The role of breastfeeding in the prevention of mother-to-child transmission of HIV
The Partnership for HIV-Free Survival (PHFS) is supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to increase HIV-free survival by reducing vertical transmission of HIV from mother to child and integrating maternal-infant health and nutrition care, essentially the 1000 Days approach for HIV-infected mothers and their exposed infants. This initiative has been guided by the WHO guidelines and recommendations on HIV and infant feeding.
In May, we participated in a Breastfeeding Seminar hosted by The TOPS Program to present how the Partnership for HIV-Free Survival has used a quality improvement approach to increase the survival of HIV-exposed infants and improve the health of those infants and their mothers.
When a woman living with HIV becomes pregnant, preventing vertical transmission of HIV requires a host of services and care for both mother and baby during pregnancy, labor and delivery, and the extended post-partum period for two years or more. When an HIV+ woman does not receive the services she needs—such as antiretroviral treatment, adherence support, etc.—the likelihood of her HIV-exposed infant being infected is very high. We know that with no intervention, the risk of a breastfeeding HIV-positive mother transmitting the virus to her child ranges from 15-45%. However, when antiretroviral therapy is provided to the mother during pregnancy and continued during breastfeeding, the mother-to-child transmission rate for HIV can drop to under 5%—the global target set by WHO for the elimination of mother-to-child transmission (eMTCT).
In addition, all HIV-exposed infants are at much greater risk of mortality if they are not breastfed—or, if they are prematurely weaned without safe and adequate replacement feeding—due to their increased exposure to water-borne pathogens and increased susceptibility to diarrhea, bacterial infections and other illnesses.
In response, PEPFAR initiated the multi-country PHFS, with technical leadership from WHO and UNICEF and leadership from the Ministries of Health and other partners in Kenya, Uganda, Tanzania, Mozambique, South Africa and Lesotho. This effort took a unique multi-pronged approach to infant survival, which focused on protecting the baby from HIV transmission and ensuring optimal infant feeding practices (exclusive breastfeeding for the first 6 months and continued breastfeeding in accordance with national guidelines) while protecting the mother’s health as well – effectively, integrating PMTCT, MNCH and nutrition services for mother-infant pairs.
PHFS used a QI—quality improvement— approach in a select number of demonstration sites in each country to learn how to better organize care delivery. The QI approach empowers facility staff to meet on a regular basis, review clinic data to identify gaps, select areas for improvement, and then test changes towards improving the services. At its core, QI is as simple as a team being data-driven and learning from practice, site-by-site.
The QI approach has also allowed us to break down the complex problem of improving HIV-free survival into more easily implementable phases. By analyzing baseline data and visiting facilities, teams prioritized the work in the order depicted in the visual below:
Impact of this work
So, what has been the impact of this work? Teams initiated many changes to bring HIV-positive mothers back to care and keep them in care in the post-partum period. Teams used information they gathered from the mothers—who told them that infant feeding counseling would motivate them to attend post-partum appointments—and ensured that infant and young child feeding counseling was included in the critical package of care mother-baby pairs received at monthly appointments. They also involved peer mentors in counseling and breastfeeding support to further encourage adherence to care and continued treatment of the mothers.
In Uganda, for example, teams in the 22 demonstrations sites increased the percentage of mother-baby pairs retained in care from 2.2% to over 90% by initiating these and other changes. Teams also increased the percentage of HIV-exposed infants in care who were adhering to recommended infant and young child feeding practices from 70% to almost 100%. They sustained this improvement even as facilities were caring for ever-increasing numbers of mothers and their babies due to the aforementioned increase of pairs retained in care; the high percentage represented higher absolute numbers of infants adhering to IYCF practices over time.
The key lessons learned for improving the HIV-free survival of exposed infants and ensuring the health of mother-baby pairs are depicted in the visual below.
Through the PHFS, country teams have successfully used a quality improvement approach to increase optimal breastfeeding practices while contributing to the decline in the rate of HIV transmission from mother to child in demonstration sites. Uganda’s key results are depicted in the chart below.
In conclusion, what is most exciting and promising is that the quality improvement approach that the PHFS has applied to PMTCT can be extended to all service delivery within clinics, as well as communities, and lead to similar results and health outcomes.