across all facilities, and 34 focus group discussions were conducted. In all four countries, program managers (number not given) felt that external and internal support for breastfeeding had been negatively influenced and in some situations paralyzed by the focus to reduce mother-to-child HIV transmission postnatally. Senior policymakers also articulated the need for greater attention toward infant feeding. All four countries had succeeded in training at least half of the staff in PMTCT sites with a minimum of five days and an average of one day devoted to infant-feeding counseling. A significant proportion (exact figure not given) of respondents also received extra training (average three days) in HIV and infant feeding. Less than half of the participants (157/334, 47%) reported any follow-up to review practices or discussed problems. Knowledge of the actual risk of HIV transmission from mother to child was poor. Most health workers (234/334, 70%) were unable to correctly estimate the transmission risks of breastfeeding. For instance, over 40% indicated that 80-100% of infants would become infected with HIV after two years of breastfeeding from an HIV-infected mother. Infant-feeding options were mentioned in 307 out of 640 (48%) observations of PMTCT counseling sessions. In only 35 observations (5.5%) were infant-feeding issues discussed in any depth, and of these, 19 (54.3%) were rated as poor. In 60% (184/307) of observations, no mention was made of the need to stop breastfeeding early or rapidly wean when alternatives to breastfeeding become safer and feasible. Overall, 122/274 (44%) and 47/274 (17%) of health workers reported at least three consultations concerning women reporting breastfeeding or formula-feeding problems in the last month, respectively. Although the Ministry of Health in Botswana and non-governmental organization-sponsored sites in Malawi, Uganda, and Kenya were supplying infant formula, 77/342 (23%) of health workers reported problems of interruptions of formula supplies. Four of 24 respondents involved in infant-feeding counseling in Botswana and seven of 34 in Kenya reported receiving free samples of infant formula outside the routine PMTCT supplies, which is in contravention of the International Code on Breastmilk Substitutes. Finally, there was an almost universal belief among laypersons that an HIV-positive mother who breastfeeds her child will always infect the child and intentional avoidance of breastfeeding by the mother indicates that she is HIV-positive.


The authors conclude that the findings of this study underline the need to implement and support systematic infant-feeding policies and program responses in the context of HIV programs.

Quality Rating

There is no quality scale for policy studies of this type. This study was limited by selection bias in that only districts where the PMTCT program had been recently established were selected (apart from Botswana, where national coverage had been reached) and only health workers who completed the questionnaires were included. It is therefore likely that these results present the best case scenarios, as the early sites have generally received greater support. Quality control of data collection was maximized through centralized training, standardization of operating procedures, central data entry, and cleaning and triangulation of results through feedback to country managers. Variability among observers, however, cannot be fully excluded.

In Context

This is the first large-scale study examining the effect of PMTCT programs on support given to early infant feeding in Africa. Health workers' poor knowledge of optimal infant-feeding practices has also been found in other studies.(1,2) Additionally, poor infant-feeding counseling is a common finding across PMTCT programs, even after training.(3,4) The lack of good counseling and subsequent support for the infant-feeding decision almost inevitably leads to mixed feeding, which increases the risk of MTCT.(5,6,7)

Programmatic Implications

PMTCT programs have been scaled up to counsel and test thousands of women and provide short-course antiretroviral therapy to HIV-positive women. However, there has been a great deal of controversy and confusion concerning the optimal infant-feeding recommendations provided in response to the challenge of HIV transmission through breastfeeding. Safe infant-feeding requires individualized counseling from well-informed, skilled, and motivated health workers. This study supports concerns that the challenges of infant feeding have received inadequate attention. Limiting the feeding options, development of appropriate educational materials, spreading the counseling over several sessions, and continued supervision are all strategies that have been used to improve infant-feeding counseling. The community perceptions in the study regarding transmission risk and choice of formula feeding indicate that more education is needed to avoid inappropriate avoidance of breastfeeding and stigmatization. In sum, the findings of this study suggest that policymakers and clinicians need to increase the investment in implementing policies, capacity development, and community support for infant-feeding activities, especially in the context of the widespread introduction of PMTCT programs.


  1. Shah S, Rollins NC, Bland R; Child Health Group. Breastfeeding knowledge among health workers in rural South Africa. J Trop Pediatr 2005 Feb;51(1):33-8.
  2. Piwoz EG, Ferguson YO, Bentley ME, Corneli AL, Moses A, Nkhoma J, et al. Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi. Int Breastfeed J 2006 Mar 9;1(1):2.
  3. Hope Humana, National Food and Nutrition Commission, Ndola District Health Management Team, Horizons Program, and Z.I.H. Program. Empowering communities to respond to HIV/AIDS: Ndola demonstration project on maternal and child health: Operations research final report. Washington, DC: Population Council, 2003. (No abstract available.)
  4. Chopra M, Doherty T, Jackson D, Ashworth A. Preventing HIV transmission to children: quality of counselling of mothers in South Africa. Acta Paediatr 2005 Mar;94(3):357-63
  5. Koniz-Booher P, Burkhalter B, de Wagt A, et al. HIV and Infant Feeding: A Compilation of Programmatic Evidence. Washington DC. US Agency for International Development 2004. (No abstract available.)
  6. Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai WY, Coovadia HM, et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001 Feb 16;15(3):379-87.
  7. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005 Apr 29;19(7):699-708.