Where formula feeding cannot be provided within the AFASS guidelines, exclusive breastfeeding for a minimum of 6 months is recommended (Table 4.
Formula or replacement feeds are only given when these are 'acceptable, feasible, affordable, sustainable and safe': the AFASS criteria.
The fear and confusion the HIV infected mother faces in tackling her own HIV status and the possibility of infecting her baby has driven some mothers to choose replacement feeding even when it was obvious that they could not meet the AFASS
It may be the denial of the 'opportunity to have an HIV-uninfected child' that will result if women are denied access to formula despite meeting AFASS
During the first 6 months of life, replacement feeding should be with a suitable breastmilk substitute AFASS
The criteria required for replacement feeding: criteria acceptable, feasible, affordable, sustainable and safe Table II.
However, provinces, and perhaps even districts, should be allowed the freedom to decide whether they wish to continue to support the provision of replacement feeding for poor women who meet the AFASS
criteria, based on their own circumstances.
All HIV-positive infants should continue breastfeeding for at least 2 years, regardless of whether the mother meets the AFASS criteria.
For example, if women meet the AFASS criteria they should still be advised not to breastfeed so that postnatal HIV transmission is eliminated; if women do not meet the AFASS criteria then the new policy may advise breastfeeding for 6 months with an ARV regimen that continues throughout the breastfeeding period.
To assess AFASS a checklist can be used (Table II).
In a recent review of solutions to operational challenges in PMTCT, (35) a novel '5-finger approach' to assess AFASS and facilitate appropriate infant feeding choices has been described by Coutsoudis and Kroon.
Regardless of the method used to assess AFASS, appropriate infant feeding choices should be encouraged to maximise child survival in the context of PMTCT.
While stakeholders engage in discussions about which is the best regimen to include in national policy on minimising postnatal transmission, SSSUPPORT should be given to all HIV-positive women to improve infant outcomes and reduce postnatal transmission: Screen all women for HIV; Send off CD4 cell counts on all HIV-positive women; Screen all HIV-positive women for AFASS using a standardised tool (e.