informed choice of infant feeding method by HIV positive women, as recommended by UNAIDS/WHO/UNICEF guidelines, may also be compromised by limited counsellor training. In-depth interviews with Tanzanian HIV/AIDS counsellors indicate lack of knowledge or confusion about the actual risks and benefits of the different infant feeding options, counsellors falling back on directive counselling and lack of follow-up support to mothers as important barriers to good quality advice.
With formula feeding,in the absence of perinatal antiretroviral treatment,evidence from a randomised trial in Kenya indicated 20.5% of HIV infection the formula-fed infants as compared to 36.7% in the breastfed group. Though the women had access to a clean water supply and could make the formula safely,mortality at 24 mouths of age was very hight and did not differ between breastfed and non-breastfed infants. Formula-feeding in this population was shown to prevent babies from acquiring HIV but not from dying of other causes.
There is concern among breastfeeding advocates that in resource-poor communities, increased use of formula-feeding by HIV positive mothers,undermining years of public health messages about the benefits of breastfeeding as a complete source of nutrition for infants.bonding stimulating infant cognitive development and prolonging post-partum amenorrhoea to suppost child spacing. However,the complexity of the choice whether to breastfeed for HIV positive women remains one with compelling benefits and risks on both sides.
Safer breastfeeding has been proposed for HIV positive women who choose to breastfeed. This involves expressing and pasteurising breastmilk. The sustainability of this practice is uncertain,since it is not only less convenient, more time-consuming and more expensive in terms of fuel,but also may be as strongly associated with stigma and discrimination as avoiding breastfeeding altogether.
Breastfeeding by women on HAART may decrease stigma,increase quality of life of HIV positive parents,contribute to parenting efforts,decrease child mortality and perhaps help to motivate people in the community to present for HIV testing and counselling. creating increased awareness about HIV. The goal is to provide HAART to people living with HIV in need. whereas giving antiretrovirals in the peri-partum period only to prevent MTCT is a short-term measure.
Infant care
The impact of the HIV epidemic on child health globally is a major emerging issue. Before large-scale national PMTCT programmers began to be implemented,600,000 new paediatric infections were estimated to occur annually,particularly in Africa. Whereas children account for only 4% of people living with HIV,20% of AIDS deaths have been in children.
Immaturity of the immune system is believed to affect an infant's ability to combat HIV infection. Consequently,perinatally infected children generally progress to AIDS more rapidly than HIV positive adults. In the pre-HAART era,approximately 25% of these children progressed to AIDS within the first year of life and the median time to AIDS development for the remaining 75% was seven years. Prognosis is still dramatic for children living in poor countries;over 50% die within two years and 89% the age of three in sub-Saharan Africa.
However. coordinated perinatal and pardiatric HIV care initiatives have been shown to be effective. In a successful collaborative programme, Jamaican nurses and midwives were trained in PMTCT, voluntary counselling and testing,and recognition and management of paediatric AIDS, following guidelines for HIV care with consequent impact on sensitising and encouraging other health care workers in the care of persons living with HIV/AIDS,on enhancing multidisciplinary collaboration,on sensitising people in the community about the disease and on improving the comfort level of women and families with accessing health care.
Early diagnosis of HIV infection is crucial for HIV positive children. However,difficulties still exist in many areas of the globe,particularly where access to antenatal and delivery care is deficient, which postpone recognition of vertically transmitted infection. Suspicion of HIV infection should target not only infant born to HIV positive mothers, but also those who exhibit clinical signs of immune suppression. The aim is to recognise HIV infection as early as possible,to prevent opportunistic infections and HIV disease progression and address psychosocial