A postnatal AFASS assessment algorithm

By Ted Greiner, PhD Senior Nutritionist, PATH
Presentation to the WHO Consultation on HIV and Infant Feeding 26 October 2006

Postnatal counseling based on AFASS assessment is not being done

‡ There is a widespread assumption that WHO guidelines require HIV+ women to stop breastfeeding by or before 6 mo (p. 69 in Guidelines for Managers) ‡ There is thus little awareness that when to stop breastfeeding needs to be based on any decision-making process, let alone counseling

Relative odds ratio of death from not breastfeeding by education of mother ROR, 6-11 months: Rutstein: 2.7 in 17 countries (DHS) WHO 2000:
‡ OR = 5.1, lowest tercile (least education) ‡ OR = 2.0 medium tercile ‡ OR = 1.1 highest tercile
SOURCES: WHO Collaborative Study Team, Lancet, 2000 Rutstein SO Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the DHS. Int J Gynaecol Obstet. 2005 Apr, 89 Suppl 1:S7-24.

Achieving a decreased period of postnatal exposure to HIV
‡ At about 12-18 months, the relative risk of death from not breastfeeding greatly declines ‡ Even only reducing the average period of BF to 18 months would cut postnatal transmission in Rwanda in half, the same impact on postnatal transmission as single dose NVP has on perinatal transmission

Defining appropriate choice in RSA
Score of appropriateness n(%) women choosing to formula feed who had these criteria Adjusted Hazard ratio 36 week HIV transmission/ death (95% CI)

(A) Piped water in house or yard (B) Piped water in house or yard plus fuel (electricity, gas or paraffin) (C) Piped water in house or yard, fuel and disclosure of HIV status

152 (52.6) 146 (50.5)

0.51 (0.31-0.84) 0.53 (0.32-0.88)

94 (32.5)

0.32 (0.16-0.62)

Doherty T. PATH Satellite, Toronto IAC (www.path.org)

Consequences of inappropriate choices
Appropriateness of feeding choice according to presence or absence of piped water, fuel and HIV disclosure (n=600) Adjusted Hazard Ratio for 36 week HIV transmission/ death

95% CI

Appropriate choice to formula feed (referent group) (n=94) Appropriate choice to breastfeed (n=216) Inappropriate choice to formula feed (n=195) Inappropriate choice to breastfeed (n=95)


2.74 3.45 2.72

(1.48-5.05) (1.89-6.32) (1.38-5.35)

Doherty T. PATH Satellite, Toronto IAC (www.path.org)

Thank you


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