FEEDING HIV-EXPOSED.html


    
        
            
                FROM THE EDITOR

            

            
                FEEDING HIV-EXPOSED INFANTS

                The most appropriate strategies for feeding HIV-exposed infants have
                been a source of great debate in South Africa for years. During this
                time policy makers, healthcare providers and (most importantly) mothers
                living with HIV infection have been concerned and sometimes confused
                about what is best for the HIV-exposed but uninfected infant.

                
                

                Over the past few months, the announcement of a new national
                policy promoting breastfeeding with daily nevirapine prophylaxis for
                infants has presented a single, unified policy for services across the
                country. This is leading to the rapid cessation of replacement feeding
                provided through the public sector to HIV-infected mothers and their
                infants. But far from ending the debate on infant feeding, these new
                policies have refreshed the discussion. There have been a number of
                newspaper editorials and media releases presenting strong voices in
                support of, and cautioning against, the wholesale withdrawal of
                replacement feeding. 

                
                

                A recent debate in Johannesburg held by the SA HIV Clinicians
                Society provided a valuable summary of the key issues and a sense of
                the complexity in any attempt to develop a nationwide infant feeding
                strategy (for those who missed it, the presentations from the debate
                are available on the Society’s website, http://sahivsoc.org). In
                this issue of the Journal,
                Haroon Saloojee and colleagues present one viewpoint on the new
                national policies. Dr Saloojee was one of the participants in the
                Johannesburg debate, and I hope that this opinion piece will help
                generate productive discussions on a topic that clearly remains
                unresolved. (Note that opinion pieces that include other perspectives
                on the new infant feeding policies were solicited, but unavailable at
                the time of going to press – we hope these will be available for
                the next issue.) 

                
                

                Looking forward, the HIV Clinicians Society has been a leader,
                nationally and internationally, in developing evidence-based guidelines
                to address various issues in HIV treatment and prevention. Given the
                ongoing debate, there is certainly scope for rational guidelines to
                address the safest infant feeding choices across a range of scenarios.
                We hope the Society will take up the challenge of developing guidelines
                on infant feeding in the coming months, as this is an important time to
                present a balanced voice on a topic that remains contentious. 

                
                

                Also in this issue, Dramowski and colleagues describe the
                ‘missed opportunities’ for reducing HIV-related paediatric
                admissions at Baragwanath Hospital in Soweto. Among the missed
                opportunities they document are the failure to deliver effective
                prevention of mother-to-child transmission (PMTCT) services, including
                antenatal counselling and testing and antiretroviral interventions,
                leading to preventable paediatric infections. This research took place
                in a period when use of replacement feeding was common in Soweto, but
                presumably this will change radically during 2012 under the new feeding
                policies. Reading the articles by Dramowski and Saloojee together, the
                future seems unusually opaque. Will we look back 10 years from now to
                view the removal of replacement feeding for HIV-exposed infants as a
                critical opportunity rightly taken to promote child health, or yet
                another opportunity missed in our efforts to eliminate paediatric HIV?

                
                

                This edition has many other exciting contributions. Innes and
                colleagues ask important questions about stavudine dosing, and provide
                an intriguing proposal for future research into a neglected issue with
                major implications given the number of patients on stavudine. Boyles
                discusses the ideal package of care for individuals who do not yet
                require antiretroviral therapy (ART), an aspect of services that may be
                sorely neglected in many parts of the country. An original article from
                Peltzer suggests a very high prevalence of depression among new
                HIV-infected mothers in KwaZulu-Natal, raising an important issue in
                thinking about PMTCT interventions in the postpartum period. Cullen
                presents a case report on an unusual case of optic neuritis in an
                HIV-infected patient, and in a review article Garone and colleagues
                discuss the progress to date and lessons learned from 10 years of
                programmes delivered through Médecins Sans Frontières in
                Khayelitsha, Cape Town. MSF’s projects in Khayelitsha have been a
                vanguard for the development of models to deliver ART as well as
                integrated HIV/TB care, and as we approach the 10-year anniversary of
                public sector ART services in South Africa, this review provides an
                important reminder of how far things have come. 

                
                

                Happy reading.

                
                

                
                

                LANDON MYER

                Editor

                Associate Professor, School of Public Health and Family Medicine, University

                of Cape Town