WHO GUIDELINES ON
HIV and INFANT FEEDING 2010
AN UPDATED
FRAMEWORK for PRIORITY ACTION
FAO
IAEA
WFP
World B ank
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The Framework’s purpose and target audience
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he purpose of this Framework is to provide guidance to governments on key priority actions, related to infant and young child feeding, that cover the special circumstances associated with human immunodeficiency virus (HIV). The aim of this guidance is to create and sustain an environment that encourages appropriate feeding practices for all infants and young children, while scalingup interventions to reduce HIV transmission. This Framework aims to build on the links and synergies between maternal and child health and investments, economic and human, in HIV prevention and control. This will bring additional benefits for all children,
not just for those who are HIV-exposed. The audience for this Framework includes national policy-makers, programme managers, regional advisory bodies, public health authorities, Country Coordinating Mechanisms, United Nations staff, professional bodies, nongovernmental organizations and other interested stakeholders, including the community. The current document is an update of the previous Framework, published in 2003, and has been developed in response to both evolving knowledge and requests for clarification from these key sectors. It is based on the latest HIV and infant feeding recommendations; the previous Framework no longer applies.
The Global Policy Environment
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rowing commitment and resources are helping to create a new focus on women’s and children’s health, including in the context of HIV. Four of the Millennium Development Goals (MDGs) with targets for 2015 are related to nutrition (MDG1), child survival (MDG4), maternal health (MDG5) and HIV/acquired immunodeficiency syndrome (AIDS) (MDG6). The United Nations Secretary General’s Global Strategy for Women’s and Children’s Health (1) sets out key areas to enhance financing, strengthen policy and improve service delivery for these vulnerable groups. Important interventions include exclusive breastfeeding and other feeding practices for improved child survival and nutrition, and integrated care for HIV/ AIDS (including prevention of mother-to-child transmission of HIV – PMTCT). A related initiative aims to eliminate new paediatric HIV infections and to improve the health and survival of HIV-positive mothers and their infants by 2015. To achieve this, UNAIDS calls for scaling-up access to and the use of quality regimens and services for PMTCT, in-
cluding through breastfeeding, ensuring mothers have continued access to HIV treatment, scaling up access to sexual and reproductive health services and protection of reproductive rights for women and their partners. Prevention of HIV transmission through breastfeeding should be considered against a backdrop of promoting appropriate feeding for all infants and young children, as set out in the Global Strategy for Infant and Young Child Feeding (2 ). The aim of infant feeding practices in the context of HIV should be not just the prevention of HIV transmission but also ensuring the health and survival of infants – referred to as HIV-free survival. The operational objectives of this Strategy include: ensuring that exclusive breastfeeding for six months is protected, promoted and supported, with continued breastfeeding up to two years or beyond; promoting timely, adequate, safe and appropriate complementary feeding; and providing guidance on feeding infants and young children in exceptionally difficult circumstances, including for infants of HIV-positive women.
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These and other global initiatives require additional investments in the expansion of maternal and child health services including nutrition programmes, and strengthening
links between the various relevant services for both the general population and HIV-positive mothers and their infants, in the Countdown to 2015.
Infant feeding and child survival
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he global recommendation for infant and young child feeding to ensure optimal health and development is that an infant should be breastfed exclusively1 for the first six months of life, with adequate and safe complementary foods from that time and continued breastfeeding up to two years of age or beyond. Breastfeeding, especially early initiation2 and exclusive breastfeeding, is one of the most critical factors in improving child survival. Any breastfeeding (either exclusive or partial) compared to lack of breastfeeding has been shown to protect children by significantly reducing the risk of malnutrition and serious infectious diseases, especially in the first year of life (3 ). Exclusive breastfeeding in the first
months appears to offer greater protection against disease (4 ), especially in low- and middle-income countries where 35% of all under-five deaths are associated with malnutrition (5 ). Not breastfeeding during the first two months of life is also associated, in resource-poor countries, with a six-fold increase in mortality due to infectious diseases (3 ). This finding most likely underestimates the benefits that exclusive breastfeeding has in lowering mortality, because sub-Saharan Africa was not represented in the study, and it compared breastfeeding with no breastfeeding rather than exclusive breastfeeding with no breastfeeding.
Breastfeeding and HIV-free survival3
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nfant feeding in the context of HIV has been a controversial issue until recently. The World Health Organization’s (WHO) 2010 recommendations (6 ) represent a turning point in terms of policy advances and clarity, and should lead to far fewer HIV infections and deaths in infants and young children. In 2009, an estimated 2.5 million children under 15 years of age were living with HIV/
AIDS (2.3 million in sub-Saharan Africa), and 370 000 children were newly infected with HIV through mother-to-child transmission (7 ). Over 1,000 children are newly infected with HIV every day, and of these more than half will die as a result of AIDS because of a lack of access to HIV treatment. In the absence of interventions, 15–25% of HIV-positive mothers who do not breast-
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Exclusive breastfeeding means that an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, mineral supplements or medicines. 2 Initiation of breastfeeding within one hour of birth. 3 HIV-free survival means that young children are both alive and HIV-uninfected at a given point in time, usually measured at 18 months. This composite measure takes into account that the intention of interventions is to both prevent HIV transmission through breastfeeding, while at the same time ensuring that mortality among these children does not increase because of avoidance of, or modifications to, breastfeeding practices. 1
feed will infect their infants during pregnancy or delivery. With breastfeeding, there is an absolute increase in transmission of about 5–20%. Available interventions that reduce transmission during pregnancy and delivery mean that the relative proportion of infants infected through breastfeeding is now higher. If gains in HIV-free survival are to be achieved, implementation of the new recommendations on HIV and infant feeding is needed urgently. Avoidance of breastfeeding eliminates the risk of HIV transmission, but is detrimental in terms of child survival. Increased infant morbidity and mortality associated with re placement feeds have been reported in several sub-Saharan African countries (8–17 ). Improved HIV-free survival has been reported in HIV-exposed infants when breastfed in similar settings, especially when exclusively breastfed, compared with mixed feeding1 or replacement feeding2 (18–19 ). Only in a few better-resourced countries and settings have outcomes been comparable (20–23 ). Exclusive breastfeeding during the first months of life carries less risk of HIV transmission than mixed feeding, affords considerable protection against infectious diseases, and provides other benefits. In a study in South Africa, infants who were exclusively breastfed were half as likely to be HIV infected by six
months of age compared to infants who were also given formula milk (7 ). Other studies have also demonstrated that exclusive breastfeeding carries a lower risk than all types of mixed feeding (19 ). The most compelling recent evidence concerns the use of antiretrovirals (ARVs) to greatly reduce the risk of HIV transmission through breastfeeding, while simultaneously ensuring the mother receives appropriate care. If an HIV-positive mother breastfeeds her infant while taking ARVs herself or giving ARVs to her infant each day, the risk of transmission over 6 months of breastfeeding is reduced to about 2%. If she breastfeeds for 12 months while taking ARVs or giving them to the infant, then the risk is about 4%. Without these ARV interventions, about 14–17% of breastfed infants of HIV-positive mothers would become HIV infected by 18 months of age (24 ). Women whose severity of disease makes them eligible for antiretroviral treatment for their own health are also most at risk of infecting their infants. The new evidence and recommendations therefore have profound implications for child survival. In addition, the health benefits to these women of starting lifelong treatment will improve their lives and enable them to better to care for their children beyond the breastfeeding period.
2010 Recommendations on infant feeding and HIV
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nfant feeding practices recommended to mothers known to be HIV-positive should support the greatest likelihood of HIV-free survival of their children and not harm the health of mothers. To achieve this, the obligation to prevent HIV transmission needs to be balanced with meeting the nutritional requirements and protection of infants against non-HIV morbidity
and mortality, and at the same time ensuring that the mothers receive appropriate HIV care and support including ARVs. Recommendations for feeding an infant whose mother is HIV-positive were modified in 2010 (6 ) to reflect the significant new evidence and knowledge regarding ARVs and breastfeeding, and to synchronize with revised
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Breastfeeding while also receiving water-based drinks, food-based fluid, semi-solid or solid food or non-human milk (also called partial breastfeeding). Giving any non-human milk with the exclusion of all breast milk, with or without other liquids or solids.
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recommendations on treating HIV (25 ) and on PMTCT (26 ). The revisions capitalize on the maximum benefit of breastfeeding to improve the infant’s chances of survival while reducing the risk of HIV transmission, and are based on the assumption that HIV-positive mothers will either receive lifelong ARV treatment to improve their own health, or if not eligible for treatment, the mother or infant will take ARVs as prophylaxis while breastfeeding.1 Significant changes have been made in the 2010 HIV and infant feeding recommendations, to reflect the wider use of ARVs, including:
fants are receiving ARVs) should exclusively breastfeed their infants for 6 months and continue breastfeeding until 12 months of age and only then consider stopping. In the past, mothers were recommended to exclusively breastfeed for six months and then stop breastfeeding completely as soon as they could provide an adequate and safe diet to the infant without breast milk. n The way in which national authorities implement these recommendations should depend on a careful assessment taking into account major factors including HIV prevalence, background infant and child mortality rates, current infant and young child feeding practices and nutritional status of infants, availability of clean water and sanitation, socio-economic status of the population and quality of health services, including provision of interventions for PMTCT. The Guidelines continue to highlight the importance of avoiding mixed feeding, to reduce the risk of HIV transmission and to avoid diarrhoea and malnutrition. Similarly, the Guidelines acknowledge that there are countries, namely those with low infant and child mortality rates, where replacement feeding may remain the best strategy to promote HIV-free survival among HIV-exposed infants.
n National health authorities are encouraged to recommend one infant feeding practice for HIV-positive mothers to be promoted and supported by maternal, newborn and child health services. In the past, health workers were expected to individually counsel all HIV-positive mothers about various infant feeding options so that the mothers could decide what was best for their infants given their circumstances. WHO is now explicit that health authorities should endorse either breastfeeding while receiving ARVs (to the mother or infant), or avoidance of all breastfeeding. Mothers will still need on-going counselling and support to optimally feed their infant. n WHO recommends that women who breast feed and receive ARVs (or whose in-
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Full details of the guidance are available at: http://www.who.int/child_adolescent_health/documents/9789241599535/en/, accessed 12 July 2011.
Priority actions for governments
Develop or revise (as appropriate) a comprehensive evidence-based national infant and young child feeding policy which includes HIV and infant feeding
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n relation to the special circumstances created by HIV/AIDS, five priority actions for national governments are proposed in the context of the Global Strategy for Infant and Young Child Feeding :
Promote and support appropriate infant and young child feeding practices, taking advantage of the opportunity of implementing the revised guidelines on HIV and infant feeding
n Develop or revise (as appropriate) a comprehensive evidence-based national infant and young child feeding policy which includes HIV and infant feeding Actions required: • Assess the current causes of morbidity and mortality in children under five in the context of HIV. • Inform and build consensus among all relevant stakeholders on the infant and young child feeding policy as it relates to HIV. • After a careful assessment of the situation within the country (as outlined above), decide whether health services will principally counsel and support mothers known to be HIVpositive to either: breastfeed while receiving ARV interventions OR avoid all breastfeeding as the strategy that will give infants the greatest chance of HIV-free survival; include in the policy a clear statement of the decision. • Draft or update policy to reflect current evidence and experience on appropriate infant and young child feeding practices in general, as well as specifically in relation to HIV. • Review other relevant policies, such as those on national HIV/AIDS programmes, nutrition, integrated management of childhood illness, safe motherhood, PMTCT, and feeding in emergencies, and ensure consistency with the overall infant and young child feeding policy. • Develop concrete plans for implementing the policy, scaling up and sustaining it, including assessing the costs and resources, especially human resources, required to do so. • Monitor policy implementation. • Establish mechanisms for learning from experience and revising policy and resulting guidance as needed.
Provide adequate support to HIVpositive women to enable them to success-fully carry out the recommended infant feeding practice, including ensuring access to antiretroviral treatment or prophylaxis
Develop and implement a communication strategy to promote appropriate feeding practices aimed at decision-makers, health workers, civil society, community workers, mothers and their families
Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (the Code)
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n Promote and support appropriate infant and young child feeding practices, taking advantage of the opportunity of implementing the revised guidelines on HIV and infant feeding Actions required: • Advocate for the prioritization of infant and young child feeding issues in national planning, both inside and outside the health sector. • Develop or update and implement guidelines on infant and young child feeding, including feeding for infants of HIV-positive women. • Facilitate coordination on infant and young child feeding issues in implementing national HIV/AIDS programmes, especially as regards ARVs for pregnant and lactating women, as well as for integrated management of childhood illness, safe motherhood, and other approaches. • Build capacity of health care decisionmakers, managers, workers and, as appropriate, peer counsellors, lay counsellors and support groups for promoting breastfeeding and complementary feeding, good nutrition for pregnant and lactating women, primary prevention of HIV, use of ARVs for preventing HIV through breastfeeding, and for dealing with HIV and infant feeding. • Assess and/or reassess health facilities for designation as Baby friendly and extend the Baby-friendly Hospital Initiative concept beyond hospitals, including through the establishment of breastfeeding support groups, and making provisions for expansion of activities to prevent HIV transmission to infants and young children to go hand-in-hand with promotion of the Initiative’s principles. • Ensure consistent application of recommendations on HIV and infant feeding in emergency situations, recognizing that the environmental risks associated with replacement feeding may be increased in these circumstances. • Consult with communities to increase know ledge and develop community capacity for acceptance, promotion and support of appropriate infant and young child feeding practices. • Provide guidance for other sectors on legislation and related national measures.
n Provide adequate support to HIVpositive women to enable them to successfully carry out the recommended infant feeding practice, including ensuring access to antiretroviral treatment or prophylaxis Actions required: • Expand access to, and demand for, quality antenatal care for women who currently do not use such services. • Expand access to, and demand for, HIV testing and counselling, before and during pregnancy and lactation, to enable women and their partners to know their HIV status, know how to prevent HIV and sexually transmitted infections and be supported in decisions related to their own behaviours and their children’s health, and where required, access maternal nutritional support. • Provide access to CD4 count testing and antiretroviral treatment or prophylaxis to HIVpositive women and their HIV-exposed infants according to international guidelines to ensure mothers’ health and PMTCT. • Revise pre-service and in-service training and related materials to reflect updated national policy and international recommendations. • Support the orientation of health-care managers and capacity-building and preservice training of counsellors (including lay counsellors) and health workers on infant and young child feeding in the context of HIV, including being able to understand and support the national recommendation while supporting mothers who make other decisions. • Improve follow-up, supervision and support of health workers to sustain their skills and the quality of counselling, and to prevent ‘burn-out’. • Integrate adequate HIV and infant feeding counselling and support into maternal and child health services. • Develop community capacity to help HIVpositive mothers carry out recommended infant feeding practices, including the involvement of trained support groups, lay counsellors and other volunteers, and encourage the involvement of family members, especially fathers.
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n Develop and implement a communication strategy to promote appropriate feeding practices aimed at decision-makers, health workers, civil society, community workers, mothers and their families Actions required: • Carry out relevant formative research, emphasizing finding approaches to modify unhelpful perspectives of health workers, community members and others on infant feeding. • Use findings from formative research to develop a communication strategy, tools and messages • Promote interventions to reduce stigmatization and increase acceptance of HIV-positive women and of recommended feeding practices. • Engage opinion leaders in communities and civil society to reinforce strategic efforts. • Develop and distribute infant feeding messages and support materials that address local beliefs and norms for mothers and communities. • Monitor implementation of the communication strategy and its impact, and update the strategy as needed.
n Implement and enforce the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (the Code)
Actions required: • Implement existing measures to give effect to the Code, and, where appropriate, strengthen and adopt new measures. • Monitor Code compliance. • Define the relevance of the Code in the context of HIV, and ensure the prevalence of HIV is not used as a pretext to misinform and undermine the Code and breastfeeding. • Ensure that the response to the HIV pandemic does not include the introduction of non Code-compliant donations of breast-milk substitutes or the promotion of breast-milk substitutes. • In countries that have decided to provide breast-milk substitutes for the infants of HIVpositive mothers (either from birth or when they stop breastfeeding), establish appropriate criteria for who should receive it, for how long, and for adequate procurement and distribution systems, in accordance with the provisions of the Code in order to protect breastfeeding and avoid spill over of breast-milk substitutes to the general population. • Ensure that the conduct of manufacturers and distributors at every level conforms to the Code. • Ensure that financial support and other incentives for programmes and health professionals working in infant and young child health do not create conflicts of interest.
Role of United Nations Agencies The United Nations agencies endorsing this Framework will:
n Advocate the priority courses of action described above with global and regional advisory bodies and national governments. Through their global, regional and country offices and United Nations Theme Groups on HIV, United Nations agencies will disseminate this Framework and encourage responses that are in accordance with its guidance.
n Convene technical consultations on this Framework, and provide governments and other stakeholders with technical guidance, information on best practices, model guidelines and tools related to HIV and infant feeding. n Assist countries in mobilizing resources to carry out these priority actions. 7
n Support capacity development related to HIV and infant feeding for policy-makers, managers, health workers and counsellors.
n Continue to promote a model of integration between HIV, maternal and child health and nutrition programmes.
Challenges
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he overall goal is to improve feeding for all infants and young children, regardless of their mother’s HIV status. Making a positive difference is often very difficult in an environment where poverty, food insecurity, maternal and child malnutrition, poor communication and high disease rates prevail. In this context, one of the greatest challenges in the area of HIV and infant feeding is to communicate clearly and simply the evidence and field experience to decision-makers, health workers and counsellors, and for governments to ensure that they adopt and implement appropriate national recommendations aimed at the greatest likelihood of child survival for all.
The health worker plays a central role in building the confidence of mothers, including HIV-positive mothers, on how to feed their babies. With only a few health workers having the correct knowledge and counselling skills to do this work efficiently, addressing this competency gap remains a major challenge. Simultaneously, governments and agencies are expected to respond to the need to move quickly on priority actions, especially the rapid scale-up of ARV interventions to mothers who need them. The difficulties in implementing actions in countries with weak health systems should not be underestimated.
Conclusion
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romoting improved infant and young child feeding practices among all women, irrespective of HIV status, brings substantial benefits to individuals, families and societies. Implementing the priority actions described in this Framework will contribute to achieving governmental commitment to increase child survival, while enhancing support for breastfeeding among the general population and promoting the attainment of related MDGs. Where a government decides to endorse breastfeeding with ARV interventions for HIVpositive mothers, the new recommendations
simplify public health messages and give the opportunity to strengthen infant and young child feeding in the entire population. Recent evidence on ARVs for the prevention of mother-to-child HIV transmission through breastfeeding has transformed the infant feeding environment. There is now adequate knowledge of appropriate programme responses to support HIV-positive mothers and their exposed children to breastfeed. The stage is set for an acceleration of actions for a scaled-up response using this Framework.
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References 1. United Nations. Global strategy for women’s and children’s health. New York, United Nations, 2010. 2. WHO. Global strategy for infant and young child feeding. Geneva, WHO, 2002. 3. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: A pooled analysis. Lancet, 2000; 355:451–5. 4. Victora CG et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet, 1987; 319–322. 5. Black RE et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 2008, 371: 243–260. 6. WHO. Guidelines on HIV and infant feeding: principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Geneva, WHO, 2010. 7. UNAIDS. UNAIDS Report on the Global AIDS epidemic. Geneva, UNAIDS, 2010. 8. Coovadia HM et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet, 2007, 369(9567):1107– 1116. 9. Creek TL et al. Hospitalization and mortality among primarily nonbreastfed children during a large outbreak of diarrhea and malnutrition in Botswana, 2006. Journal of Acquired Immune Deficiency Syndromes, 2010, 53(1):14–19. 10. Doherty T et al. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS, 2007, 21(13):1791–1797. 11. Homsy J et al. Breastfeeding, mother-to-child HIV transmission, and mortality among infants born to HIV-Infected women on highly active antiretroviral therapy in rural Uganda. Journal of Acquired Immune Deficiency Syndromes, 2010, 53(1):28–35. 12. Jackson DJ et al. Operational effectiveness and 36 week HIV-free survival in the South African programme to prevent mother-to-child transmission of HIV-1. AIDS, 2007, 21(4):509–516. 13. Kagaayi J et al. Survival of infants born to HIVpositive mothers, by feeding modality, in Rakai, Uganda. Public Library of Science ONE, 2008, 3(12):e3877. 14. Kafulafula G et al. Frequency of gastroenteritis and gastroenteritis-associated mortality with early weaning in HIV-1-uninfected children born to HIV-infected women in Malawi. Journal of Acquired Immune Deficiency Syndromes, 2010, 53(1):6–13. 15. Onyango-Makumbi C et al. Early Weaning of HIV-Exposed Uninfected Infants and risk of serious gastroenteritis: findings from two perinatal HIV prevention trials in Kampala, Uganda. Journal of Acquired Immune Deficiency Syndromes, 2010, 53(1):20–27. 16. Phadke MA et al. Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization. Journal of Nutrition, 2003, 133(10):3153–3157. 17. Thior I et al. Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study. Journal of the American Medical Association, 2006, 296(7):794–805. 18. Rollins NC et al. Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes. AIDS, 2008, 22(17):2349– 2357. 19. Iliff PJ et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS, 2005, 19(7):699–708. 20. Becquet R et al. Two-year morbidity-mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Cote d’Ivoire. Public Library of Science Medicine, 2007, 4(1):e17. 21. Becquet R et al. Two-year morbidity and mortality in breastfed and formula-fed children born to HIV-infected mothers, ANRS 1201/1202 Ditrame plus, Abidjan, Côte d’Ivoire. Abstract TUPE0350, XVI International AIDS Conference, Toronto, Canada, 13–18 August 2006. 22. Becquet R et al. Duration, pattern of breastfeeding and postnatal transmission of HIV: pooled analysis of individual data from West and South African cohorts. Public Library of Science ONE, 2009, 4(10):e7397. 23. UNICEF et al. Report of the United Nations Regional Task Force on prevention of mother-to-child transmission of HIV, Southeast Asia and the Pacific. Bangkok, UNICEF, August 2003. 24. UNAIDS Reference Group on Estimates, Modelling and Projections. Working Paper on Mother-to-Child HIV Transmission Rates for use in Spectrum, 6 June 2011, available at http://www. epidem.org/Publications/MTCTratesworkingpaper.pdf, accessed 13 July 2011. 25. WHO. Antiretroviral therapy for HIV-infection in adults and adolescents: Recommendations for a public health approach. Geneva, WHO, 2010. 26. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Recommendations for a public health approach. Geneva, WHO, 2010.
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nfant feeding practices recommended to mothers known to be HIV-positive should support the greatest likelihood of HIV-free survival of their children and not harm the health of mothers. To achieve this, the obligation to prevent HIV transmission needs to be balanced with
meeting the nutritional requirements and protection of infants against non-HIV morbidity and mortality. The purpose of this HIV and Infant Feeding Framework for Priority Action is to recommend to governments key actions, related to infant and young child feeding, that cover the special circumstances associated with HIV/AIDS. The aim of these actions is to create and sustain an environment that encourages appropriate feeding practices for all infants, while scalingup interventions to reduce HIV transmission, notably the provision of antiretrovirals to pregnant and lactating HIV-positive women and their infants. The audience of the Framework includes national policymakers, programme managers, regional advisory bodies, Country Coordination Mechanisms, United Nations staff, professional bodies, non-governmental organizations and other interested stakeholders, including the community. This Framework has been developed as a collaborative effort between all the United Nations agencies whose logos appear on the cover. For further information, contact the Department of Maternal, Newborn, Child and Adolescent Health (cah@who.int), HIV/AIDS (hiv-aids@who.int) or Nutrition for Health and Development (nutrition@who.int).