FROM THE EDITOR

FEEDING HIV-EXPOSED INFANTS

The most appropriate strategies for feeding HIV-exposed infants have been a source of great debate in South Africa for years. During this time policy makers, healthcare providers and (most importantly) mothers living with HIV infection have been concerned and sometimes confused about what is best for the HIV-exposed but uninfected infant.

Over the past few months, the announcement of a new national policy promoting breastfeeding with daily nevirapine prophylaxis for infants has presented a single, unified policy for services across the country. This is leading to the rapid cessation of replacement feeding provided through the public sector to HIV-infected mothers and their infants. But far from ending the debate on infant feeding, these new policies have refreshed the discussion. There have been a number of newspaper editorials and media releases presenting strong voices in support of, and cautioning against, the wholesale withdrawal of replacement feeding.

A recent debate in Johannesburg held by the SA HIV Clinicians Society provided a valuable summary of the key issues and a sense of the complexity in any attempt to develop a nationwide infant feeding strategy (for those who missed it, the presentations from the debate are available on the Society’s website, http://sahivsoc.org). In this issue of the Journal, Haroon Saloojee and colleagues present one viewpoint on the new national policies. Dr Saloojee was one of the participants in the Johannesburg debate, and I hope that this opinion piece will help generate productive discussions on a topic that clearly remains unresolved. (Note that opinion pieces that include other perspectives on the new infant feeding policies were solicited, but unavailable at the time of going to press – we hope these will be available for the next issue.)

Looking forward, the HIV Clinicians Society has been a leader, nationally and internationally, in developing evidence-based guidelines to address various issues in HIV treatment and prevention. Given the ongoing debate, there is certainly scope for rational guidelines to address the safest infant feeding choices across a range of scenarios. We hope the Society will take up the challenge of developing guidelines on infant feeding in the coming months, as this is an important time to present a balanced voice on a topic that remains contentious.

Also in this issue, Dramowski and colleagues describe the ‘missed opportunities’ for reducing HIV-related paediatric admissions at Baragwanath Hospital in Soweto. Among the missed opportunities they document are the failure to deliver effective prevention of mother-to-child transmission (PMTCT) services, including antenatal counselling and testing and antiretroviral interventions, leading to preventable paediatric infections. This research took place in a period when use of replacement feeding was common in Soweto, but presumably this will change radically during 2012 under the new feeding policies. Reading the articles by Dramowski and Saloojee together, the future seems unusually opaque. Will we look back 10 years from now to view the removal of replacement feeding for HIV-exposed infants as a critical opportunity rightly taken to promote child health, or yet another opportunity missed in our efforts to eliminate paediatric HIV?

This edition has many other exciting contributions. Innes and colleagues ask important questions about stavudine dosing, and provide an intriguing proposal for future research into a neglected issue with major implications given the number of patients on stavudine. Boyles discusses the ideal package of care for individuals who do not yet require antiretroviral therapy (ART), an aspect of services that may be sorely neglected in many parts of the country. An original article from Peltzer suggests a very high prevalence of depression among new HIV-infected mothers in KwaZulu-Natal, raising an important issue in thinking about PMTCT interventions in the postpartum period. Cullen presents a case report on an unusual case of optic neuritis in an HIV-infected patient, and in a review article Garone and colleagues discuss the progress to date and lessons learned from 10 years of programmes delivered through Médecins Sans Frontières in Khayelitsha, Cape Town. MSF’s projects in Khayelitsha have been a vanguard for the development of models to deliver ART as well as integrated HIV/TB care, and as we approach the 10-year anniversary of public sector ART services in South Africa, this review provides an important reminder of how far things have come.

Happy reading.

LANDON MYER

Editor

Associate Professor, School of Public Health and Family Medicine, University

of Cape Town