In accordance with World Health Organization guidelines, South Africa (SA) introduced routine periodic high-dose vitamin A supplementation (VAS) in 2002. These guidelines were developed after research in the 1980s and 1990s showed the efficacy of VAS in reducing childhood mortality. However, two recent studies in low- to middle-income countries (2013 and 2014) have shown no effect of high-dose VAS on mortality. Additionally, there is no clear research evidence that 6-monthly doses of vitamin A result in a sustained shift in serum retinol levels or reduce subclinical vitamin A deficiency. These two points should encourage SA to re-examine the validity of these guidelines. A long-term view of what is in the best interests of the majority of the people is needed. The short-term intervention of administering vitamin A capsules not only fails to improve serum retinol levels but may create dependence on a 'technical fix' to address the fundamental problem of poor nutrition, which is ultimately underpinned by poverty. It may also cause harm. Although there are those, some with vested interests, who will argue for continuation of the routine high-dose VAS programmes, SA policymakers and scientists need to evaluate the facts and be prepared to rethink this policy. There is cause for optimism: SA's health policymakers have previously taken bold stands on the basis of evidence. The examples of regulation of tobacco products and taxation of sugar-sweetened beverages, ending the free distribution of formula milk for HIV-positive mothers and legislating against the marketing of breastmilk substitutes provide precedents. Here is a time yet again for decision-makers to make bold choices in the interests of the people of SA. While the cleanest choice would be national discontinuation of the routine VAS programme, there may be other possibilities, such as first stopping the programme in Northern Cape Province (where there is clear evidence of hypervitaminosis A), followed by the other provinces in time.

BACKGROUND: With the largest antiretroviral therapy (ART) programme globally, demand for effective HIV management is increasing in South Africa. While viral load (VL) testing is conducted, VL follow-up and management are sub-optimal OBJECTIVES: The objective of this study was to address gaps in the VL cascade to improve VL testing and management METHODS: Antiretroviral therapy records were sampled for an in-depth review. The study team then reviewed individual records, focusing on ART management, virological suppression and retention. Multifaceted interventions focused on virological control, including a clinical summary chart for ART care; streamlining laboratory results receipt and management; monitoring VL suppression, flagging virological failure and missed visits for follow-up; down-referral of stable patients eligible for the chronic club system; and training of personnel and patients RESULTS: Pre-intervention, 78% (94/120) of eligible patients had VL tests, versus 92% (145/158) post-intervention (p = 0.0009). Pre-intervention, 59% (71/120) of patients accessed their VL results, versus 86% (136/158) post-intervention (p < 0.0001). Post-intervention, 73% (19/26) of patients eligible for ART change were appropriately managed, versus 11% (4/36) pre-intervention (p < 0.0001). Only 27% had no regimen changes (7/26) post-intervention, versus 81% (29/36) pre-intervention (p < 0.0001 CONCLUSION: Service delivery was streamlined to facilitate HIV services by focusing on VL test monitoring, protocol training and accessibility of results, thereby improving clinical management

BACKGROUND. Acute viral respiratory infections are common within the paediatric population. Nucleic acid amplification tests can identify a wide range of respiratory viruses. Virally infected patients can now be diagnosed early and more accurately in the acute phase of illness. OBJECTIVES. To examine the association between HIV status and mortality in children with viral lower respiratory tract infection (LRTI) and to delineate the profile of identified viruses. METHODS. We conducted a retrospective review of charts of children aged from birth to 10 years of age who were admitted to the paediatric intensive care unit at Inkosi Albert Luthuli Central Hospital with a viral LRTI between December 2010 and May 2015. Only patients who had a positive respiratory viral multiplex test were eligible for entry into the study. Patients were grouped according to their HIV status and mortality was assessed. RESULTS. A total of 338 records were analysed in this study. Sixty-five patients tested HIV-positive (19.2%) and 80.8% were HIV-negative (n=273). There were 55 mortalities: 12 were among the 65 HIV-positive patients (18.5%) and 43 among the 273 HIV-negative patients (15.8%). The difference in mortality according to HIV status was not statistically significant (p=0.595). Respiratory syncytial virus was the most prevalent virus identified overall, with adenovirus being most prevalent in the HIV-positive group. CONCLUSION. The results showed that patients with viral LRTIs who required respiratory support had a similar mortality regardless of HIV status.

BACKGROUND: Human breastmilk provides gold standard nutrition and immunological support to infants. For low birth weight, HIV-infected, HIV-exposed or otherwise vulnerable babies, it can mean the difference between life and death. When a mother's own milk is not available, safe, donated human breastmilk is an excellent alternative. High rates of under-5 mortality have prompted the South African (SA) Ministry of Health to commit to scaling up human milk banks in key health facilities. Community-based human milk banks (CBHMBs) have the potential to complement these efforts, but there is little research on the feasibility and acceptability of this approach. OBJECTIVE: To determine mothers' perceptions of breastfeeding and CBHMBs, and to ascertain how training could affect those perceptions. METHODS: A total of 40 black mothers in KwaZulu-Natal, SA, participated in a survey on breastfeeding and human milk banks (HMBs) prior to commencing a breastfeeding peer-counselling training course that included information on HMBs. The survey was re-administered following the completion of the module on HMBs. The questionnaire was repeated ~4 months later. RESULTS: Following training, significant changes were observed in mothers' knowledge and perceptions around donor milk and safety. No significant changes were observed in reports of what these mothers presumed the community's perceptions around donor milk banking were. CONCLUSION: Education of mothers can play an important role in supporting CBHMBs by improving mothers' perceptions and acceptance of breastfeeding, donor milk, and milk banking. Changing community concerns around HMBs will require more than just changing the perceptions of mothers.

BACKGROUND: The Expanded Programme on Immunisation (EPI) in South Africa (SA) has had a large effect on vaccine-preventable illnesses, yet there is little in the literature describing access to and utilisation of the programme beyond 1 year of age. Coverage of vitamin A supplementation is examined through District Health Information System data, but this does not give a fair assessment of the lifetime coverage in a child or provide any correlation with the immunisation status of the child. OBJECTIVES: To describe utilisation and dropout rate with the vitamin A and immunisation programmes over the first 6 years of life among children aged 6 - 8 years in a semi-urban population in KwaZulu-Natal (KZN) Province, SA. A secondary objective was to investigate whether access and dropout rates are associated between these two programmes. METHODS: A retrospective cohort analysis was performed on 923 anonymised Road-to-Health cards, extracting information on immunisation and vitamin A coverage. RESULTS: Overall, 92.9% (95% confidence interval (CI) 91.2 - 94.6) and 88.5% (95% CI 86.4 - 90.5) of children were fully immunised by 12 months and 18 months of age, respectively. The percentage of children fully immunised by 6 years of age dropped to 44% (95% CI 41.2 - 47.6). The dropout rates for measles, and diphtheria, pertussis and tetanus 1 - 3 vaccination were 2.4% and 1.2%, respectively. Vitamin A had an overall coverage of 34.9% during 6 - 60 months of life for this population, with children receiving, on average, three doses (interquartile range 2 - 5). CONCLUSION: Despite good immunisation coverage in the first 18 months of life, there was relatively poor vitamin A coverage, suggesting a need for re-evaluation of the current vitamin A capsule distribution programme.

The transmission of HIV through breastmilk, with the potential to infect the newborn, has had a major impact on child health worldwide. Although South African studies confirmed that exclusive breastfeeding reduced rates of mother-to-child transmission of HIV, the recommendation of formula feeding for HIV-exposed newborn infants, provided their mothers had the facilities for safe preparation of formula milk and complied with the AFASS criteria (formula feeding to be Acceptable, Feasible, Affordable, Sustainable, Safe), was introduced. Observations made by the nursing staff, fully aware of the risks of formula feeding, in the neonatal unit at King Edward VIII Hospital in 2009 showed that an increasing number of small, sick newborns were being formula fed. By conducting focus group discussions with nurses, mothers and counsellors and teasing out the confusions and misconceptions, relevant information was imparted to the groups to allow them to re-consider their misconceptions. Within a period of 2 months nurses were confident about re-counselling mothers with respect to appropriate feeding choices. HIV-positive mothers were trained to flash-heat their milk. Subsequently, policies for the unit were derived from the focus group discussions. In addition, regional hospitals in the Durban area (eThekweni) considered the introduction of flash-heating to their units. The South African Department of Health opted for infants to receive prophylaxis with daily nevirapine as long as they are breastfed, and the Nutrition Directorate decided to withdraw the issue of free replacement feeds in HIV-exposed babies. KwaZulu-Natal was the first province to institute this policy. The Department of Health has recommended that neonatal units no longer encourage HIV-infected mothers to flash-heat their breastmilk unless the infant is not receiving ARV prophylaxis or the mother is not on treatment.

BACKGROUND: Obesity and undernutrition are common in South Africa and influence the health outcomes of people living with the human immunodeficiency virus (PLHIV). Aim. To describe the anthropometric changes and perceptions of body weight in adults initiated on antiretroviral therapy (ART). METHODS: A cohort of 230 PLHIV was enrolled at an HIV clinic in Durban. Changes in their body mass index, and waist and hip girth were measured 6-monthly in the 12 months following initiation of ART. Data on demographic and socio-economic variables, CD4 counts, opportunistic infections and drug regimens used were recorded. Perceptions of body weight and desire to change these were ascertained. RESULTS: Weight perceptions of respondents were incongruent with their body mass index, with the trend being to judge themselves as weighing less than their actual weight. Those wanting to gain weight gained an average of 7.8 kg - 2.8 times more than those satisfied with their weight (p<0.001). After 12 months on ART, there was a statistically significant increase in anthropometric measurements (p<0.001) with 43 of the 110 women having waist circumferences that increased their risk of cardiovascular disease; the incidence of lipodystrophy was 35% (62/177) (95% confidence interval 27 - 42%), 36% (64/177) were overweight and 22% (39/177) were obese, compared with 21% (49/230) and 12% (28/230) respectively at baseline (p=0.002). CONCLUSION: There is a strong association between PLHIV's perception of body weight, their desire to gain weight and their actual weight gain on ART. Lipodystrophy, weight gain and truncal obesity are common among PLHIV after initiating ART.

The release of the new WHO guidelines on HIV and infant feeding, in a global context of widespread impoverishment, requires countries to re-examine their infant-feeding policies in relation to broader socioeconomic issues. This widening scope is necessitated by compelling new reports on the scale of global underdevelopment in developing countries. This paper explores these issues by addressing feeding choices made by HIV-infected mothers and programmes supplying free formula milks within a global environment of persistent poverty. Accumulating evidence on the increase in malnutrition, morbidity and mortality associated with the avoidance or early cessation of breastfeeding by HIV-infected mothers, and the unanticipated hazards of formula feeding, demand a deeper assessment of the measures necessary for optimum policies on infant and child nutrition and for the amelioration of poverty. Piecemeal interventions that increase resources directed at only a fraction of a family's impoverishment, such as basic materials for preparation of hygienic formula feeds and making flawed decisions on choice of infant feeding, are bound to fail. These are not alternatives to taking fundamental steps to alleviate poverty. The economic opportunity costs of such programmes, the equity costs of providing resources to some and not others, and the leakages due to temptation to sell capital goods require careful evaluation. Providing formula to poor populations with high HIV prevalence cannot be justified by the evidence, by humanitarian considerations, by respect for local traditions or by economic outcomes. Exclusive breastfeeding, which is threatened by the HIV epidemic, remains an unfailing anchor of child survival.

La publicación de las nuevas directrices de la OMS sobre el VIH y la alimentación del lactante, en un contexto mundial de empobrecimiento generalizado, obliga a los países a revisar sus políticas de alimentación del lactante en relación con algunos aspectos socioeconómicos más amplios. Esta perspectiva más amplia es imprescindible a la vista de la contundencia de los últimos datos sobre la magnitud del subdesarrollo global en los países en desarrollo. En este artículo se analizan esas cuestiones centrando la atención en las decisiones de alimentación de sus hijos que toman las madres infectadas por el VIH y en los programas que suministran leche artificial gratuita en un contexto mundial de pobreza persistente. La creciente evidencia de un aumento de la malnutrición, la morbilidad y la mortalidad asociadas a la evitación o la interrupción temprana de la lactancia materna por las madres infectadas por el VIH y los riesgos imprevisibles de las preparaciones para lactantes exigen una evaluación más profunda de las medidas necesarias para formular políticas óptimas sobre la nutrición del lactante y del niño y para mitigar la pobreza. Las intervenciones fragmentarias de incremento de los recursos con miras a paliar sólo una parte del empobrecimiento de las familias, como productos básicos para la elaboración higiénica de las preparaciones y algunas decisiones desacertadas en materia de alimentación del lactante, están destinadas a fracasar. No son ésas alternativas que puedan suplir medidas fundamentales de mitigación de la pobreza. Los costos de oportunidad económicos de esos programas, la inequidad que supone proporcionar recursos a unos y no a otros, y las pérdidas debidas a la tentación de vender los bienes de capital exigen una detenida evaluación. El suministro de preparaciones a las poblaciones pobres con alta prevalencia de infección por VIH no puede justificarse aduciendo la evidencia disponible, consideraciones humanitarias, el respeto de las tradiciones locales o los efectos económicos. La lactancia materna exclusiva, amenazada por la epidemia de VIH, sigue siendo un arma fundamental para la supervivencia infantil.

Dans le contexte mondial actuel d'appauvrissement généralisé, les nouvelles directives de l'OMS sur le VIH et l'alimentation du nourrisson récemment publiés demandent aux pays de réexaminer leurs politiques d'alimentation du nourrisson en tenant compte d'aspects socioéconomiques plus larges. Cet élargissement de la perspective est motivé par de nouveaux rapports convaincants sur l'ampleur à l'échelle mondiale du sous-développement dans les pays en développement. Le présent article étudie ces aspects en examinant les choix en matière d'alimentation du nourrisson faits par les mères infectées par le VIH et les programmes fournissant gratuitement du lait pour nourrisson dans un contexte mondial de pauvreté persistante. Les preuves qui s'accumulent d'une augmentation de la malnutrition, de la morbidité et de la mortalité liée à l'abstention ou à l'arrêt précoce de l'alimentation au sein par les mères infectées et les dangers imprévus de l'alimentation artificielle exigent une évaluation plus approfondie des mesures nécessaires pour optimiser les politiques en matière d'alimentation du nourrisson et de l'enfant et pour faire reculer la pauvreté. Les interventions fragmentaires pour augmenter les ressources qui ne compensent qu'une partie de l'appauvrissement familial (fourniture de matières de base pour préparer des aliments pour nourrissons conformes à l'hygiène par exemple) et prennent de mauvaises décisions concernant l'alimentation du nourrisson, sont condamnées à échouer. Il n'existe pas d'alternative à la prise de mesures fondamentales pour atténuer la pauvreté. Les coûts d'opportunité de tels programmes, les coûts en matière d'équité de la fourniture sélective de ressources et les pertes dues aux tentations de vendre des biens en capital doivent être soigneusement évalués. La fourniture de préparations pour nourrissons à des populations pauvres subissant une forte prévalence du VIH ne peut se justifier par des éléments factuels, des considérations humanitaires, le respect des traditions locales ou des résultats économiques. L'alimentation exclusivement au sein, menacée par l'épidémie de VIH, reste la base inébranlable de la survie de l'enfant.

BACKGROUND: Dual protection is recommended for prevention of unwanted pregnancies and protection against sexually transmitted infections, including HIV. It is critical for HIV-negative women to prevent seroconversion and HIV transmission to their infants during pregnancy and breastfeeding. METHODS: Women were followed up after delivery, monthly for the first 9 months and then 3-monthly to 24 months, in a cohort study investigating postnatal HIV transmission. Study nurses discussed family planning, including condom use, at each visit. Contraceptive methods used since the last visit were recorded. All women knew their HIV status, and most women breastfed for a minimum of 6 months. RESULTS: Among 1 137 HIV-positive and 1 220 HIV-negative women the most common contraceptive method was the hormonal injectable; few women used condoms alone or as dual contraception (0 - 3 months 6.8%; 7 - 12 months 16.3%; 19 - 24 months 14.4%). Compared with uninfected women, HIV-positive women were more likely to use condoms in years 1 and 2 after delivery (adjusted odds ratio (AOR) 1.72, 95% confidence interval (CI) 1.38 - 2.14, p<0.001; AOR 1.61, 95% CI 1.15 - 2.25, p=0.006 respectively). Compared with women with a flush toilet, those with a pit latrine were less likely to use condoms in years 1 and 2 (AOR 0.22, 95% CI 01.7 - 0.28, p<0.001; AOR 0.27, 95% CI 0.19 - 0.39, p<0.001). Older women were more likely to use condoms in the first postpartum year (AOR 1.78, 95% CI 1.03 - 3.09, p=0.040). CONCLUSIONS: More creative ways of promoting condoms and dual contraception need to be found if new HIV infections, in women and children, are to be prevented.

OBJECTIVE: To examine infant feeding intentions of HIV-infected and uninfected women and the appropriateness of their choices according to their home resources; and to determine their adherence to their intentions in the first postnatal week. METHODS: Feeding intentions of pregnant women were compared against four resources that facilitate replacement feeding: clean water, adequate fuel, access to a refrigerator and regular maternal income. First-week feeding practices were documented. FINDINGS: The antenatal feeding intentions of 1253 HIV-infected women were: exclusive breastfeeding 73%; replacement feeding 9%; undecided 18%. Three percent had access to all four resources, of whom 23% chose replacement feeding. Of those choosing replacement feeding, 8% had access to all four resources. A clean water supply and regular maternal income were independently associated with intention to replacement feed (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI) 1.2-3.2; AOR 2.1, 95% CI: 1.2-3.5, respectively). Significantly more HIV-infected women intending to exclusively breastfeed, rather than replacement feed, adhered to their intention in week one (exclusive breastfeeding 78%; replacement feeding 42%; P < 0.001). Of 1238 HIV-uninfected women, 82% intended to exclusively breastfeed; 2% to replacement feed; and 16% were undecided. Seventy-five percent who intended to exclusively breastfeed adhered to this intention postnatally, and only 11 infants (< 1%) received no breast milk. The number of antenatal home visits significantly influenced adherence to feeding intention. CONCLUSION: Most HIV-infected women did not have the resources for safe replacement feeding, instead choosing appropriately to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counselling and support, spillover of suboptimal feeding practices to HIV-negative women is minimal.

OBJETIVO: Estudiar las intenciones de las mujeres VIH-positivas y VIH-negativas en lo relativo a la alimentación del lactante; la idoneidad de sus decisiones en función de sus recursos domésticos; y el cumplimiento de esas decisiones al cabo de una semana del nacimiento. MÉTODOS: Se procedió a comparar las decisiones sobre el tipo de alimentación tomadas por las mujeres embarazadas en relación con cuatro recursos que facilitan la alimentación sustitutiva (AS), a saber, el agua salubre, la disponibilidad de combustible suficiente, el acceso a un frigorífico, y unos ingresos maternos regulares. Durante la primera semana tras el parto se documentaron las prácticas de alimentación. RESULTADOS: Las intenciones prenatales que respecto a la alimentación manifestaron 1253 madres infectadas por el VIH fueron las siguientes: LNE (lactancia natural exclusiva), 73%; AS, 9%; no decidido, 18%. El 3% de las mujeres tenían acceso a los cuatro recursos considerados, y el 23% de ellas eligieron la AS. Entre quienes optaron por la AS, el 8% tenían acceso a los cuatro recursos. El suministro de agua salubre y unos ingresos maternos regulares se asociaron de forma independiente al deseo de recurrir a la AS (AOR (razón de posibilidades ajustada): 1,94; IC95%: 1,2-3,2; AOR: 2,1; IC95%: 1,2-3,5 respectivamente). Entre las mujeres VIH-positivas con intención de practicar la LNE se observó un porcentaje significativamente mayor de cumplimiento de ese deseo durante la primera semana en comparación con las que optaron por la AS (LNE, 78%; AS, 42%; p < 0,001). De las 1238 mujeres no infectadas por el VIH, 1021 (82%) optaron por la LNE; 21 (2%) por la AS; y 193 (16%) estaban indecisas. El 75% de las que optaron por la LNE la practicaron efectivamente tras el parto, y sólo 11 lactantes (<1%) no fueron amamantados. El número de visitas domiciliarias prenatales influyó de forma considerable en el cumplimiento de los deseos en materia de alimentación. CONCLUSIÓN: La mayoría de las mujeres infectadas por el VIH no disponían de los recursos necesarios para garantizar una AS segura, y eligieron acertadamente la LNE. El cumplimiento de las decisiones en materia de alimentación entre las mujeres infectadas por el VIH fue mayor entre las que optaron por la LNE que entre las que se inclinaron por la AS. Si existe un asesoramiento y un apoyo apropiados, la propagación de las prácticas de alimentación subóptimas a las mujeres VIH-negativas es mínima.

OBJECTIF: Examiner les intentions en matière d’alimentation de leur nourrisson de femmes infectées et non-infectées par le VIH ; la pertinence de leur choix en fonction des ressources dont elles disposent à domicile ; et le maintien de ces options une semaine après l’accouchement. MÉTHODES: Les intentions en matière d’alimentation de leur futur enfant de femmes enceintes ont été confrontées à quatre éléments de ressource facilitant l’utilisation de substituts du lait maternel : eau saine, combustible adéquat, accès à un réfrigérateur et revenus maternels réguliers. RÉSULTATS: L’analyse des intentions émises avant l’accouchement par 1253 femmes infectées par le VIH au sujet de l’alimentation de leur nourrisson a donné les résultats suivants : allaitement maternel exclusif 73 % ; utilisation de substituts du lait maternel 9 % ; pas de décision arrêtée 18 %. Parmi les femmes ayant choisi de recourir à une alimentation de substitution, 8 % avaient accès aux 4 éléments de ressources précités. Des corrélations indépendantes ont été relevées entre l’intention de donner à l’enfant un substitut du lait maternel et la disponibilité pour la mère d’un approvisionnement en eau saine et celle de revenus réguliers (odds ratio ajusté = 1,94, IC à 95 % = 1,2-3,2 et odds ratio = 2,1 ; IC à 95 % = 1,2-3,5, respectivement). Parmi les femmes infectées par le VIH, la proportion de celles se conformant pendant la première semaine postpartum à l’intention exprimée était notablement plus importante chez les mères ayant prévu de nourrir leur enfant exclusivement au sein que chez celles ayant d’abord opté pour un substitut du lait maternel (allaitement exclusif : 78 % ; alimentation de substitution : 42 %, p < 0,001). Parmi les 1238 femmes non-infectées, 1021 (82 %) avaient l’intention de donner exclusivement le sein, 21 (2 %) comptaient utiliser un substitut du lait maternel et 193 (16 %) n’avaient pas pris de décision. 75 % des femmes ayant opté pour l’allaitement exclusif se sont tenues à leur choix après l’accouchement et 11 nourrissons seulement (< 1 %) n’ont pas reçu de lait maternel. Le nombre de visites anténatales à domicile influait de manière significative sur le maintien de l’option d’alimentation. CONCLUSION: La plupart des femmes infectées par le VIH ne disposaient pas des ressources permettant une alimentation de substitution sans risque de leur nourrisson et ont choisi l’option la plus appropriée, à savoir l’allaitement exclusif. La proportion de femmes infectées par le VIH respectant leur intention d’alimentation était plus importante chez celles ayant opté pour l’allaitement exclusif que chez celles ayant l’intention de donner un substitut du lait maternel. L’apport de conseils et d’un soutien appropriés permet donc de réduire au minimum la diffusion de pratiques non optimales chez les femmes non-infectées par le VIH.