The effect of an exclusive breastfeeding support intervention on subsequent development of children in the context of HIV

Country of Implementation:

South Africa





Target Beneficiary:

0-2 years

Delivery Intermediaries:

Caregiver; Non-specialists


To increase the practice of exclusive breast-feeding among HIV positive and negative women.

Innovation Description:

Home-based intervention delivered by lay counsellors to support exclusive breast-feeding in first 180 days of life.

Stage of Innovation:

Proof of Concept

The effect of an exclusive breastfeeding support intervention on subsequent development of children in the context of HIV





Target Beneficiary

0-2 years

Delivery Intermediaries

Caregiver; Non-specialists


To increase the practice of exclusive breast-feeding among HIV positive and negative women.

Innovation Description

Home-based intervention delivered by lay counsellors to support exclusive breast-feeding in first 180 days of life.

Stage of Innovation

Proof of Concept

Innovation Summary

0063 - UKZN logoThe South African Vertical Transmission Study (VTS) supported HIV-positive and HIV-negative women to exclusively breastfeed (EBF) their infants in a rural area of South Africa where mixed breastfeeding (i.e. breastmilk and other fluids and solids) was the norm. We aim to investigate whether this early feeding intervention is associated with further benefits for children, in terms of development, health and school readiness of HIV-negative children 7-10 years of age. We will compare their development to HIV-negative children from the same area in the Africa Centre Demographic Surveillance area whose mothers were not part of the VTS intervention (control group). Those in the control were exposed to the same standard of care provided by local clinics, including the same messages regarding HIV and early infant feeding. However, unlike the VTS cohort, they did not receive home-based counseling by lay counsellors  to support EBF. If benefits for the children are established, this will have major policy and clinical implications especially in view of the relative simplicity and low cost of the intervention and global recommendations about breastfeeding.


  • Assessments conducted on 1579 children and 1579 mothers 7-10 years after the original EBF intervention.
  • Assessments focused on cognitive outcomes, socio-emotional wellbeing of children, physical growth of children, and maternal mental health.
  • Breastfeeding is recommended for all infants of HIV-negative mothers to 2 years of age, and also for infants of HIV-positive women for one year with antiretroviral cover, in areas of the world where formula feeding is not feasible or safe. However, there is strong evidence that without support women do not manage to EBF for 6 months, and EBF rates remain low globally. This research has the potential to demonstrate the longer term benefits of EBF using a sustainable counselor model.
  • Public health investment decisions may be motivated and informed by the availability of evidence on the longer term impact for human capital potential of children born to HIV-positive and HIV-negative children provided by this work.


Women were enrolled during pregnancy and supported to EBF their infants for the first 6 months of life. Lay counselors from the local community conducted home visits: 4 antenatal visits, and fortnightly postnatal visits to 6 months, including a visit within 48 hours of birth to ensure optimal breast attachment and to help the mother to respond appropriately to her infant. Simple and practical principles were used, making it reproducible and sustainable. The package included:

  1. Specific help with breastfeeding within 72 hours after delivery including: (a) good position and attachment and effective suckling; (b) supporting mother-infant face-to-face communications during feeding; (c) the mother’s recognition of, and responsiveness to, infant’s cues and signals.
  1. Information and support for infant crying by encouraging mothers to interpret and manage the many reasons for crying.
  2. Help to manage any breast health problems (e.g. engorgement and sore nipples).

Throughout the intervention the mother was encouraged to respond to her child’s cues, breastfeed on demand, interpret the reasons for infant crying (e.g. hunger, dirty nappy) and spend as much time as possible in skin-to-skin contact with her baby. Mothers also received support from monthly well-baby clinic visits by study nurses.



  • The original VTS was funded by the Wellcome Trust, UK, and conducted at the Africa Centre for Health and Population Studies, South Africa. The Africa Centre is funded by the Wellcome Trust.
  • Grand Challenges Canada


Key Drivers

Interventions that increase EBF are important, timely and need to be informed by cost, sustainability and suitability to a wide array of resource-poor settings. A key variable to wider implementation of the VTS intervention is that it was delivered by lay counselors, local women with no tertiary or previous health training and mostly previously unemployed. All counselors were trained in basic counseling techniques and breastfeeding support using the WHO/UNICEF Breastfeeding Counselling Course which is freely available. Ongoing in-service support was provided throughout the original VTS This training model is cost appropriate to many low resource settings and several additional resources, including a DVD, have already been developed and are available to support scale-up activities.


EBF was not previously practiced in the area (similar to most settings globally) – most women mixed breast fed (i.e. gave breastmilk + formula/water/other fluids or foods) to their infants from early in their lives. The challenge was to change breastfeeding practice amongst both women, and to convince health workers and the families of the mothers that EBF was the optimal way to feed infants.

Evaluation Methods

This current study aims to examine the development and growth of children who were EBF. Internationally recognized assessment tools, including the Kaufmann Battery Assessment for Children will be used.

Impact of Innovation

The original VTS was the first unequivocal demonstration that EBF reduced the risk of mother-to-child transmission of HIV, compared to mixed breastfeeding, and demonstrated that, with support, high rates of EBF were possible in an area where mixed breastfeeding was known to be the norm. These findings have influenced national and international policy. [3]


An economic analysis of the original intervention has been conducted and published. A further cost analysis of the longer term benefits of breastfeeding, depending on the outcomes of this study, will be undertaken.


  1. Bland R, et al. (2009) Cohort Profile: Mamanengane or the Africa Centre Vertical Transmission Study. Int J Epidemiol. Mar 31 2009.
  2. Bland RM, et al. (2008) Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS. Apr 23 2008;22(7):883-891.
  3. Coovadia HM, et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. Mar 31 2007;369(9567):1107-1116.
  4. Bland RM, et al. (2007) Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ. Apr 2007;85(4):289-296.
  5. Patel D, et al. (2010) Breastfeeding, HIV status and weights in South African children: a comparison of HIV-exposed and unexposed children. AIDS. Jan 28 2010;24(3):437-445.
  6. Rollins NC, et al. (2008) Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes. AIDS. Nov 12 2008;22(17):2349-2357.
  7. Coutsoudis A, et al. (2010) Women’s morbidity and mortality in the first 2 years after delivery according to HIV status. AIDS. Nov 27 2010;24(18):2859-2866.
  8. Bland RM, et al. (2007) Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa. Clin Infect Dis. Dec 1 2007;45(11):1502-1510.


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