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 n(%) women Adjusted Hazard ratio
appropriateness choosing to formula 36 week HIV
feed who had these transmission/ death
criteria (95% CI)
(A) Piped water in 152 (52.6) 0.51 (0.31-0.84)
house or yard

(B) Piped water in 146 (50.5) 0.53 (0.32-0.88)

house or yard plus
fuel (electricity, gas or
paraffin)
(C) Piped water in 94 (32.5) 0.32 (0.16-0.62)
house or yard, fuel
and disclosure of HIV
status

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

 Consequences of inappropriate
choices
Appropriateness of feeding Adjusted Hazard Ratio 95% CI
choice according to presence or for 36 week HIV
absence of piped water, fuel and transmission/ death
HIV disclosure (n=600)

Appropriate choice to 1
formula feed (referent
group) (n=94)
Appropriate choice to 2.74 (1.48-5.05)
breastfeed (n=216)
Inappropriate choice to 3.45 (1.89-6.32)
formula feed (n=195)
Inappropriate choice to 2.72 (1.38-5.35)
breastfeed (n=95)
Doherty T. PATH Satellite, Toronto IAC (www.path.org)
 Thank you

Tgreiner@path.org