Mother-to-child transmission (MTCT) of HIV, now nearly unheard of in the United States, remains a ranking problem in most resource-poor countries where it can be as high as 25 to 40 percent because of lack of access to testing and treatment and because of postnatal transmission of the virus during breastfeeding. In populations where HIV-positive mothers routinely breastfeed, 30 to 50 percent of MTCT is attributable to breastfeeding. Although the U.S. Centers for Disease Control and Prevention has recommended since 1986 that women with HIV infection avoid breastfeeding, breastfeeding is heavily implicated in ongoing vertical transmission in resource-poor settings.

Despite evidence that breastfeeding contributes to high rates of MTCT, many health experts continue to recommend it in resource-poor settings, where the availability of infant formula and potable water is limited. However, obtaining formula and improving water sources is less complicated than administering lifelong care to HIV-infected infants. Providing clean water also has a positive impact on the health of the mother, the family, and the community at large. We believe that the provision of clean water and aggressive diarrheal prevention is a critical cornerstone of linking HIV programs to evidence-based primary care. Similarly, the medical management of diarrheal diseases and close monitoring of growth and nutritional status is central to all child survival programs, whether or not infants have HIV. Given these considerations, recommending formula-feeding for infants born to HIV-infected mothers makes sense both practically and ethically.

PIH supports and promotes exclusive breastfeeding for infants except when the mother is HIV-positive. We recognize, however, that certain circumstances, such as fear of HIV status disclosure or lack of access to potable water, may compel women to continue to breastfeed. Evaluation of the social and economic barriers that might lead to such a decision is encouraged.

PIH's experience in Haiti has shown that we are able to reduce rates of MTCT to as low as two percent by:

1. providing combination antiretroviral therapy to the mother during pregnancy and to the infant after birth;
2. launching potable water projects within the catchment area and providing household water filters for HIV-positive new mothers; and
3. enabling formula-feeding and close follow-up of infants by providing formula and supplies free of charge by prescription to HIV-positive new mothers.

For a discussion of how PIH has applied lessons learned in rural Haiti to prevent pediatric AIDS in rural Rwanda, see the article: Farmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Medicine 2006;3(10):e449.

To prevent postpartum transmission of HIV via breastmilk, PIH advocates formula-feeding for all HIV-positive mothers and provides the training, formula, and supplies necessary for safe formula preparation.

Planning considerations

• Identify the target patient population and calculate estimated formula needs. How large is the catchment area being served? What is the estimated number of HIV-positive women of childbearing age? How many children are born to HIV-positive women annually?

• Provide free formula and all necessary supplies. Typically, HIV-positive mothers receive a nine-month supply of formula free-of-charge. Wherever possible, PIH procures infant formula locally. Across PIH program sites, the monthly cost per child is between US$48 and US$72 per month, based on the price of infant formula currently between US$4 and US$6 per 450g of formula, with an average need of 5,400g per child per month.

• Educate and support mothers on safe formula preparation. Training takes place during prenatal care, in maternity wards and before mothers leave hospital. This is followed up with home visits and monthly education sessions by midwives or nurses specializing in HIV care.

• Provide regular follow-up. Every month, HIV-positive mothers and their infants are seen by medical staff to track the child's and mother's health.

• Provide additional support at the time of weaning. Weaning is a time of particular vulnerability for infants, even those who are not affected by HIV. PIH works with new mothers to ensure the availability of sufficient nutritious weaning foods.

Key functions and roles in an infant formula program

• Clinical oversight (physicians, midwives/nurses)
• Formula stock management
• Supplies management
• Social workers for home visits
• Community health workers

A special note on the role of community health workers

As in all PIH efforts, community health workers are vital to the success of a formula feeding program. Community health workers (CHWs) can help train mothers on safe formula preparation, accompany mothers and infants to clinic visits, actively monitor the health of the mother and the baby during regular home visits, provide social support and links to other resources, and help reduce any sense of stigma or isolation surrounding HIV status or formula feeding. Furthermore, CHWs who are familiar with the formula feeding program can help identify other women in the community who might be in need of clinical referrals and similar services.

Critical supplies Uninterrupted supply of infant formula Stoves (boiling water for formula and sterilizing baby bottles) Kerosene Pots Thermoses Wide-mouthed containers Baby bottles Clean water filters

Logistical Requirements

See HIV- and TB-targeted food assistance section.

Implementation

PIH's infant formula programs are integrated within comprehensive maternal and child health programs, thus allowing for long-term follow-up of both mother and baby.

Inshuti Mu Buzima, Rwanda

The infant formula program at Inshuti Mu Buzima was initiated in 2005, enrolling children under two years of age who were born to HIV-positive women. Mothers receive information on feeding options during prenatal visits and training on formula preparation by nurses and local traditional birth attendants. In the maternity ward, mothers receive more training and help with formula preparation and feeding by a "milk mom," who is a member of the local community.

Mothers leave the hospital with all the supplies necessary for clean water preparation and formula and return to the health center every two weeks for more formula and kerosene. Formula is distributed until the infant reaches nine months of age; sosoma, a mixture of sorghum, soya, and maize flour, is given from 9 to 18 months of age.

Every mother and infant is visited weekly by a community health worker during the first month to ensure good formula preparation. Social workers perform additional regular home visits. The infant's height, weight, and health status (including signs of malnutrition) are carefully monitored.

Mothers receive bi-weekly or monthly education on hygiene, nutrition, avoidance of mixed feeding, HIV prevention and treatment, family planning, and child development; husbands/partners/fathers are also invited to monthly trainings.