1. Contributing factors to poor infant feeding practices in SA Longstanding cultural practices of early introduction of other fluids and foods Support of formula milk through the PEM scheme Lack of legalization of the Code of Marketing of Breastmilk Substitutes Provision of formula milk through PMTCT Lack of breastfeeding promotion

2. Mixed feeding is common amongst HIV positive and negative women Formula feeding choices are not based on AFASS assessments Key messages Counselling is weak – difficulties of presenting two options There is now evidence from Africa showing that in the presence of ARVs, breastfeeding results in greater child survival compared with avoiding breastfeeding

3. Comparison of two delivery systems (BFHI vs BFHI + 10 home visits) Exclusive breastfeeding 0 20 40 60 80 100 110306090120150180 Age (days) % Pre-intervention Hospitals trained: no home visits Hospitals trained + Home visits Coutinho et al Lancet 2005

4. Can we continue to promote “two choices” Are the two choices ‘equivalent’?- current evidence suggests not! The balance has shifted Has the time come when the current policy causes more harm?

5. What is needed? Implement a national media and communication campaign for health workers and the general public promoting breastfeeding as a key intervention to reduce child mortality Communicate the benefits of exclusive breastfeeding for the first 6 months in HIV-positive and HIV-negative women Train all health workers in the above, including doctors, nurses, dieticians and community health workers during initial training and reinforced during in service training. Rapidly increase the proportion of hospitals with Baby Friendly status Employ breastfeeding counsellors in health facilities and at community level using savings from removal of formula. Train existing community health workers to support breastfeeding and establish a system of home visits to women postpartum for lactation support

6. What is needed? Legally enforce the Code of Marketing of Breastmilk Substitutes Avoid using formula milk in health facilities No advertising of formula in health facilities. Restrict advertising/promotion of formula, including at professional conferences. Review the current policy of provision of free formula milk to HIV-positive women