Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi.

OBJECTIVE: To assess the continuity of care and outcome of pediatric HIV prevention, testing, and treatment services, focusing on early infant diagnosis with DNA polymerase chain reaction (PCR). DESIGN: A retrospective observational cohort. METHODS: Maternal HIV antibody, infant HIV DNA PCR test results, and outcome data from HIV-infected infants from the prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV treatment programs operating in Lilongwe, Malawi, between 2004 and 2008 were collected, merged, and analyzed. RESULTS: Of the 14,669 pregnant women who tested HIV antibody positive, 7875 infants (53.7%) received HIV DNA PCR testing. One thousand eighty-four infants (13.8%) were HIV infected. Three hundred twenty (29.5%) children enrolled into pediatric HIV care, with 202 (63.1%) at the Baylor Center of Excellence. Among these, antiretroviral therapy was initiated on 110 infants (54.5%) whose median age was 9.1 months (interquartile range, 5.4-13.8) and a median of 2.5 months (interquartile range, 1.4-5.2) after HIV clinic registration. Sixty-nine HIV-infected infants (34.2%) died or were lost by December 2008. Initiation of antiretroviral therapy increased the likelihood of survival 7-fold (odds ratio, 7.1; 95% confidence interval, 3.68 to 13.70). CONCLUSIONS: Separate programs for maternal and infant HIV prevention and care services demonstrated high attrition rates of HIV-exposed and HIV-infected infants, elevated levels of mother-to-child transmission, late infant diagnosis, delayed pediatric antiretroviral therapy initiation, and high HIV-infected infant mortality. Antiretroviral therapy increased HIV-infected infant survival, emphasizing the urgent need for improved service coordination and strategies that increase access to infant HIV diagnosis, improve patient retention, and reduce antiretroviral therapy initiation delays.

"We grandmothers know plenty": breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi.

This paper has two purposes: first of all, we examine grandmothers' role and views of child feeding practices in northern Malawi, and their influence on younger women's practices. Secondly, we consider the implications of these findings for health promotion activities and models of health education. Data were collected from semi-structured interviews, focus groups and a participatory workshop. Findings demonstrate that, to address child feeding practices which have an effect on nutrition, attention must be paid to the broader context that influences child nutrition, including extended family relations. Paternal grandmothers have a powerful and multifaceted role within the extended family in northern Malawi, both in terms of childcare and in other arenas such as agricultural practices and marital relations. Grandmothers often differ in their ideas about early child feeding from conventional Western medicine. Some practices have existed in the area at least since colonial times, and have strong cultural significance. Despite the important integrated role, older women have within households and communities in this part of Malawi, hospital personnel often have disparaging and paternalistic attitudes towards 'grannies' and their knowledge. Health education rarely involves grandmothers, and even if they are involved, their perspectives are not taken into consideration. Hospital staff often reject grandmother knowledge as part of a broader modernization paradigm which views 'traditional knowledge' as backward. Grandmothers view current child health conditions within a broader context of changing livelihood conditions and a high prevalence of HIV/AIDS. The paper concludes by discussing the challenges of involving grandmothers in health education, and the difficulties of incorporating local knowledge into a medical system that largely rejects it.

Breastfeeding and mixed feeding practices in Malawi: timing, reasons, decision makers, and child health consequences.

BACKGROUND: In order to effectively promote exclusive breastfeeding, it is important to first understand who makes child-care and child-feeding decisions, and why those decisions are made; as in most parts of the world, exclusive breastfeeding until 6 months of age is uncommon in Malawi. OBJECTIVE: To characterize early infant foods in rural northern Malawi, who the decision-makers are, their motivation, and the consequences for child growth, in order to design a more effective program for improved child health and nutrition. METHODS: In a rural area of northern Malawi, 160 caregivers of children 6 to 48 months of age were asked to recall the child's age at introduction of 19 common early infant foods, who decided to introduce the food, and why. The heights and weights of the 160 children were measured. RESULTS: Sixty-five percent of the children were given food in their first month, and only 4% of the children were exclusively breastfed for 6 months. Mzuwula and dawale (two herbal infusions), water, and porridge were common early foods. Grandmothers introduced mzuwula to protect the children from illness; other foods were usually introduced by mothers or grandmothers in response to perceived hunger. The early introduction of porridge and dawale, but not mzuwula, was associated with worse anthropometric status. Mzuwula, which is not associated with poor growth, is usually made with boiled water and given in small amounts. Conversely, porridge, which is associated with poor child growth, is potentially contaminated and is served in larger amounts, which would displace breastmilk. CONCLUSIONS: Promoters of exclusive breastfeeding should target their messages to appropriate decision makers and consider targeting foods that are most harmful to child growth.