HIV infection in mothers during and after pregnancy
A study conducted in Botswana in 2007 estimated that 43% of HIV infected children became infected when their mothers were in the initial
stage of their infection. The contamination of the mother could have occurred during pregnancy or during the breastfeeding period.
Consequently the researchers recommend that women who tested HIVnegative at the beginning of their pregnancies be routinely re-tested
later. This practice would also encourage the women’s partners to test for HIV. This study also demonstrates the need for improving prevention counselling for women and their partners.

Reducing maternal resistance to Nevirapine
Several studies conducted in Thailand and Africa showed that administering AZT or ddI in combination with LPV/r, for one month after giving birth reduced mothers’ chances of becoming resistant to Nevirapine if they had taken single dose NVP to prevent their babies from being infected with HIV. The lopinavir/r -based medicine (Kaletra® or Aluvia®) in particular reduced rates of virological failure and mortality. Finally, the best way to prevent resistance to Nevirapine is to administer triple-therapy during pregnancy and throughout post-partum including to women who do not necessarily require this for their own health.

Reminder: The WHO recommends that mothers take a seven-day course of AZT+3TC during post-partum to reduce the chances of developing resistance to Nevirapine.

Save the dates!
The International Dominique Dormont Conference: The 5th International Dominique Dormont Conference will be devoted to mother to child transmission of viral diseases: from prevention to children care. It will be held March 26th to 28th 2009 at Val de Grâce in Paris, France. The conference program is available on the website: http://www.ddormont-conferences.org/.

HIV and the desire to have children: The Fourth National HIV and Procreation Days in the era of highly active treatments will take place on April 16th and 17th, 2009 at Hôtel-Dieu Saint-Jacques, in Toulouse (France). This two-day conference’s purpose is to review current knowledge about HIV and genitalia, medicines, sperm, the risk of transmission and the desire to have children. The various options available to sero-different couples who wish to become parents will be reviewed including natural and medically-assisted procreation.
Professor Françoise Barré-Sinoussi, the winner of the Nobel Prize for medicine in 2008 will preside over the conference. The scientific conference program is available at the following address and you can register online: http://www.desirenfant-vih.eu/programme/.

As of 2008, Togo boasts 34 clinics devoted to Preventing Mother to Child Transmission of HIV (PMTCT). These sites offer HIV tests to pregnant women during their first prenatal consultation. When a pregnant woman tests positive for HIV she is eligible for ARVs as part of the national PMTCT program. PCR is not available in Togo (the equipment arrived in September 2008 but remains inoperational). It is therefore difficult to test HIV-exposed infants early. Access to infant formula is also quite limited because it is not subsidized by the government.
Espoir Vie Togo (EVT), with support from the Growing Up program, involved in PMTCT by providing nutritional support to HIV-exposed children. This includes infant formula, enriched flour and food kits for older and malnourished children. EVT also offers monthly support groups for pregnant women and young mothers. It is one of the oldest organizations of people living with HIV in Togo. This organization conducts HIV/AIDS prevention awareness and also provides care to its members. EVT works with PMTCT centers of CHU TOKOIN, the prefectural hospital in Bé and the Lomé health center.
Dr. Andrée Bassuka, EVT’s paediatrician for the last 3 years, is in charge of nutritional follow-up of children exposed to HIV. We feature her work in this special issue of Growing Up Info.

What does EVT do for PMTCT in Lomé?
EVT’s main work with PMTCT has to do with nutritional assistance. EVT offers support groups to pregnant HIV-positive women who have been involved with EVT since the beginning of their pregnancy. During these meetings we review the two feeding options that are available to the women: breastfeeding with early cessation for infants between 4 - 6 weeks old, or replacement feeding using infant formula. Then, once the mothers have given birth, nutritional support for the infants is set up according to the kind of feeding option the mother has chosen. We also receives women who have been referred to us from other organizations so they can receive infant formula.
When these mothers come to EVT they have already chosen the feeding method they will use with their infants. We are willing to help all women by providing them with infant formula for as long as stocks allow us. The women who already participate in our discussion groups have priority over women who are recommended to us by other organizations. All women are invited to particpate in our dissusion groups...

What are the feeding methods commonly practiced by the mothers at EVT?
Feeding methods vary depending on various factors: whether or not the woman’s partner is aware of her HIV status, their financial resources… Most of the women (75%) at EVT choose to feed their baby infant formula.

How is this nutritional support organized?
There are two groups of children: those who are fed infant formula and those who are breastfeeding with early cessation.
The babies who are fed infant formula receive 6 tins/month of formula until they reach 6 months of age. From 6-9 months they receive 4 tins/month of formula for babies over 6 months old. At 9 months they receive commercially available powdered milk.
The children who are exclusively breastfeeding from 0 - 4 months with early cessation receive formula for infants under 6 months old once they stop breastfeeding and then formula for infants over 6 months old once they reach 6 months of age.
During monthly support group meetings we teach all the mothers (regardless of which feeding method they have chosen for their infant) how to introduce vegetables into the baby’s diet at the age of 4 months (vegetable puree mixed with milk) and fruits as of the 5th month. Both groups of children start eating enriched flour-based porridge at 6 months of age.
At 12 months, the babies receive their first HIV test and if the result is negative we stop providing nutritional support but continue providing medical care until the baby is 18 months old. In the case of a positive or inconclusive result the test is repeated at 15 months and again at 18 months; during which time the baby continues to receive whole powdered milk every month until s/he is18 months old. There are two follow-up sessions per week (on Monday and Wednesday afternoons) for children exposed to HIV. During these sessions we evaluate the children’s nutritional state and offer support if needed. All the children receive iron and folic acid supplements as well as regular deparasiting treatments until they are 5 years old as part of the national program.

What material support do women opting to feed their babies infant formula receive?
We donate infant formula. The families pay one sixth of the cost of a tin. For example if a tin of formula costs 3000 CFA the family buys it for 500 CFA. This means we can buy commercially available whole powdered milk, which we then distribute, free of charge, to children 9 months old.
It is interesting that you recommend using cups for feeding babies- why?
We ask mothers to feed babies from cups to prevent the kinds of sanitation problems that are associated with the use of baby bottles.

Do you find cases of malnutrition in both groups of children (those on infant formula and those being breastfed with early cessation)?
There are cases of malnutrition but they are uncommon, however, most of the babies that suffer from malnutrition are HIV-positive. Weighing and measuring the children every month as well as providing regular counselling to mothers promotes better hygien and health care. We also explain growth curves to the mother and show her her own child’s position on the chart at each visit. If we notice a problem during the course of a child’s follow-up, the mother is put in contact with a nurse-nutritionist—or to a counsellor who has also been trained in HIV-exposed infant nutrition. Individualized support is then offered to address the problem.
When a child is unable to gain weight despite home visits from nurses or counsellors we ask for a CD4 count to be done to check for the presence of HIV infection.

What kinds of problems do you encounter in your support of these women?
If the fathers do not support the mothers, it is difficult to take care of the mother and her child. Stigmatisation and discrimination are two factors that make home visits difficult for us. We try to avoid making appointments with women in their homes, we prefer, when possible to suggest meeting at their workplace however this is especially difficult for mothers who are obliged to be constantly on the move, and this makes it hard for us to provide the best follow-up. Most of the women’s partners have not taken an HIV test. And several women have not revealed their HIV status to their partners. Antenatal follow-up is sometimes irregular especially when we run out of infant formula. The demand for infant formula exceeds our capacity to provide for all the mothers who are currently enrolled in this programme, and we are obliged to refuse new enrollements. The fact that we enroll women only after they have given birth also limits our capacity to act effectively in PMTCT.

What are the main positive aspects?
The nutritional support that we offer to women makes it possible to provide regular monthly support to infants exposed to HIV. As a result of this proximity, we are capable of following their staturo ponderal growth and promptly detect nutritional problems. We also encourage mothers to vaccinate their babies. Providing nutritional support also helps to limit the number of women who drop out of the program. And having families who return regularly for care makes it easier later to have children take an HIV test.

In Bénin, RACINES offers special support to pregnant HIV positive women and nutritional support to children exposed to or living with HIV. Counselling on infant feeding options, home visits, cooking workshops-- introducing Edwige d’Almeida and her staff.

With her little braids and big smile, 34 year-old Edwige d’Almeida, is a nutrition counsellor at RACINES. This organization in Cotonou offers medical and social care to people living with HIV at the ADIS center (Support, Testing, Information, Solidarity-STIS) a center with a particular focus on PMTCT.
Having earned her degree in social work, Edwige went on to learn about nutrition. She has focused on nutritional support since 2007 at RACINES where she works under Dr. Alice Gougounon, Growing Up project’s coordinator. « This program has many goals: to teach pregnant women living with HIV about infant feeding options, to support them when they give birth, to prevent malnutrition in infants exposed to and living with HIV », she explains. « By offering nutritional support to these women they become regular clients and therefore it becomes possible to do HIV testing and general healthcare.», Dr. Gougounon adds.

« What will your relatives say if you do not breastfeed your child? »

For pregnant women living with HIV choosing a feeding option for their infants is a critical issue. Breastfeeding represents a risk of passing HIV to the child (from 5-20% depending on the case) and the infant must stop breastfeeding at 6 months. Replacement feeding has to be practiced under the right conditions or it can endanger the infant’s health, i.e.: malnutrition, diarrhea.
Edwige d’Almeida enlightens families on this sensitive decision. Today, she has an interview with Fatou (1). First the women talk about the advantages of breast milk, which is free and requires no preparation. But the mother-to-be is aware of the possibility of passing HIV to the infant this way and prefers infant formula. Edwige then stresses sanitary measures required for cleaning baby bottles, necessary supplies… and asks her a series of questions. « Do you have clean drinking water in your home? Even if we supply tins of formula would you be able to pay for them? What will the family say if you are not breastfeeding your child? » Breastfeeding has significant symbolic meaning and relatives who think they are « not taking good care of their babies » can criticize women who do not breastfeed. In addition, in a context where people living with HIV are highly stigmatized, women who are afraid of rejection might try to hide their situation from their families and lie about why they aren’t breastfeeding their infants. They might say, for example, that they don’t have enough breast milk or that their doctors told them there was something wrong with their breasts. However, Fatou is determined: « My husband is aware of my illness and won’t say anything if I don’t breastfeed my child. Also, we do not live with our family so I will not have to answer questions.» Edwige schedules a home visit and asks Fatou if she can talk to her partner at the same time. This is critical: the nutrition counsellor needs to see Fatou’s family environment and review replacement feeding with her before the child is born. In 2008, RACINES supported 41 women who opted to feed their babies infant formula and 56 who chose to breast-feed. « The partner’s attitude is a determining factor. If a partner knows his wife’s HIV status and is willing to contribute financially, it makes it easier for a woman to choose formula », explains Edwige.
The organization supports the families by giving them tins of both kinds of infant formula (for babies under and over 6 months old), supplies including bottles, thermoses, pots and buckets as well as packets of enriched flour for porridge.

« We check to make sure that the bottles of formula are correctly prepared.»
Once the babies are born, Edwige schedules visits at the families’ homes. « We check to make sure that the baby bottles are correctly prepared, that the women follow appropriate sanitation measures. We have to make sure that mothers who are breastfeeding do not practice mixed feeding and that they are supported during the difficult period when they have to stop breastfeeding.» Edwige d’Almeida and the other social workers at RACINES, evaluate babies’ health by visiting their homes every month. « If an infant appears to have lost weight we tell the parents to bring him/her in to be seen right away », Edwige adds. They have to soothe the families’ fears as they wait for their child to be tested for HIV. « In 2008, 2 out of 91 infants tested positive. It is a relief for us too when the children test negative », Edwige emphasizes.

Today, accompanied by Mathias Dossou, social mediator at RACINES, Edwige will criss-cross Cotonou on her motorcycle visiting several families. Their first stop is in front of a modest sheet metal house in a working-class neighbourhood. A young couple lives here with their 9 month old son. She is a seamstress and he is a security guard. Edwige and Mathias check to make sure the porridge isn’t too runny, recently they have been having trouble preparing it. This time it is fine. They also give some practical advice: « You shouldn’t keep flour in a plastic bag. Put it in a receptacle instead », Mathias recommends.
Next stop is at Ekpe, a district of Sèmè, a suburb about 10kms from Cotonou’s center. After a long ride, the road gives way to a sandy path that is hard to pass on a motorcycle. In their little house Lucie shows Edwige and Mathias the baby bottles and the baby’s cup that have been sterilized in a pot of hot water. She is thorough and proud to be able show how she is taking good care of her child. But she also confides her problems to the team: « I tested positive during my pregnancy. When my husband found out he left me. He pays the rent and comes to see us now and then but it isn’t the same as it was before.» These visits are also a chance to support women who have often been left by their husbands who do not want to hear about the illness. Sometimes the husbands accuse their wives of having « brought AIDS into the family ». This is because the mothers are the first to be diagnosed at the beginning of their pregnancy. Sometimes the entire family rejects the mothers who then rely on RACINES to maintain a social contact.
Edwige and Mathias then go to Fatima’s house. She has an 8-month old son. « I sell bread and my sister helps me financially but it is still hard to get by », she explains. Edwige tells her that she understands hers problems but stresses the necessity to diversify the baby’s diet: « He is growing and porridge alone isn’t enough for him anymore. It is possible to make a balanced meal even with very little money.» She reminds her of recipe ideas that were suggested at RACINES last cooking workshop.

« Red paste » especially for infants
The cooking workshops are specially designed for families of children exposed to or living with HIV. How can we prepare inexpensive balanced meals for these children? This is the challenge that their parents or guardians (in the case of orphans) face. During these sessions Edwige suggests low-cost recipes adapted to the children’s needs that families will be able to prepare at home. RACINES’ staff also distributes food support kits comprised of corn, soy, millet, and rice. This Wednesday afternoon, 15 women participate in the workshop in a school courtyard. They talk in a relaxed atmosphere. They have come with their children who will take turns being weighed by Edwige and Mathias. The goal here is to compare their weight to the previous month and make sure that their growth curve is satisfactory. Then Edwige introduces the women to the menu of the day: « red paste ». She has adapted this traditional dish so that it can be fed to 7-month infants.
« Soy is good for growth », « …the protective effect of tomatoes »… she lists the positive attributes of the various ingredients. Then the demonstration begins: the nutrition counsellor and Gisèle Aïtchedji, a social worker at RACINES break the recipe into stages. Ms. Aïtchedji stirs the ingredients together in a large pot over the embers while the women watch attentively. Finally it’s time to eat! Both adults and children appear to enjoy this soy-decorated
corn puree!

1 – Names have been changed.

Patrice is 7 months old and stopped breastfeeding last month because his mother is living with HIV. He has stopped breastfeeding just when he is ready to start diversifying his diet. Patrice is growing and his nutritional needs are growing too.
Here is sample daylong menu adapted to his needs:

In the morning when he gets up: enriched cereal porridge (soy).
Ingredients: enriched flour (soy), water, sugar.
Preparation: Put a quarter liter of water to boil, add a small amount of flour to water and pour the mixture into the boiling water and stir. Let cook for 20 minutes. Add the sugar and let cook for 5 more minutes. The porridge should be a relatively thick consistency. Let cool slightly and then serve.

Around 10am: give Patrice half of a banana mashed.

Lunch time: mashed yam and spinach with egg.
Ingredients: yam, spinach, 1 egg, 1/2 teaspoon of oil.
Preparation: peel the yam and cut it into small pieces; wash the pieces; add water and put it on the stove to boil; cook the yam for 15 minutes. Put the egg into another pot of water, and boil it for 10 minutes. Peel the egg and separate the yolk from the white. Set aside half of the yolk. (You can use the rest of the yolk and the egg white in a different dish for your family). Wash the spinach. Add the half-yolk and the spinach to the yams and cook it for 10 minutes while stirring. Mash this altogether with a spatula (the yam has to be thoroughly cooked). Add oil, and serve.

Around 4pm: give Patrice a cup of milk (200 to 250 ml of milk preferaldy formulated for babies over 6 months).

Evening: mashed vegetables with fish.
Ingredients: a large handful of leafy vegetables, a handful of corn flour, 15 to 20 grams of dried fish, a small peeled tomato, 1/2 teaspoon of oil.
Preparation: Bring a half-liter of water to boil, add the vegetable leaves (that have already been washed thoroughly), let cook for around 10 minutes. Take out the leaves, cover and set aside. Dip the tomato in boiling water and then peel it; crush the peeled tomato, crush the dried fish to a powder, add the crushed tomato and fish powder to the boiling water and stir thoroughly. Sprinkle the corn flour in a little water and add it to the mixture in the pot. Stir for 3-5 minutes. Mashed the cooked leafy vegetable and add to the mixture. Add oil and take off the fire as soon as the mixture has started to boil. The dish is now ready to serve.
Give Patrice clean safe drinking water to drink throughout the day (a 7 -month old infant who is not breastfeeding needs 700 to 1200 ml of water/day in a warm climate).
Note: a 7-month old infant’s meal is equal to just about half of a 250-ml bowl.

In upcoming Growing Up! publications you will find a series of fact sheets about nutrition and children exposed to, or living with HIV, including menus and recipes.

Mariam is 23 years old and pregnant for the first time. She lives in a village around 30 km from your health center. She has been referred to you by the regional hospital after testing positive for HIV. She brings with her a CD4 count (200/mm3) that was done 4 months ago. She is 36 weeks pregnant. Mariam is with her mother in law, and she doesn’t seem to understand what is going on. She is exhausted. During the course of your conversation with Mariam you learn that she is the 2nd wife in the household and her only income is what her husband earns. What role will your staff play faced with this young woman’s situation?