Infant feeding in three specific areas: 1. Percent HIV-exposed infants who are exclusively BF at 3 months 2. Percent HIV-exposed infants who are replacement feeding at 3 months 3. Percent HIV-exposed infants who are mixed feeding at 3 months

The percentages of HIV-exposed infants who are receiving each of three specific types of infant feeding at three months of age (i.e., at time of third dose of diphtheria, pertussis, and tetanus (DPT3) vaccine given at 14 weeks or at the closest visit after 3 months). The three types of feeding are: (1) exclusively breastfeeding; (2) replacement feeding receiving no breast milk; or (3) mixed feeding with breast milk and replacement feeding.

Exclusive breastfeeding is defined as receiving only breast milk and no other liquids or solids except drops of syrups consisting of vitamins, minerals, or medicines.  Breast milk can include mother’s expressed milk or milk from a wet nurse.

Replacement feeding is defined as the infant receives no breast milk and is being fed suitable breast milk substitutes in the form of commercial infant formula since animal milk is no longer recommended for feeding infants during the first 6 months of life, except as an emergency measure.

Mixed feeding is defined as both breast milk and breast milk substitutes (i.e., commercial infant formula).

This indicator is calculated in three levels as:

(Number of HIV-exposed infants who are exclusively breastfed at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x 100

(Number of HIV-exposed infants who are replacement feeding at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x 100

(Number of HIV-exposed infants who are mixed feeding at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x100

During each visit, the health provider should inquire about infant-feeding practices during the previous 24 hours and record the response as one of three types - exclusively breastfeeding, replacement feeding, or mixed feeding. While this information should be recorded at each visit, only the DPT3 vaccination visit at about 14 weeks postpartum or the closest visit after the infant is at least 3 months old should be used to calculate this indicator.  The denominator is calculated from the total number of HIV-exposed infants whose infant feeding practices were assessed. Where the data are available, the indicator can be disaggregated by province and district, urban/rural location, and type of facility (e.g., public, private, community-based).

Ideally data can be aggregated from sites and registers, such as stand-alone sites or integrated HIV service facility infant registers, depending on where the services are located and where data are recorded. Efforts should be made to include data from public, private, non-governmental, and community-based health facilities that provide HIV-exposed infant follow-up services.

This indicator allows the monitoring of program or country progress toward safer infant feeding practices among HIV-positive mothers and their exposed infants. It can be used as a proxy of the quality of infant feeding counseling with low rates of mixed feeding (the least healthy form) as a likely indicator of adequate counseling and support.  The information can be compared with population-based surveys, such as DHS which monitor infant-feeding in the general population. The indicator is included in the PEPFAR list of new generation indicators (PEPFAR, 2009) and the WHO/UNICEF/UNAIDS (2011) guide on indicators for monitoring the health sector response to HIV/AIDS.  

Where breastfeeding is common and prolonged, HIV transmission through breast milk may account for up to half the infections in infants and young children (PEPFAR, 2006). Mother-to-child transmission (MTCT) of HIV can take place even in settings where 100 percent of HIV-positive women are receiving either lifelong antiretroviral (ARV) therapy or a prophylactic course of ARVs for prevention of mother-to-child transmission (PMTCT) of HIV. Given the nutritional and immunological benefits of breast milk and the finding that, compared with exclusive breastfeeding, mixed feeding before six months increases risk for MTCT, WHO and UNICEF (2003; 2007) have recommended exclusive breastfeeding for the first few months of life where safe and affordable alternatives are not feasible. For more background on recommendations, interventions and indicators for infant feeding and PMTCT, see WHO/UNICEF (2007), PEPFAR (2006), UNAIDS (2010), and WHO/UNICEF/UNAIDS (2011)).  

The indicator does not provide information about the quality of replacement feeds or the impact of infant-feeding practices on child survival. Using a 24-hour recall period to measure current status may slightly overestimate the proportion of exclusively breast-fed infants because some infants who are given other liquids or foods irregularly may not have received them in the 24 hours before the survey. The indicator may not reflect the actual feeding patterns for HIV-exposed infants at national or district levels since it does not include infants who may have already died, whose HIV status is unknown, or infants whose mothers did not attend a facility with their infants for DPT3 or at around 3 months. 

breastfeeding (BF), nutrition, newborn (NB), HIV/AIDS

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR.

PEPFAR, 2006, Report on food and Nutrition for People Living with HIV/AIDS, Washington, DC: USAID/PEPFAR.

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS.

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO.

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO.