The majority of mothers live in conditions where the AFASS criteria cannot be met, and yet a large-scale move away from breastfeeding occurred even among mothers who without knowing their status feared being HIV-infected and refrained from breastfeeding, further eroding breastfeeding practice.
It became evident that even though the AFASS criteria for advising formula feeding were a scientific and medical attempt to discriminate between risk categories, counsellors, nurses and doctors could only promote breastfeeding half-heartedly when there was a real possibility that HIV infection could be transmitted to babies via breastmilk.
Though the 2010 guidelines build on previous guidelines clarifying some concepts such as AFASS, it also introduces new concepts including the following:
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 condition.
s view, the government should provide free formula for women in the wealthier provinces, such as Gauteng and Western Cape, where women are sufficiently well-off to meet AFASS criteria but not so much as to purchase formula themselves.
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 criteria.
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.
Yet inadequate training on infant feeding guidelines, AFASS
criteria and the new WHO recommendations1 impacts on the quality of counselling they can confidently offer.
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.
Formula or replacement feeds are only given when these are 'acceptable, feasible, affordable, sustainable and safe': the AFASS