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Distribution of feeding practices (exclusive breastfeeding, replacement feeding, mixed feeding/other) for infants born to HIV-infected women at DPT3 visit

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Distribution of feeding practices (exclusive breastfeeding, replacement feeding, mixed feeding/other) for infants born to HIV-infected women at DPT3 visit
What it measures

Feeding of HIV-exposed infants, derived from 24-h recall, measured at the time of the third dose of diphtheria, pertussis and tetanus vaccine (DPT3), which is often around 3 months of age or at the closest visit after 3 months.

HIV can be transmitted during breastfeeding even in settings where 100% of HIV-infected pregnant women receive either lifelong antiretroviral therapy or antiretroviral medicines as prophylaxis for the prevention of mother-to child transmission of HIV. Mixed feeding before 6 months of age increases the risk for HIV transmission when compared with exclusive breastfeeding. WHO therefore recommends that when mothers known to be HIV-infected breastfeed, they should be given ARVs to reduce the risk of transmission and also exclusively breastfeed for the first 6 months, introduce complementary feeds from 6 months and continue breastfeeding until 12 months of age.
Coverage with the third dose of diphtheria, pertussis and tetanus vaccine close to the recommended age of 14 weeks is relatively high in most countries. It is proposed to collect data at this time because most infants are seen then and it is mid-way between birth and the time at which exclusive breastfeeding would stop, making it comparable to the way that exclusive breastfeeding is usually reported for the general population in demographic and health surveys.

Rationale
Numerator

The numerators are disaggregated as follows:
I12a number of HIV-exposed infants who were exclusively breastfeeding at or around the DPT3 visit;
I12b number of HIV-exposed infants who received replacement feeding at or around the DPT3 visit; and
I12c number of HIV-exposed infants who received mixed feeding at or around the DPT3 visit.
The numerators capture feeding practices only for known HIV-exposed infants who visit a health facility.

Denominator

The denominator is the same for all three indicators: the number of HIV exposed infants whose feeding practice has been assessed at a DPT3 visit. Infants will be aged around 3 months or more.

Calculation

Numerator / Denominator

Method of measurement

The numerators are calculated from national programme records aggregated from facility registers.
Ideally, data from appropriate sites and registers such as a stand-alone or integrated HIV-exposed infant registers should be aggregated, depending on where the services are and where data are recorded.
At each visit, the health-care provider should enquire about infant-feeding practices during the previous 24 hours, by asking: “What did you give your infant to eat or drink yesterday during the day and during the night?” After each response, the health provider should ask: “Anything else?” The response will be recorded as exclusive breastfeeding, replacement feeding or mixed feeding. While this information is collected and recorded on the child health card at every visit, providers should record it in the register only once, during the third visit for diphtheria, pertussis and tetanus vaccination. This record will be used for compilation and reporting to national level. In settings where HIV-exposed infants are seen in HIV care and treatment facilities, data should be collected at a visit when the infant is around 3 months.
The denominator is calculated from the total number of exposed infants whose feeding was assessed. Exposed infants who did not attend facilities are not included in the denominator.
All public, private and nongovernmental organization-run health facilities that provide HIV-exposed infant follow-up services should be included.

Disaggregation: Report distribution of IF practice: EBF, RF, MF/Other; Uncategorized/other

Data Quality Control and Notes for the Reporting Tool:
•Please provide any relevant information that would allow us to better interpret the data reported •If this data is not available, please provide an estimate of the distribution of IF practice among HIV+ women in the country in the Comments section.

Measurement frequency
Disaggregation
Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

The indicators measure important progress in safer infant feeding practices among HIV-infected women and their exposed infants. They can also be used to indicate the quality of infant feeding counselling (with low rates of mixed feeding likely to indicate adequate infant feeding counselling and support), and can also be used to model the impact of the intervention in a country (see Core Indicator 12 in the PMTCT M&E guide, or GARPR 3.3 - modelled MTCT rate). It should be noted that the indicator says nothing about the quality of replacement feeding given, nor the impact of the feeding practices on child survival.
The information can be compared with population surveys (e.g. DHS), which monitor infant feeding practices in the general population.
The indicators may not reflect the actual distribution of infant feeding practices of HIV-exposed infants at the national level, as it does not include HIV-exposed infants who may have already died, infants whose exposure status is unknown, nor HIV-exposed infants whose mothers did not attend a facility with their infant for DPT3 or for another reason at or around 3 months.

Additional considerations:
To fully understand the extent and type of infant feeding practices, countries may consider carrying out special studies with a cohort of HIV-infected women who choose to replacement feed and exclusively breastfeed. As well as measuring infant feeding practices, these studies could examine the reasons why women who have chosen either breastfeeding or replacement feeding are or are not practicing the chosen option exclusively, and whether the AFASS criteria were present. It could also examine the types of foods and liquids given to infants in addition to breast milk or formula before six months, and issues around cessation of exclusive breastfeeding at six months and complementary feeding after that time. Another issue to be examined is the impact of early infant diagnosis on infant feeding practices, and if the impact is negative, what can be done to better support mothers at this time.
In countries where exposed infant follow-up has been integrated into community outreach services, programmes should consider identifying a system for collecting data at the community level for this indicator. Countries may wish to consider collecting this information at other time points, for example at both 6 weeks and 6 months. They may also wish to calculate the indicators using different denominators, such as the estimated number of HIV-exposed infants who should have been followed-up.

Data utilization: Review the distribution of infant feeding practice and discuss strategies to move towards safer practices.

Further information