Integrated HIV Training for Healthcare Workers

Session 12: ART in Pregnant and Breastfeeding Women

Infant Feeding and Exposed Infants

In this section we will learn about safer infant feeding and then we will discuss special considerations for HIV-exposed babies. This section will wrap up the PMTCT session.

Learning Objectives

By the end of this section, you will be able to:

  • Describe safer infant feeding.
  • Explain the special considerations needed for HIV-exposed babies.

Learning Activities

  • Infant Feeding (5 min)

    The Ministry of Health and Child Care promotes, supports, and protects breastfeeding on the basis that it is the first and the best investment for a child’s nutrition and health. Breastfed babies have been shown to have lower morbidity and mortality rates compared to their non-breastfed counterparts. In response to the WHO 2010 HIV and Infant Feeding recommendations, Zimbabwe has chosen breastfeeding as the national feeding method of choice for all mothers irrespective of HIV status. Safe infant feeding is an important PMTCT intervention. Without intervention, 5 to 20% of infants may acquire HIV infection through breastfeeding. Infant feeding practices that carefully follow national guidelines can also reduce the risks of MTCT through breastfeeding and reduce the risk of infant death from diarrhoea, malnutrition, and other childhood infections.

    Exclusive Breastfeeding

    All messages and recommendations are aimed at protecting exclusive breastfeeding for the first six months and continued breastfeeding into the second year of a child’s life. Other feeding alternatives will be discussed with HIV-infected mothers when breastfeeding is not possible for the mother/family.

    Testing and counselling for HIV is essential during pregnancy and labour and after birth if parental HIV status remains unknown. Knowing their status allows HIV-positive breastfeeding mothers to access ART as per national guidelines, which will greatly reduce any additional risk of HIV transmission during the breastfeeding period. In addition, all pregnant and lactating women and their partners should adopt safer sex practices because mothers who newly acquire HIV during pregnancy or breastfeeding are at particularly high risk of HIV transmission to the baby.

  • Recommendations (10 min)

    Tap on each scenario to learn more about infant feeding recommendations.

    Mother’s status unknown or HIV-negative

    It is important to breastfeed exclusively for the first six months of life. When the infant reaches six months of age, continue breastfeeding and introduce adequate complementary foods that are nutritionally balanced and safe. Continue breastfeeding for 24 months or longer.

    Mothers living with HIV

    Breastfeed exclusively for the first six months of life regardless of the DNA PCR results of the infant. The risk of MTCT may be reduced if the baby is breastfed exclusively. By comparison, not breastfeeding increases the risk of diarrhoea and malnutrition. Mixed feeding (breast milk and other foods or liquids) increases the risk of diarrhoea and may also increase the risk of HIV transmission.

    When the infant reaches six months of age, continue breastfeeding and introduce adequate complementary foods that are nutritionally balanced and safe. Continue breastfeeding until the infant is 24 months old.

    HIV-infected mothers should be provided with appropriate ART interventions to reduce HIV transmission through breastfeeding according to the national guidelines. If the mother is on ART, the baby should breastfeed for 24 months or longer and should receive ART prophylaxis guided by infant risk status.

    When a mother decides to stop breastfeeding, she should do so gradually within one month and only after the baby is 12 months old. Breastfeeding should only stop if a nutritionally adequate and safe diet without breast milk can be provided.

    Mothers unable to breastfeed

    Commercial infant formula should be given exclusively for the first six months. After six months, continue giving followon commercial infant formula or boiled animal milk until the infant is 12 months. After 12 months, continue to provide animal milk until up to 24 months or beyond along with adequate complementary foods that are nutritionally balanced and safe.

    Conditions for safe formula feeding include:

    • Safe water and sanitation are assured at the household level and in the community, and,
    • The mother or other caregiver can reliably provide sufficient formula milk to support normal growth and development of the infant, and,
    • The mother or caregiver can prepare the formula milk cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition, and,
    • The mother or caregiver can, in the first six months, feed the infant formula milk only and completely refrain from all breastfeeding, and,
    • The family is supportive of this practice, and,
    • The mother and/or caregiver can access health care that offers comprehensive child health services

    Interventions to reduce the risk of MTCT during breastfeeding

    There are a number of recommendations to reduce the newborn’s exposure to the virus during breastfeeding. These include:

    • Exclusive breastfeeding of the infant for the first 6 months and continued breastfeeding for 24 months along with complementary feeding
    • Aggressively treating oral problems in the breastfeeding infant
    • Preventing HIV re-infection in breastfeeding women and their partners
    • Correctly and consistently using condoms
    • Providing ART prophylaxis to the breastfed baby up to 12weeks after initiation of mother on ART. This is guided by infant’s risk status
    • Providing ART to all HIV-positive lactating women, which will also reduce the risks of HIV transmission to the baby during breastfeeding

    You should also inform clients that they can reduce the HIV viral load in breast milk by:

    • Preventing and aggressively treating any coinfections in the mother, especially breast infections and cracked nipples
    • Reducing factors that lead to progression of HIV-infection in the mother
  • Martha: Infant Feeding (5 min)

    We met Martha earlier when she came in to deliver her baby boy and tested HIV-positive during labour. You provided pre- and post-test counselling and discussed with her and her husband the medications she and her baby will take at home.

    Martha tells you she had planned on breastfeeding her baby, but she’s very worried about giving the virus to her baby. You conduct infant and young child feeding counselling and tell her to introduce nutritionally sound complementary foods at six months.

    1What are some things that you can say to Martha to help her feel less worried? Select all that apply.

    2When should early initiation of breastfeeding occur?

    3What advice would you give to Martha and her husband about breastfeeding? (Select all that apply.)

    4How long should Martha exclusively breastfeed for?

  • Managing HIV-Exposed Children (5 min)

    An HIV-exposed infant is at high risk and needs regular follow-up. At follow-up:

    • Ensure adherence to NVP or NVP and AZT for 6 weeks and 12 weeks respectively according to MTCT risk stratification
    • Recommend HIV testing (NAT) at birth (high risk), at 6 weeks, or as early as possible thereafter
    • Initiate cotrimoxazole prophylaxis at 6 weeks of age, or as soon as possible thereafter
    • Provide continued HIV care to the mother and partner
    • Address any feeding problems
    • Give immunisations when scheduled
    • Start ART if DNA-PCR positive
  • Child Health Card (5 min)

    It is very important to have organized ways to record information and to track the HIV-infected mother and her baby. Administration of ART to the mother and her infant should be carefully recorded on both the maternal and child health cards.

    The maternity service may already have special registers to record the results of HIV testing and counselling, ART prophylaxis, and other postpartum follow-up information. Tap on each tab to read about how to use the following items as integral parts of a postpartum maternal register.

    Facility register

    Where there is a postpartum register and an underfive register, HIV-related information can easily be integrated into these registers. The facility should also use both the HIV care/ART card and pre-ART/ART registers to follow-up with HIV-positive postpartum women.

    Maternal health card

    Advise the mother to bring her card to each postpartum visit. The maternal and child health cards should be updated during each visit.

    Mother baby follow up register

    This is a fairly new register, but captures vital care, treatment, and program data.

  • Nyasha (20 min)

    Nyasha is 18 years old and delivered her first child six weeks ago at your facility. She tested HIV positive during labour. You note on her record that she was started on lifelong ART of EFV 600 mg/3TC 300 mg/TDF 300 mg (FDC) once daily and given a prescription for cotrimoxazole 960 mg daily.

    Her boyfriend and mother were with her for the delivery. Nyasha did not tell either one of them her test results. A note in the ANC card states that Nyasha refused to tell them but promised that she would when she got home.

    You note in her ANC clinic card that Nyasha’s baby was given his first dose of NVP/AZT along with a BCG vaccine. Nyasha was given a prescription for NVP and AZT syrup and instructions on how it should be administered. She decided on exclusive breastfeeding for her son.

    She was seen in the clinic three days after delivery and the note reveals a normal post-natal examination with no complications noted. One week after delivery, she was complaining of sore breasts. She was given further instructions by another nurse in the clinic on how to breastfeed her son, told to use warm compresses on her breasts, and told to continue trying and her breasts would stop being sore. There is a follow-up appointment date for one month after delivery.

    Nyasha is in clinic today and you note that her appointment was for two weeks ago!

    1What topics will you cover at today’s visit? Select all that apply.

    2All of the following statements are acceptable to ask Nyasha about breastfeeding except:

    3What are some questions you will ask about disclosure and support? Select all that apply.

    Nyasha tells you that she was not able to come to the clinic due to lack of transportation. She tells you that she is feeling okay, just very tired since her baby doesn’t sleep well at night. He seems hungry all the time. She admits to giving him formula some evenings to see if he will sleep better. Her mother told her it was okay and that she did it with her children. Nyasha tells you that she has been giving her son the medication he started at the hospital. The last dose was a few days ago.

    Nyasha tells you she did not like the way she felt after taking the medication she was given so she stopped it a few weeks ago. She was also afraid of her boyfriend and mother finding the medication since their house is very small and there are no places to hide the pills.

    4Based on the information provided so far, what are some areas of concern that you have for Nyasha and her son that you will cover in your counselling session? Select all that apply.

    You start talking to Nyasha about breastfeeding her son.

    5Why is Nyasha’s son at risk for HIV? Select all that apply.

    6Should you continue cotrimoxazole and if so, for how long? (Select all that apply.)

    7Should you resume ART for Nyasha?

    8Should you make any changes to the medications she was prescribed (EFV/3TC/TDF (FDC) once daily at bedtime)?

    9Resistance to ART typically occurs when patients miss doses rather than stopping ART completely.

    10What will you include in the physical exam for Nyasha’s baby at today’s visit? (Select all that apply.)

    11What labs should you draw for the baby?

    12When should the DNA PCR test be repeated if it is negative today?

    13If the DNA PCR test is positive, what should be done before initiating the baby on ART? Select all that apply.

    14What medications will you recommend for Nyasha’s son?

    15For how long should Nyasha’s baby continue with cotrimoxazole?

    You confirm that Nyasha’s son has been entered into the HIV Exposed Infant registry. In going over your plan for care for Nyasha’s baby, you tell her what vaccines are necessary according to the National Immunization Schedule and give her a list of when to schedule vaccines. You let Nyasha know that you’ll continue monitoring his developmental milestones.

    16When educating Nyasha about the medications, what messages should you convey? (Select all that apply.)

    17What education will you give Nyasha about her son’s medication and testing? Select all that apply.

    18In the next month, how frequently should Nyasha be seen at the clinic to make sure she stays in care?

  • Key Points (5 min)
    • Zimbabwe recommends breastfeeding as the infant feeding method of choice for all mothers regardless of HIV status.
    • HIV-exposed infants need regular follow-up.
    • Maternal and child health cards should be updated during each and every clinic encounter.