Adhikari, M.

Bland, R.M.

Bobat, R.

Coutsoudis, A.

Rollins, N.C.

English

Enlighten

       Coutsoudis, A., Rollins, N.C., Adhikari, M., Bobat, R. and Bland, R.M. (2004) The prevention of mother-to-child HIV transmission programme and infant feeding practices. South African Medical Journal, 94 (2). p. 70. ISSN 0256-9574  http://eprints.gla.ac.uk/59415/  Deposited on: 25 January 2012   Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk February 2004, Vol. 94, No. 2  SAMJBRIEWEThe prevention of mother-to-child HIV transmissionprogramme and infant feedingpracticesTo the Editor: We commend Hilderbrand et al.’s1 attempts toevaluate the infant feeding policy in their prevention ofmother-to-child transmission (PMTCT) programme. However,we are concerned that the results of this study have beenextrapolated into an inappropriate and misleading statement,viz. ‘that the use of formula increases overall child survival’.We have a number of key criticisms.The sample size of 113 (from probably more than 5 000 HIV-infected women seen between 1999 and 2002) is grosslyinadequate in terms of drawing any conclusions aboutdiarrhoea prevalence or mortality. Moreover there is no breast-fed comparison group and interventions to study diarrhoearisk typically involve thousands of subjects.2Diarrhoea incidence data based on recall of more than 1 or 2weeks are notoriously unreliable. In this study, critical periodsof recall are not given and may have been 3 months or longer.The cohort is quite unrepresentative (even of urbanpopulations) as the infant mortality rate (IMR) in this provinceis 8.4 (compared with 61.2 in the Eastern Cape),3 and water(71%) and electricity (75%) provision are above the nationaland continental averages. This is striking when these resultsare contrasted with those from appropriately designed studieswhich show different outcomes.4,5There was no long-term follow-up to assess survival,morbidity, and mortality, and the inquiry is biased towardsthose women who chose formula-feeding and who wereattending to receive their free supply. Dissatisfied mothers,those breast-feeding, and those whose babies had died, wereless likely to comprise the study sample.Diarrhoea is not the only outcome of importance; there aremultiple short- and long-term benefits of breast-feeding to beconsidered. One factor is the cost of formula. In KwaZulu-Natal this accounts for about 50% of the cost of the PMTCTprogramme. What is the opportunity cost of this allocation?Every year more than 10 million children die because we denythem access to proven, inexpensive services. As a recentreview6 laments, ‘levels of effort directed at preventing thesmall proportion of child deaths due to AIDS . . . seem . . . to beoutstripping . . . efforts to save millions of children every yearwith a few cents‘ worth of simple therapies’.We urge policy makers to eschew simplistic solutions to anessentially social, cultural, and economic issue, which is deeplyrooted in the human experience of beneficent motherhood. Inthe worst case scenario the risk of breast-feeding for 6 monthsis about 4 - 5% only. The facile route is to recommend formula— it requires no imagination and reveals a poverty of visionfor child health promotion. The difficult path is to ensure theprotection of breast-feeding during the HIV pandemic,Glimpses of this approach are beginning to appear in recentstudies.Anna CoutsoudisNigel RollinsMiriam AdhikariRaziya BobatDepartment of Paediatrics and Child HealthNelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurbanRuth BlandAfrica Centre for Health and Population Studies.SomkheleKwaZulu-Natal1. Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmissionprogramme and infant feeding practices. S Afr Med J 2003; 93: 779-781.2. Baqui AH, Black RE, El Arifeen S, et al. Effect of zinc supplementation started duringdiarrhoea on morbidity and mortality in Bangladeshi children: community randomised trial.BMJ 2002; 325: 1062.3. South African Demographic and Health Survey, 1998.4. Coutsoudis A, Pillay K, Spooner E, Coovadia HM, Pembrey L, Newell ML. Morbidity inchildren born to women infected with HIV in SA: does mode of feeding matter? ActaPaediatrica 2003; 92: 890-895.5. World Health Organisation. WHO collaborative study on the role of breastfeeding on theprevention of infant mortality. Effect of breastfeeding on infant and child mortality due toinfectious diseases in less developed countries: a pooled analysis. Lancet 2000; 355: 451-455.6. Jones G, Steketee RW, Black RE, et al. How many child deaths can we prevent this year?Lancet 2003; 362: 65-71.MRC mapping — extending theuse of spatial data in healthTo the Editor: The Health GIS (Geographic InformationSystems) Centre and Malaria Research Lead Programme of theMRC, together with InterMap, have developed a web-basedGIS application which is available on the internet(http://www.mrcmapping.org.za). The availability of newtechnology has enabled us to provide users with direct accessto spatial data relevant to both health researchers and thehealth service community for the purposes of queries,presentations, reports and training material.The provincial Departments of Health have made theirhealth facility databases available for the purposes of thisapplication and these data can now be viewed in relation toother datasets, such as schools, roads and population data,without the user needing to invest in expensive GIS softwareor attend specialised courses. A metadata file outlining thereference source and date of the respective data files isavailable on the system.At the broadest level, household service data from the 2001census data (sanitation, water and fuel for cooking) areavailable as thematic maps according to municipal boundaries70

The prevention of mother-to-child HIV transmission programme and infant feeding practices

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The prevention of mother-to-child HIV transmission programme and infant feeding practices

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