The documentation of breastfeeding as a source of human immunodeficiency virus (HIV) infection in babies born to HIV positive mothers represents a public health dilemma, especially in countries with a high HIV prevalence rate and where breastfeeding is the norm and essential to child survival [1
]. According to the UNAIDS update for 2005, 700,000 infants are HIV infected every year, with an estimated 5 to 15 percent of children born to HIV positive women being infected through their mother's milk [5
]. As knowledge about the risk of HIV transmission through breastfeeding has reached health care workers, the general population, and individual mothers, uncertainty has developed on how best to feed infants in the context of HIV. Women who know or suspect they are HIV positive are faced with difficult and complex choices [6
Current international guidelines [2
] on infant feeding for HIV positive mothers promote replacement feeding
(infant formula or animal milk) or exclusive breastfeeding
(with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission [7
] and is strongly discouraged. Current guidelines state: 'When replacement feeding is not
acceptable, feasible, affordable, sustainable and safe (AFASS), exclusive breastfeeding is recommended during the first months of life' [2
]. Based on the principle of informed choice
, health workers are encouraged to give HIV infected women the best available information on the risks and benefits of each feeding method, with 'specific guidance in selecting the option most likely to be suitable for their situation'
Prevention of Mother To Child Transmission (pMTCT) programmes are rapidly expanding throughout sub-Saharan Africa, with several key intervention pillars: voluntary counselling and testing (VCT), anti-retroviral prophylaxis and infant feeding counselling [10
]. However, inadequate training of health workers, particularly pMTCT counsellors, related to the relative risks associated with infant feeding in the context of HIV, the feasibility and safety of replacement feeding, lack of culturally sensitive counselling tools and the stigma associated with both replacement feeding and exclusive breastfeeding make appropriate and effective infant feeding counselling difficult [7
]. According to previous research, mothers' adoption of and adherence to the recommended feeding methods is also a problem [11
]. A study in Nairobi, Kenya, that aimed to determine feeding practices and the nutritional status of infants born to HIV-1 infected women, for example, reported that 31% of the HIV positive, counselled mothers participating in the study practised mixed feeding six weeks after delivery [14
]. One of the major challenges facing women in adopting and adhering to current recommendations is access to good quality information [15
]. Research shows that many counsellors are not adequately informed about how to protect infants from HIV transmission and may not even be aware of the existence of updated guidelines [6
]. Few have received sufficient training on counselling in the context of HIV [16
], and pMTCT programmes in general lack counselling tools and other resources [17
]. Staff shortages and the associated lack of time to counsel properly, even for those adequately trained in infant feeding counselling are further barriers to the provision of informed infant feeding choices [18
This article describes the development of an integrated set of counselling tools, referred to as 'job aids', based on the updated international guidelines and related World Health Organization (WHO) and UNICEF generic counselling materials. The development process followed an intervention mapping (IM) framework [19
], with the ultimate aim of producing a cost-effective, culturally sensitive and technologically appropriate set of tools to improve the quality and relevance of infant feeding counselling. A further objective was to strengthen HIV positive mothers' ability to both make an informed choice and safely execute a feeding method appropriate to their personal situation.
Job aids have gained status in health promotion as a cost-effective way to improve the performance
of service providers, such as nurses, and are often defined as tools that reduce guesswork, minimize reliance on memory and promote compliance with standards [20
]. Decision aids, or client oriented job aids, are often used to guide patients through a series of steps, giving them personalized information and/or helping them clarify their values and risk exposure in the context of health related options [20
]. Job aids often feature visual images or graphics to enhance users' understanding of written information. To strengthen the relevance and potential for identification, both the images and the written messages should resonate with people's beliefs. In the development of the job aids reported here, both written messages and visual images were developed to reflect the local social and cultural context in the communities.
The study was located at the pMTCT clinic at KCMC (Kilimanjaro Christian Medical Centre) outside Moshi town in Kilimanjaro Region in northern Tanzania, where the HIV prevalence rate in the antenatal population is estimated at 5.7% [23
]. Breastfeeding is normative in the area, but early supplementation with water, cow's milk and porridge ('partial' or 'mixed' breastfeeding) is standard practice [11
]. The pMTCT clinic at KCMC recruits patients from the antenatal clinic, which primarily serves women from Moshi town and its rural outskirts. It offers the standard package of VCT, ARV prophylactics and infant feeding counselling to pregnant women and their partners.