HIV and Infant Feeding Guidelines and Tools: Toward Global Utilization

Presented at the Global Health Council's 33rd Annual International Conference on Global Health (May 30 - June 2 2006, Washington, DC, United States), this 21-page evaluation report examines strategies for facilitating global use of HIV and infant feeding guidelines and tools. It explores the role of both printed materials, such as flipcharts, and training in interpersonal communication (counselling) to inform mothers about options for feeding their babies, and to help guide their choices in this regard. In particular, this resource focuses on how the strategy of implementing international guidelines to shape this communication process works in practice, in different settings around the world.

The team of authors, led by paediatrician Constanza Vallenas, begins by providing some background and data about the risks of mother-to-child HIV transmission (MTCT) in relation to infant feeding. She and her colleagues/co-authors indicate that, in the fall of 2003, WHO, the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), and the Joint United Nations Programme on HIV/AIDS (UNAIDS) released the updated International HIV and Infant Feeding Guidelines for decision-makers and health-care managers, following a global review of the evidence, both scientific and programmatic. This evidence suggested that the quality of counselling is often inadequate, in spite of good general counselling skills.

So, in a parallel process that was based on previous experience and the updated guidelines, a set of generic counselling tools was developed. This process was informed by field tests in a rural area of South Africa, which featured such methods as focus group discussions (FGDs) and one-on-one interviews with women and health workers. The recommendations that emerged were that a printed flipchart be created, with content including a clear flowchart, assessment of the mother's situation, and complementary feeding instructions.

As indicated here, the final set of tools that emerged - which includes a flipchart, reference guide, take-home flyer, orientation guide, and adaptation guide - was disseminated globally, through the UN system's country and regional offices, beginning in January 2005. (These tools are described in more detail within the presentation.) During 2005, efforts to disseminate and adapt these tools were systematically increased.

In this context, the authors present the United Nations (UN) international guidelines for breastfeeding, depending on HIV status (known or unknown). It is noted here that the UN recommends that all HIV-infected mothers should receive counselling which includes the provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option that best fits their particular situation. This decision is based on the fact that, beginning in 2005, WHO provided direct technical assistance and other support for the introduction and local adaptation of the counselling tools in several countries. Because the use of these materials by health workers requires specific training, WHO encourages participation in the new "Infant and Young Child Feeding Counselling: An Integrated Course," launched in October 2005, or a 1- to 2-day orientation if health workers have previous training on infant feeding counselling.

To further encourage culturally appropriate adaptations and provide evidence related to the impact of the materials on counselling, the WHO Department of Child and Adolescent Health and Development supported the design and execution of operations research in Zambia to compare prevention of mother-to-child transmission (PMTCT) sites using the protocol and counselling tools with those having no standardised tools. The authors indicate that, by the autumn of 2005, several countries had committed to and/or had initiated the adaptation of all or parts of the generic set of counselling tools, including Guyana, Nigeria, Uganda, and Vietnam. Other organisations had developed and/or adapted counselling tools based heavily on (inspired by) the international guidelines and generic materials. Early findings from the operations research in Zambia indicated a positive correlation between the use of counselling tools with improved counselling.

While challenges remain (e.g., "urgent demand for simplified tools" and gaps in knowledge and coverage of in-service training), the authors conclude that infant feeding counselling in the context of HIV can be greatly strengthened at the country level when generic, standardised counselling protocol and tools, based on current scientific and programmatic evidence, are made available to countries for local adaptation. A world map illustrates some of the places where - as of December 2005 - the strategy of training health workers to carry out infant feeding counselling had been implemented.