PARTNER: EGPAF

Title: Evaluation of the quality of infant feeding and nutrition counseling and infant feeding practices for

children born to HIV-infected mothers in selected sites in Cote d'Ivoire

Time and money summary:

Estimated budget is $200,000; expected duration is 18 months.

Local co-investigator:

The study will be managed by EGPAF and conducted in collaboration with IYCN, CDC and USAID.

Project description and programmatic importance:

Counseling and support for safe infant feeding practices and health and nutritional care for HIV+ women

and their infants are key components of PMTCT services, yet are currently only being provided in a limited

fashion in Côte d'Ivoire. Even when infant feeding counseling is provided, little is known about the quality of

counseling and support and mothers' actual infant feeding practices.

EGPAF has been working with PATH's assistance to strengthen and introduce infant feeding and nutrition

support as part of clinical service delivery from pregnancy through 2 years postpartum. Successful models

will be extended to other clinical sites and assist the USG PEPFAR team and Ministry of Health in

developing a comprehensive infant feeding and nutrition strategy.

The purpose of these efforts have been to train and support health workers implementing PMTCT services

and HIV+ mothers to decide and implement recommendations about infant feeding, including safe feeding

(exclusive breastfeeding or exclusive replacement feeding) during the first six months postpartum, how and

when they should stop breastfeeding, and how they should safely feed their infants between weaning and

24 months to maximize HIV-free survival. The pilot nutrition activities currently include comprehensive and

intensive support to introduce and strengthen clinical care and routine postpartum follow-up (birth to 2

years) of all infants of HIV+ mothers with regard to infant feeding at 9 clinical PMTCT sites in Abidjan,

Abengourou, and San Pedro. Specific inputs have included training courses and on-site refresher trainings;

developing, disseminating and support of the use of clinical support tools (AFASS algorithms to determine

appropriate timing and conduct of breastfeeding cessation when AFASS); developing, disseminating and

supporting the use of counseling and IEC materials (counseling cards, take-home brochures); developing

and implementing systems and tools for individual and site-based monitoring of infant feeding and nutrition

activities and their impact; and developing and implementing routines for supportive supervision of the

intensive infant feeding support activities at each site.

The purpose of the proposed public health evaluation is to assess the effectiveness of the pilot efforts in

terms of 1) coverage of essential infant feeding and nutrition care postpartum (e.g. increases in routine

infant feeding counseling visits postpartum; and reductions in loss-to-follow-up); 2) infant feeding and

nutrition counseling and care at key intervals from birth to 18 months; 3) improved infant feeding and

nutrition behaviors of HIV+ mothers (e.g. increased rates of exclusive BF &/or exclusive FF in the first 6

months; increased rates of appropriate timing of breastfeeding cessation; increased rates of appropriate

feeding practices in non-breastfed infants over 6 months of age); 4) health and nutritional outcomes of the

infants (at 3 months, 6 months, 15 and 18 months). The effect of maternal HAART, maternal disease status

(CD4 count), HIV disclosure status, and partner involvement on infant feeding decision and practice will also

be assessed.

The results of the study will inform the guidance, teaching and implementation of infant feeding and nutrition

counseling and support in Cote d'Ivoire and the use of WHO guidance on counseling on AFASS, in the

context of HIV programs. The study will also inform the development and evaluation of a tool/algorithm to

facilitate health worker implementation of AFASS counseling at different points in time (at birth, at return

visits 1-6 months and at decision time for cessation of breastfeeding).

Evaluation questions:

• Have pilot program interventions improved the quality of infant feeding counseling and support provided by

health care workers over time (in ANC, at birth, at first postnatal visit, at 6 months, at 9 months, 12 months,

18 months), including types of messages, frequency of infant feeding counseling, explanation of risks and

benefits of different infant feeding modes, explanation of AFASS, transition period from breastfeeding to

other feeds? How? What are the key issues?

• What algorithm and job aide can support health care worker implementation of AFASS and mothers'

understanding of AFASS at different points in time (at birth, at return visits 1-6 months and at decision time

for cessation of breastfeeding)?

• What are the factors that influence appropriate and inappropriate maternal decisions on infant feeding?

• Do infant feeding and nutritional counseling and support interventions in the study group increase the

prevalence and duration of exclusive breastfeeding or exclusive replacement feeding?

• Do infant feeding and nutritional counseling and support interventions in the study group increase effective

weaning practices?

What is the effect of infant feeding and nutrition interventions on the quality of essential infant feeding and

nutrition care postpartum (e.g. increased use and quality of clinical AFASS algorithms at key moments - at

ANC/or at birth when first counseling is done, at first postnatal visit, 6 months, 9 months, 12 months, 18

months; and improvements in counseling quality); improved infant feeding and nutrition behaviors of HIV +

mothers (e.g. increased rates of exclusive BF or exclusive FF in the first 6 months; increased rates of

appropriate timing of breastfeeding cessation; increased rates of appropriate feeding practices in non-

breastfed infants over 6 months of age)?

• What is the impact of nutritional interventions on health and nutritional outcomes of infants at 3 months, 6

months, 12 months, 15 months and 18 months and mothers (growth and nutritional status, morbidity,

mortality)?

• What is the impact of nutritional interventions on the coverage of essential infant feeding and nutrition care

postpartum (e.g. increases in routine infant feeding counseling visits postpartum; and reductions in loss to

follow up)?

• What are the effects of maternal HAART, maternal disease status (CD4 count), HIV disclosure status, and

partner involvement on infant feeding decision and practice?

• What can be done to improve health and nutritional outcomes within breastfeeding or formula feeding

Activity Narrative: populations in clinical sites (e.g. improved teaching & counseling regarding exclusive breastfeeding, formula

feeding, and weaning; development of AFASS guidance tool for different points in time, provision of

supplemental food)?

Methods:

This study is an evaluation of existing infant feeding and nutrition interventions: 1) pilot intervention

conducted by PATH and 2) other PMTCT sites. We propose to conduct an observational, prospective

cohort study of XX health care providers and XX HIV-positive women/HIV-exposed infant pairs who

received the pilot program services with XX HIV-infected women /HIV-exposed infants who did not receive

pilot program interventions and therefore had current regular program infant feeding counseling. The

outcome data will be infant and child feeding practices and infant health and growth and nutritional status of

infants less than 2 years.

Infant morbidity and growth and nutrition status will be assessed to determine if a correlation exists between

infant feeding method and health outcomes. Severity of maternal disease (through CD4 count), maternal

HAART, HIV disclosure status, and partner involvement will also be assessed to determine if there is a

correlation with infant feeding decision and practice.

Additionally, we propose to conduct in-depth interviews of HIV-infected women to better understand factors

that influence infant/child feeding decisions.

Population of interest:

Health care providers and HIV-positive women/HIV-exposed infant pairs who received the pilot program

services with HIV-infected women/HIV-exposed infants who did not receive pilot program interventions.

Information dissemination plan:

The study will inform national infant feeding policy and program scale-up plans. The results will also inform

global discussions on infant feeding, and food and nutrition counseling and support.

Budget justification for the project period: To be developed

Year 1 budget (please use US Dollars): TBD