"Why Aren't You Breastfeeding?": How Mothers Living With HIV Talk About Infant Feeding in a "Breast Is Best" World

Infant feeding knowledge among women living with HIV and their interaction with healthcare providers in a high-income setting: a longitudinal mixed methods study

BACKGROUND

Recent changes in the infant feeding guidelines for women living with HIV from high-income countries recommend a more supportive approach focusing on shared decision-making. Limited information is available on the infant feeding knowledge of women living with HIV and how healthcare providers engage with them in this context. This multicenter, longitudinal, mixed methods study aims to get a comprehensive and nuanced understanding of infant feeding knowledge among women living with HIV of Nordic and non-Nordic origin living in Nordic countries, and their interaction with healthcare providers regarding infant feeding planning.

METHODS

Pregnant women living with HIV in Denmark, Finland, and Sweden were recruited in 2019-2020. The Positive Attitudes Concerning Infant Feeding (PACIFY) questionnaire was completed in the 3rd trimester (T1), three (T2), and six (T3) months postpartum. Women who completed the quantitative survey were also invited to participate in qualitative semi-structured interviews at T1 and T3. Results from the survey and interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the datasets and to draw meta-inferences.

RESULTS

In total, 44 women living with HIV completed the survey, of whom 31 also participated in the interviews. The merged analyses identified two overarching domains: Knowledge about breastfeeding in the U = U era and Communications with healthcare providers. The women expressed confusion about breastfeeding in the context of undetectable equals untransmittable (U = U). Women of Nordic origin were more unsure about whether breastfeeding was possible in the context of U = U than women of non-Nordic origin. Increased postpartum monitoring with monthly testing of the mother was not seen as a barrier to breastfeeding, but concerns were found regarding infant testing and infant ART exposure. Infant feeding discussions with healthcare providers were welcome but could also question whether breastfeeding was feasible, and many participants highlighted a need for more information.

CONCLUSIONS

Healthcare providers caring for women living with HIV must have up-to-date knowledge of HIV transmission risks during breastfeeding and engage in shared decision-making to optimally support infant feeding choices.

Modelling the role of tourism in the spread of HIV: A case study from Malaysia

This study aimed to assess the role of tourism in the spread of human immunodeficiency virus (HIV) using Malaysian epidemiological data on HIV and acquired immunodeficiency syndrome (AIDS) incidence from 1986 to 2004. A population-level mathematical model was developed with the following compartments: the population susceptible to HIV infection, the clinically confirmed HIV-positive population, the population diagnosed with AIDS, and the tourist population. Additionally, newborns infected with HIV were considered. Sensitivity analyses and variations in fixed parameter values were used to explore the effect of changes to various parameter values on HIV incidence in the model. It was determined that variations in the rate of HIV-positive inbound tourist entries and the rate of foreign tourist exits (i.e., the duration of time tourists spent in Malaysia) significantly impacted the predicted incidence of HIV and AIDS in Malaysia. The model's fit to observed HIV and AIDS incidence was evaluated, resulting in adjusted R2 values of 53.3% and 53.2% for HIV and AIDS, respectively. Furthermore, the reproduction number (R0) was also calculated to quantify the stability of the HIV endemicity in Malaysia. The findings suggest that a steady-state level of HIV in Malaysia is achievable based on the low value ofR 0  = 0.0136, and the disease-free equilibrium was stable from the negative eigenvalues obtained, which is encouraging from a public health perspective. The Partial Rank Correlation Coefficient (PRCC) values between the proportion of newborns born HIV-positive, the rate of Malaysian tourist entries returning home after contracting HIV, and the rate of foreign tourist exits have a significant impact on theR 0 . The methods provide a framework for epidemiological modelling of HIV spread through transient population groups. The model results suggest that the role of tourism should not be overlooked within the set of available measures to mitigate the spread of HIV.

How women living with HIV in the UK manage infant-feeding decisions and vertical transmission risk - a qualitative study

BACKGROUND

The World Health Organization (WHO) recommends that women with HIV breastfeed for a minimum of one year. In contrast, across high-income countries, HIV and infant-feeding guidelines recommend exclusive formula feeding if parents want to avoid all risk of postpartum transmission. However, recently these guidelines (including in the United Kingdom (UK)) increasingly state that individuals with HIV should be supported to breast/chest feed if they meet certain criteria; such as an undetectable maternal HIV viral load and consent to additional clinical monitoring. Between 600 and 800 pregnancies are reported annually in women with HIV in the UK, with low rates of vertical transmission (0.22%). Informed infant-feeding decision-making requires clinical support. Currently, little research addresses how individuals with HIV in high-income countries navigate infant-feeding decisions with their clinical teams and familial and social networks, and the resources needed to reach an informed decision.

METHODS

Semi-structured remote interviews were conducted between April 2021 - January 2022 with UK-based individuals with a confirmed HIV diagnosis who were pregnant or one-year postpartum. Using purposive sampling, pregnant and postpartum participants were recruited through NHS HIV clinics, community-based organisations and snowballing. Data were analysed thematically and organised using NVivo 12.

RESULTS

Of the 36 cisgender women interviewed, 28 were postpartum. The majority were of Black African descent (n = 22) and born outside the UK. The majority of postpartum women had chosen to formula feed. Women's decision-making regarding infant-feeding was determined by (1) information and support; (2) practicalities of implementing medical guidance; (3) social implications of infant-feeding decisions.

CONCLUSION

The evolution of UK HIV and infant-feeding guidelines are not reflected in the experiences of women living with HIV. Clinicians' emphasis on reducing the risk of vertical transmission, without adequately considering personal, social and financial concerns, prevents women from making fully informed infant-feeding decisions. For some, seeking advice beyond their immediate clinical team was key to feeling empowered in their decision. The significant informational and support need among women with HIV around their infant-feeding options must be addressed. Furthermore, training for and communication by healthcare professionals supporting women with HIV is essential if women are to make fully informed decisions.

Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission

OBJECTIVE

This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations.

TARGET POPULATION

Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant.

OUTCOMES

Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV.

BENEFITS, HARMS, AND COSTS

The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission.

EVIDENCE

Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV.

SOCIAL MEDIA SUMMARY

Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report

Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.

The Mental Health Effects and Experiences of Breastfeeding Decision-Making Among Postpartum Women Living with HIV

Prior to January 2023, women living with HIV (WLWH) in the United States (US) were discouraged from breastfeeding due to the potential risk of mother-to-child HIV transmission through breastfeeding. Lack of breastfeeding decision-making and experience among WLWH may negatively affect maternal mental health. We implemented a quality improvement initiative to screen WLWH for postpartum depression (PPD), evaluate their attitudes toward breastfeeding, and assess their experience with breastfeeding decision-making. We collected quantitative data from WLWH using a voluntary, self-administered 6-item breastfeeding decision-making and experience survey (administered 1 month postpartum) and a 10-item Edinburgh Postnatal Depression Scale (EPDS, negative = 0-9; administered 1 and 4 months postpartum) tool. We conducted descriptive statistics and cross tabulation analysis. We analyzed 106 WLWH (93.4% non-Hispanic Black/African American; mean age 33.1 years; 82.1% HIV RNA < 200 copies/mL). One in five (19.1%) WLWH had a positive baseline EPDS screen, with the mean EPDS scores decreasing from 5.3 ± 5.4 (baseline) to 4.6 ± 4.8 (follow-up). Among 55 WLWH who provided baseline and follow-up EPDS scores, only 3/13 with a positive baseline EPDS screen had resolved depressive symptoms at follow-up. Over one-third (37.7%) of WLWH indicated feeling "sadness" when asked whether lack of breastfeeding negatively affected their feelings or emotions. Over half of WLWH (51.9%) were aware of the US breastfeeding recommendations, but the majority (60.4%) had never discussed breastfeeding options with a medical provider. Improved provider-patient discussions on infant feeding options among WLWH is needed to increase awareness of breastfeeding choices and promote informed, autonomous breastfeeding decision-making among WLWH.

Perception and Emotional Experiences of Infant Feeding Among Women Living With HIV in a High-Income Setting: A Longitudinal Mixed Methods Study

BACKGROUND

The recommendation of breastfeeding avoidance for women living with HIV in high-income settings may be influenced by cultural beliefs and come at an emotional cost. This multicenter, longitudinal, convergent mixed methods study aimed to compare differences in attitudes, concerns, and experiences surrounding breastfeeding in women living with HIV of Nordic and non-Nordic origin.

SETTING

High-income setting.

METHODS

Pregnant women living with HIV in the Nordic countries Denmark, Finland, and Sweden were recruited in 2019-2020. Quantitative data on attitudes surrounding infant feeding were assessed using the Positive Attitudes Concerning Infant Feeding questionnaire completed in the third trimester (T1), and 3 (T2) and 6 (T3) months postpartum. Women who completed the survey were also invited to participate in semistructured interviews at T1 and T3. The findings from the quantitative survey and qualitative interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the data sets and to draw metainferences.

RESULTS

In total, 44 women completed the survey, of whom 31 also participated in qualitative interviews. The merged analyses identified three overarching domains representing commonalities across the quantitative and qualitative data: emotional impact, justifying not breastfeeding, and coping strategies. Not being able to breastfeed was emotionally challenging. Cultural expectations influenced the women's experiences and the strategies they used to justify their infant feeding choice.

CONCLUSIONS

For women living with HIV in Nordic countries not breastfeeding was a complex, multilayered process substantially influenced by social and cultural expectations.

Practices, support and stigma related to infant feeding and postpartum engagement in care among women living with HIV in Canada

Background: Breastfeeding is not recommended for women living with HIV (WLWH) in Canada. We described the prevalence of breastfeeding and explored experiences of care, support, and stigma related to infant feeding. Setting: Quebec, Ontario, and British Columbia (Canada). Methods: Data were obtained from the HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) surveys, conducted between 2013 and 2018. Results: Breastfeeding was reported by 73.5% of the 786 women who delivered before HIV diagnosis and 7.3% of the 289 women who delivered after HIV diagnosis. Among them, earlier year of delivery, delivery outside of Canada, and African, Caribbean, Black ethnicity were independently associated with increased odds of breastfeeding. Among WLWH who had a live birth during the last year, 77% (40/52) felt that they had received support regarding infant feeding practices, and 77% (23/30) were concerned that not breastfeeding could lead to them being identified as WLWH. Among 71 women within one year postpartum at any one of the study waves, 89% reported having an undetectable viral load. Conclusion: Breastfeeding experiences were common among WLWH, most often prior to HIV diagnosis. Fear of unintentional HIV status disclosure when not breastfeeding and challenges to maintain an undetectable HIV viral load are important issues to address during postpartum care.

Breastfeeding Among People With Human Immunodeficiency Virus in North America: A Multisite Study

BACKGROUND

In North American countries, national guidelines have strongly recommended formula over breastmilk for people with human immunodeficiency virus (HIV) because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is <1% among virally suppressed people. Information regarding breastfeeding experience in high-resource settings is lacking.

METHODS

A retrospective multisite study was performed for individuals with HIV who breastfed during 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis.

RESULTS

Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range, 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available ≥6 weeks after weaning.

CONCLUSIONS

This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients with HIV who chose to breastfeed at any 1 location, and the need for further multisite studies to identify best care practices.

Women's Experiences of Infant Feeding Practices While Living With HIV in Malaysia: A Community-Based Qualitative Study

BACKGROUND

With the advancement of antiretroviral therapy scale-up, it is possible for women living with HIV to breastfeed safely. However, this practice has not been adopted in Malaysia. Instead, infants are provided with subsidized human milk substitutes for their first 2 years of life.

RESEARCH AIM

This study describes the infant feeding experiences of women living with HIV in Malaysia.

METHODS

From August to October 2021, a nationwide, community-based qualitative study was conducted among women living with HIV and who received care from the Malaysian Ministry of Health. Using purposive sampling, participants who met the inclusion criteria were recruited. Interview and focus group transcripts were coded based on a secondary thematic analysis.

RESULTS

Six in-depth interviews and five focus group discussions were conducted among 32 participants. Study participants were mostly Malay secondary school graduates in their 30s and 40s. Due to the fear of vertical transmission, which was explained by healthcare providers to the participants, none of the women breastfed their infants. The three primary themes that emerged from analyzing the women's infant feeding experiences were (1) a human milk substitute was the only option and was encouraged; (2) feeding infants with a human milk substitute made the women feel incomplete as mothers; and (3) the women encountered difficulties in obtaining the subsidized human milk substitute.

CONCLUSION

Women living with HIV in Malaysia have been advised to provide human milk substitutes to their infants in fear of HIV transmission.

"Go With the Flow": A Qualitative Description of Infant Feeding Experiences Among Women With HIV in the United States

ABSTRACT

Breastfeeding affords numerous health benefits to mothers and children, but for women with HIV in the United States, avoidance of breastfeeding is recommended. Evidence from low-income countries demonstrates low risk of HIV transmission during breastfeeding with antiretroviral therapy, and the World Health Organization recommends exclusive breastfeeding and shared decision making about infant feeding options in low-income and middle-income countries. In the United States, gaps in knowledge exist surrounding the experiences, beliefs, and feelings of women with HIV surrounding infant feeding decisions. Undergirded by a framework of person-centered care, this study describes the experiences, beliefs, and feelings of women with HIV in the United States surrounding recommendations for breastfeeding avoidance. Although no participants reported consideration of breastfeeding, multiple gaps were identified with implications for the clinical care and counseling of the mother-infant dyad.

Exploring the Breastfeeding Desires and Decision-Making of Women Living with HIV in the Netherlands: Implications for Perinatal HIV Management in Developed Countries

Introduction: Guidelines in high-income countries recommend women living with human immunodeficiency virus (HIV) to formula feed their newborns, because the possibility of mother-to-child-transmission of HIV during breastfeeding cannot be ruled out. It is an ongoing debate if the possible transmission risk outweighs the medical, cultural, psychological, and social importance of breastfeeding in women stable on current first-line suppressive antiretroviral regimens. The study aim was to explore breastfeeding desires and decision-making of immigrant and nonimmigrant women living with HIV in the Netherlands. Method: A questionnaire was administered orally or online to 82 women living with HIV in the Netherlands. The breastfeeding desires of the participants were collected as categorical data, and breastfeeding decision-making and willingness to adhere to additional monitoring were collected on a 5-point Likert scale. Categorical data were presented as proportions, and Likert scale data were presented in Likert scale bar plots. Results: Seventy-one percent of the participants expressed a desire to breastfeed in the future. The most important factors influencing decision-making to breastfeed were the chance of transmission of HIV to the infant and the advice by the doctor or nurse practitioner. Of the participants, 42% expressed their interest in breastfeeding with a <1/100 transmission risk. More than half of the participants expressed their interest to breastfeed with additional monitoring. Conclusions: A substantial proportion of the women living with HIV in the Netherlands has a desire to breastfeed, of which the majority are willing to adhere to additional monitoring to do so.

Antiretroviral Options and Treatment Decisions During Pregnancy

The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.

Canadian Paediatric and Perinatal HIV/AIDS Research Group consensus recommendations for infant feeding in the HIV context

Background:

Providing comprehensive infant feeding guidance to families affected by HIV is complex and requires a multidisciplinary approach. While exclusive formula feeding remains the preferred recommendation for infants born to women living with HIV (WLWH) in high-income countries, a more nuanced approach that may include the option of breastfeeding under certain circumstances is emerging in many resource-rich countries.

Methods:

The Canadian Paediatric & Perinatal HIV/AIDS Research Group (CPARG) hosted a Canadian Institute of Health Research-funded meeting in 2016 to develop consensus among multidisciplinary providers around counselling and recommendations for infant feeding. After presentations by adult and pediatric health care providers, basic scientists, and community-based researchers, a subgroup drafted summary evidence-informed recommendations. Along with revisions among CPARG members, a community review was performed by a convenience sample of WLWH who had given birth in the past 5 years from Ontario and Quebec. A legal review was also conducted to ensure understanding of the criminalization potential and concern of HIV transmission and exposure.

Results:

The Canadian consensus guidelines continue to support formula feeding as the preferred method of infant feeding as it eliminates any residual risk of postnatal vertical transmission. Formula should be made available for all infants born to mothers living with HIV for their first year of life. A comprehensive approach to counselling WLWH is outlined to assist providers to effectively counsel on current evidence to ensure WLWH are fully informed in their decision making. For women meeting criteria to and elect to breastfeed, frequent maternal virologic monitoring, and follow-up is required of both mother and infant. Antiretroviral prophylaxis and monitoring are recommended for breastfed infants. The community review highlighted the importance of other supports and counselling needed for implementing effective formula feeding, aside from access to formula. The legal review provided clarifying language around child protection services involvement and the need to provide referral to legal resources or information upon request. Surveillance systems to monitor for cases of breastmilk transmission should be in place to improve gaps in care and develop further knowledge in this area.

Conclusion:

The Canadian infant feeding consensus guideline is designed to inform and enable better care for WLWH and their babies. Ongoing evaluation of these guidelines as new evidence emerges will be important.

Being a Black Mother Living with HIV Is a “Whole Story”: Implications for Intersectionality Approach

While African, Caribbean, and Black (ACB) mothers living with HIV in Canada are required to follow public health guidelines by exclusively formula feeding their infants, they also face cultural expectations from peers and family members to breastfeed. They face multiple challenges because of their race, ethnicity, gender, class, and geographical location, among other factors. Previously published studies on this subject did not analyze how the intersectionality of these factors impacts Black mothers’ infant feeding experiences. In this article, we discuss the infant feeding practices of Black mothers living with HIV in Ottawa (Canada). We followed a qualitative methods research design that utilized intersectionality and a community-based participatory research approach. We used the intersectionality framework as a lens to analyze the complex mesh of determinants influencing motherhood experiences of ACB women living with HIV. Being a Black/ACB mother while living with HIV is a “whole story” permeated with cutting-across issues such as race, class, gender, socio-political, and cultural contexts. These issues are interwoven and often difficult to unravel. Multiple layers of structural determinants of Black/ACB women’s HIV vulnerability and health are described. Intersectionality is important for an in-depth understanding of societal power dynamics and their impact on women’s health inequities.

HIV-related stigma among healthcare providers working within infectious diseases and gynecology and obstetrics at a large teaching hospital in Denmark

HIV-related stigma experienced in healthcare settings may be particularly detrimental to people with HIV (PWH). This study aims to examine the drivers of stigma and enacted HIV-related stigma among healthcare providers working in HIV and non-HIV care at a large teaching hospital in Denmark. In total, 162 providers working in gynecology and obstetrics, and 57 providers working in infectious diseases completed the "Measuring HIV stigma and discrimination among health facility staff" questionnaire. Compared to providers working in infectious diseases, providers working in gynecology and obstetrics had less training in infection control, HIV, and stigma, and although their level of worry and negative attitudes toward PWH was overall low, they were more like to use extra precaution measures (e.g., double gloves) when caring for PWH (20% versus 0%). Addressing HIV-related stigma in healthcare is important, as any amount of HIV-related stigma from providers has the potential to compromise the patients' engagement in care and health outcomes.

When law and science part ways: the criminalization of breastfeeding by women living with HIV

Stigma and discrimination are a constant reality for the 37.7 million people living with human immunodeficiency virus (HIV) around the globe. Fear over vertical transmission has fuelled HIV criminalization: laws that target people living with HIV for acts deemed to be a transmission risk. Research has now shown that many of these behaviours, including breastfeeding, pose an extremely low risk of transmission when people have proper medical care, access to treatment and open relationships with medical professionals. Yet, we are witnessing a wave of criminal cases against women living with HIV for breastfeeding, an act which is actively promoted worldwide as the best infant feeding strategy. In this review, we will place the criminalization of breastfeeding within the context of current medical recommendations and cultural views of breastfeeding. We will highlight the criminal cases against women living with HIV for breastfeeding around the globe and the criteria for justifiable criminalization. Finally, we will provide recommendations for moving towards decriminalization, removing this barrier to HIV prevention, treatment and care.

Determinants of infant feeding practices among Black mothers living with HIV: a multinomial logistic regression analysis

BACKGROUND

Infant feeding practices are imperative for babies' and mothers' health and emotional wellbeing. Although infant feeding may seem simple, the decisions surrounding it are complex and have far-reaching implications for women globally. This is an especially difficult concern among mothers living with HIV because breastfeeding can transmit HIV from mother to child. This is further complicated by cultural expectations in case of Black mothers living with HIV. This paper discusses determinants of infant feeding practices among Black mothers living with HIV who were on anti-retroviral therapy (ART) in two North American cites and one African city.

METHODS

A cross-sectional, multi-country survey using venue-based convenience sampling of Black mothers living with HIV was employed. The effective response rates were 89% (n = 89) in Ottawa, Canada; 67% (n = 201) in Miami, Florida, US; and 100% (n = 400) in Port Harcourt, Nigeria, equaling a total sample size of 690. Data were collected in Qualtrics and managed in Excel and SPSS. Multinomial logistic regression analyses were used to determine the factors influencing the mothers' infant feeding practices (Exclusive Formula Feeding [EFF] = 1; Mixed Feeding [MF] = 2; and Exclusive Breastfeeding [EBF while on ART] =3).

RESULTS

The results highlight socio-demographics, EFF determinants, and EBF determinants. The statistically significant determinants of infant feeding practices included national guideline on infant feeding, cultural beliefs and practices, healthcare systems, healthcare personnel, infant feeding attitudes, social support, and perceived stress. Mothers' mean ages were Ottawa (36.6 ± 6.4), Miami (32.4 ± 5.8), and Port Harcourt (34.7 ± 5.7). All sampled women gave birth to least one infant after their HIV diagnoses. Statistically significant (p < .05) determinants of EFF relative to MF were the national guideline of EFF (relative risk [RR] = 218.19), cultural beliefs (RR = .15), received healthcare (RR = 21.17), received healthcare through a nurse/midwife (RR = 3.1), and perceived stress (RR = .9). Statistically significant determinants of EBF relative to MF were received healthcare (RR = 20.26), received healthcare through a nurse/midwife (RR = 2.31), functional social support (RR = 1.07), and perceived stress (RR = .9).

CONCLUSION

While cultural beliefs and perceived stress favoured MF over EFF, advice of healthcare workers, and the care received from a nurse/midwife improved EFF over MF. Also while the mothers' perceived stress favoured MF over EBF, advice of their nurses or midwife and the social support improved EBF over MF. The providers advice was congruent with WHO and national guidelines for infant feeding among mothers living with HIV. These results have implications for nursing, healthcare practice, and policies on infant feeding practices for mothers living with HIV.

Perinatal depressive symptoms and breastfeeding behaviors: A systematic literature review and biosocial research agenda

BACKGROUND

Breastfeeding is recommended to improve maternal and infant health globally. Depression has been posited to negatively impact breastfeeding, although potential causal and bidirectional pathways between these two phenomena have not been sufficiently characterized. We therefore conducted a systematic review to critically evaluate available evidence on the relationship between perinatal depressive symptoms and breastfeeding behaviors; to identify knowledge gaps and propose a biosocial research agenda to advance our understanding of this topic.

METHODS

A systematic search strategy was applied across seven databases. Data were extracted and aggregated using the matrix method to provide a narrative synthesis of findings.

RESULTS

Thirty-eight studies from 20 countries spanning 1988 through 2018 fit the inclusion criteria. In general, methods across studies were heterogeneous. Fourteen different tools were used to measure perinatal depressive symptoms. Nearly half the studies did not provide breastfeeding definitions. No studies from low-income countries met inclusion criteria. More than half (63%) of studies demonstrated a negative association between depressive symptoms across the perinatal period and less exclusive breastfeeding and/or shorter breastfeeding durations.

LIMITATIONS

Heterogeneity in study design, definitions, assessment tools, and measurement time points limited the comparability of study findings. Causality cannot be assessed.

CONCLUSIONS

Available evidence suggests perinatal depressive symptoms negatively associated with breastfeeding exclusivity and duration, which can lead to suboptimal infant nutrition and detrimental impacts on maternal mental and physical health. To better understand this relationship, we propose including consistent operationalization and assessment of depression and breastfeeding globally and concurrent repeated measures of key biological and social factors.

Psychosocial Experiences of HIV-Positive Women of African Descent in the Cultural Context of Infant Feeding: A Three-Country Comparative Analyses

Infant feeding among mothers of African descent living with Human Immunodeficiency Virus (HIV) is a critical practice that is influenced by policies, cultural expectations, and the resultant psychosocial state of the mother. Hence, this paper draws insights from a broader infant feeding study. It provides insights into how guidelines on infant feeding practices, cultural expectations, migration, or geographic status intersect to influence the psychosocial experiences of mothers living with HIV. We compared psychosocial experiences of Black mothers of African descent living with HIV in Nigeria versus those in high-income countries (Canada and USA), in the context of contrasting national infant feeding guidelines, cultural beliefs about breastfeeding, and geographic locations. Survey was conducted in venue-based convenience samples in two comparative groups: (Ottawa, Canada and Miami-FL, USA combined [n = 290]), and (Port Harcourt, Nigeria [n = 400]). Using independent samples t-statistics, we compared the means and distributions of six psychosocial attributes between Black mothers in two distinct: Infant feeding groups (IFGs), cultural, and geographical contexts at p < 0.05. Psychosocial attributes, such as discrimination and stigma, were greater in women who exclusively formula feed (EFF) than in women who exclusively breastfeed (EBF) at p < 0.01. Heightened vigilance, discrimination, and stigma scores were greater in women whose infant feeding practices were informed by cultural beliefs (CBs) compared to those not informed by CBs at p < 0.001. Discrimination and stigma scores were greater among mothers in Canada and the USA than in Nigeria at p < 0.001. Heightened vigilance and perceived stress scores were less among women in Canada and the USA than in Nigeria at p < 0.001. The guidelines on infant feeding practices for mothers with HIV should consider cultural expectations and migration/locational status of mothers.

Social Determinants of Breastfeeding Preferences among Black Mothers Living with HIV in Two North American Cities

The study is motivated by the need to understand the social determinants of breastfeeding attitudes among HIV-positive African, Caribbean, and Black (ACB) mothers. To address the central issue identified in this study, analysis was conducted with datasets from two North American cities, where unique country-specific guidelines complicate infant feeding discourse, decisions, and practices for HIV-positive mothers. These national infant feeding guidelines in Canada and the US present a source of conflict and tension for ACB mothers as they try to navigate the spaces between contradictory cultural expectations and national guidelines. Analyses in this paper were drawn from a broader mixed methods study guided by a community-based participatory research (CBPR) approach to examine infant feeding practices among HIV-positive Black mothers in three countries. The survey were distributed through Qualtrics and SPSS was used for data cleaning and analysis. Results revealed a direct correlation between social determinants and breastfeeding attitude. Country of residence, relatives' opinion, healthcare providers' advice and HIV-related stigma had statistically significant association with breastfeeding attitude. While the two countries' guidelines, which recommend exclusive formula feeding, are cardinal in preventing vertical transmission, they can also be a source of stress. We recommend due consideration of the cultural contexts of women's lives in infant feeding guidelines, to ensure inclusion of diverse women.

Assessing Medical Neglect in HIV-Exposed or Infected Children

Human Immunodeficiency Virus (HIV) causes a chronic illness requiring lifelong medical care to prevent opportunistic infections and death. It is important to identify medical neglect in children that are perinatally exposed to or living with human immunodeficiency virus and to take steps to prevent it. Diagnosis of medical neglect must be considered in the context of the caregivers' understanding of the risks of harm, and the logistical, cultural and social factors that may influence their actions or non-actions. When medical neglect as failure of treatment or prevention of infection is suspected, medical providers should work collaboratively with caregivers to assess and address barriers to adherence and to provide resources and support. Medical neglect may be diagnosed if repeated preventive efforts fail.

"I was afraid my baby would be upset with me" - women living with HIV's accounts going through non-breastfeeding in São Paulo, Brazil

In Brazil prevention of mother to child HIV transmission guidelines recommend formula feeding. This qualitative study, carried out in a public clinic (CEADIPE/UNIFESP), aimed at exploring experiences of breastfeeding avoidance of women living with HIV living in São Paulo. Individual interviews were carried out with the support of a semi-structured questionnaire. Data was analyzed in a thematic approach with the support of AtlasTi^®. During the months of January-February 2010, 25 women were interviewed, including women with (n = 12) and without previous breastfeeding experience (n = 13). Major themes identified were: Non-breastfeeding as a trigger for stigmatization, Non-breastfeeding, guilt and coping, Attitudes around non-breastfeeding for women with and without previous breastfeeding experience, and Women's support through non-breastfeeding. In conclusion women interviewed faced challenges related to HIV diagnosis, which got entangled with difficulties with breastfeeding avoidance. Different patterns of reaction and coping could be identified, regardless of mothers' previous breastfeeding experiences. Health systems were key in providing women living with HIV with tailored services and the necessary support.

Keeping secrets, disclosing health information: an institutional ethnography of the social organisation of perinatal care for women living with HIV in Canada

This paper describes findings from an institutional ethnography that arose out of the concerns of women living with HIV in Ontario, Canada, regarding the disclosure of their HIV status while accessing perinatal care. The enquiry traces the connections between women's experiences of perinatal care, the activities of healthcare providers delivering such care and the ruling relations that organise women's experiences and healthcare providers' activities. Focusing on HIV disclosure as a concern expressed by women, the findings make visible the day-to-day, routinised practices of healthcare providers working in perinatal care for women living with HIV, as well as the ideological discourses of 'fear of contagion' and 'AIDS hysteria' that contributed to producing the kinds of care experiences that were articulated by women. Opportunities to strengthen perinatal care policies and practices for women living with HIV are discussed.

Women Living With HIV in High Income Countries and the Deeper Meaning of Breastfeeding Avoidance: A Metasynthesis

BACKGROUND

Recommendations to avoid breastfeeding for women living with HIV in high income countries has resulted in a gap in the literature on how healthcare professionals can provide the highest standard of lactation counseling.

RESEARCH AIMS

(1) Describe social and emotional experiences of infant feeding for women living with HIV in high income countries; (2) raise ethical considerations surrounding the clinical recommendation in high income countries to avoid breastfeeding.

METHODS

A systematic literature search was conducted between January 1, 2008 and June 20, 2019. A total of 900 papers were screened and six met the inclusion criteria: (a) the sample was drawn from a high-income country regardless of the nativity of participants; (b) some or all participants were women living with HIV. Metasynthesis, according to Noblit and Hare (1988), was used to synthesize the experiences of women living with HIV in high-income countries and their experiences in infant feeding decisions.

RESULTS

Participants in this sample suffered a substantial emotional burden associated with infant feeding experiences potentially leading to risk of internalized stigma, suggesting that infant feeding considerations may contribute to HIV stigma in unique ways. Four overarching themes were identified expressing the meaning of avoidance of breastfeeding: maternal self-worth, deculturalization, surveillance, and intersectionality.

CONCLUSION

Women in high-income countries living with HIV deserve the highest standard of lactation care and counseling available. Healthcare professionals in high-income countries are ethically obligated to provide evidenced-based lactation care and counseling to women living with HIV.

Women living with HIV in high-income settings and breastfeeding

Guidelines in high-income settings recommend breastfeeding avoidance amongst women living with HIV (WLWH). Increasingly, WLWH in high-income settings, who are well-treated with fully suppressed viral loads, are choosing to breastfeed their infants, even with these recommendations. The purpose of this article is to review existing research and guidance on infant feeding amongst WLWH in high-income countries and to identify gaps in this evidence that require further investigation. Current evidence on the risk of HIV transmission through breastfeeding in the context of antiretroviral therapy (ART), the significance of cell-associated virus, transmission risk factors, retention in care and adherence postpartum, infant prophylaxis and antiretroviral exposure, and monitoring of the breastfeeding WLWH are summarized. A latent HIV reservoir is persistently present in breast milk, even in the context of ART. Thus, suppressive maternal ART significantly reduces, but does not eliminate, the risk of postnatal transmission of HIV. There are currently limited data to guide the optimal frequency of virologic monitoring and the clinical actions to take in case of maternal detectable viral load whilst breastfeeding. Moreover, retention in care and adherence to ART in the postpartum period may be difficult and more research is needed to understand what clinical and psychosocial support would benefit these mothers so that successful engagement in care can be achieved. The long-term effects of antiretroviral drug exposure in the infants also need further exploration. Thus, there is a need for collecting enhanced surveillance data on WLWH who breastfeed and their infants to augment clinical guidance in high-income settings.

Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study)

INTRODUCTION

The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood.

METHODS AND ANALYSIS

This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets.

ETHICS AND DISSEMINATION

Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.

Mothers living with HIV: replacing breastfeeding by infant formula

OBJECTIVE

To explore factors that interact and shape the meaning and experience of mothers of HIV-exposed children in relation to replacing breastfeeding by infant formula.

METHOD

A qualitative study was carried out with 23 mothers living with HIV, whose children were up to 18 months of age and under follow-up in a specialized care service. Symbolic Interactionism, semi-structured interviews and content analysis were adopted as theoretical framework.

RESULTS

The social symbols of breastfeeding, the (un)availability of the milk formula and the (lack of)support of health professionals influenced the mothers' experience with formula feeding. Social, cultural and economic constraints have proved capable of undermining the conditions necessary for the replacement of breastfeeding.

FINAL CONSIDERATIONS

The availability of infant formula, access to lactation inhibitor and quality of health services still represent challenges to eradicate new HIV infections in children.

"In the United States, we say, 'No breastfeeding,' but that is no longer realistic": provider perspectives towards infant feeding among women living with HIV in the United States

INTRODUCTION

Currently, the United States (U.S.) recommends that infants born to women living with HIV (WLHIV) be fed formula, whereas many low-resource settings follow the World Health Organization's recommendation to exclusively breastfeed with ongoing antiretroviral therapy. Evidence on infant feeding among WLHIV in high-resource countries suggest that these contrasting recommendations create challenges for providers and patients. Our study used multiple methods to understand providers' infant feeding perspectives on caring for their pregnant and post-partum WLHIV in the U.S.

METHODS

We sent a survey (n = 93) to providers across the U.S. who have cared for WLHIV. A subset of survey participants opted into a follow-up qualitative interview (n = 21). These methods allowed us to capture a broad understanding of provider attitudes via the survey and more nuanced qualitative interviews. The study was completed prior to an updated breastfeeding section of the U.S. Perinatal Guidelines.

RESULTS

The majority of providers (66.7%) discussed infant feeding intent with their patients using open-ended questions. Many also discussed alternative feeding methods (37.6%) and disclosure avoidance strategies (34.4%). Over 75% (95% confidence interval (CI): 65.1 to 84.2) of participants reported that a WLHIV asked if she could breastfeed her child, and 29% (95% CI 20 to 40.3) reported caring for a patient who breastfed despite recommendations against breastfeeding. Providers reported that their patients' primary concern was stigma associated with not breastfeeding (58%), while providers were primarily concerned about medication adherence during breastfeeding (70%). Through qualitative analysis, four overarching categories emerged that reflect providers' sentiments, including (1) U.S. guidelines inadequately addressing WLHIV's desire to breastfeed; (2) negotiating patient autonomy amidst complex feeding situations; (3) harm reduction approaches to supporting WLHIV in breastfeeding; and (4) providers anticipating multilayered patient stigmatization.

CONCLUSIONS

The majority of provider respondents cared for a WLHIV who desired to breastfeed, and a third had WLHIV who breastfed despite recommendations against it. Providers found that the status of U.S. guidelines and their incongruity with WHO guidelines left them without adequate resources to support WLHIV's infant feeding decisions. Our findings provide important insight to inform professional associations' discussions about public health policy as they consider future directions for infant feeding guidelines among WLHIV.

Loneliness and perceived social support in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

The HIV Mothering Study (n = 72) was a prospective, observational, cohort study exploring psychosocial experiences and needs of WLWHIV in pregnancy and postpartum. We performed quantitative analysis of determinants of loneliness (UCLA Loneliness Scale) and lower perceived social support (SS) (Medical Outcomes Study-Social Support Survey). The hypothesized determinants included: age, years with HIV, racism (Everyday Discrimination Scale), depression (Edinburgh Postnatal Depression Scale [EPDS]), nadir CD4 (<200 cells/μL), tertiary vs. community HIV care, and marital status. The median age was 33 (IQR = 30-37); 65.3% were African/Caribbean/Black. Multivariable analyses revealed associations between marital status and perceived social support (β = -16.48, p < 0.0001), and this association was also seen with change over time (p = 0.02). Variables associated with SS that did not change over time were: income, EDS racism, EPDS score. Significant associations with loneliness were seen with the same variables associated with SS. Variables associated with loneliness that also changed over time were: EDS Racism (β = 0.22, p = 0.0005, and over time p = 0.003), and EPDS score (β = 0.74, p < 0.0001), and over time (p = 0.0211). Variables associated with loneliness but that did not change over time were: marital status and income. This analysis provides clinicians with prenatal risk factors which may be associated with increase loneliness and lower SS during pregnancy and postpartum: marital status, income, racism and depression.

Sociocultural factors influencing infant-feeding choices among African immigrant women living with HIV: A synthesis of the literature

BACKGROUND AND PURPOSE

The World Health Organizations (WHO) strategy is to eliminate pediatric HIV. HIV prevention guidelines in high-income countries recommend mothers living with HIV avoid breastfeeding. Yet, breastfeeding is promoted as the normal and unequalled method of feeding infants. This creates a paradox for mothers coming from cultures where breastfeeding is an expectation and formula feeding suggests illness. Therefore, the purpose of this literature review is to examine the context influencing infant feeding among African immigrant women living with HIV to develop interventions to reduce the risk of HIV mother-to-child transmission.

METHODS

Using the PEN-3 cultural model as a guide, we selected 45 empirical studies between 2001 and 2016 using 5 electronic databases on the sociocultural factors influencing infant-feeding choices and practices among African women from HIV endemic countries.

CONCLUSIONS

Findings are congruent with the importance of culture when developing guidelines. Our review provides support that culture-centered interventions are crucial toward achieving the WHO's strategy to eliminate pediatric HIV.

IMPLICATIONS FOR PRACTICE

Understanding the sociocultural determinants of infant-feeding choices is critical to the development of prevention initiatives to eliminate pediatric HIV.

Surviving Surveillance: How Pregnant Women and Mothers Living With HIV Respond to Medical and Social Surveillance

Pregnant women and mothers living with HIV are under surveillance of service providers, family members, and the community at large. Surveillance occurs throughout the medical management of their HIV during pregnancy, preventing HIV transmission to their baby, infant feeding practices, and as part of assessments related to their ability to mother. Enacted and anticipatory HIV-related stigma can exacerbate the negative impact that being under surveillance has on mothers living with HIV as they move through their pregnancy, birthing, and mothering experiences. In response, women living with HIV find ways to manage their experiences of surveillance through engaging in acts of distancing, planning, and resisting at different points in time, and sometimes enacting all three practices at once. Positioning the narratives of pregnant women and mothers living with HIV in relation to their experiences of surveillance illuminates the relationship between the surveillance of mothers living with HIV and HIV-related stigma.

Qualitative exploration of psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana

Background

Exploring the psychological reactions of breastfeeding mothers living with Human Immunodeficiency Virus (HIV) is an important step which may improve guidelines for counselling. The purpose of this study was to explore the psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana.

Methods

Qualitative descriptive exploratory design was used to explore the psychological experiences and coping strategies of 13 breastfeeding mothers living with HIV in a main referral public hospital, at the greater Accra Region of Ghana. An interview guide was designed and piloted before it was used to collect data between November, 2014 and February, 2015. Data was content analyzed for themes and subthemes to emerge.

Results

The two major themes that emerged included psychological reactions and coping strategies. Some of the subthemes were fear, anxiety, blame, hope, denial, prayer and trust in positive situations of life.

Conclusion

The women used denial, prayer and hope in ART, among others to cope with their emotions. This highlights the need for HIV counsellors to detect signs of denial since it can lead to non-adherence to ART as well as relapse. Health workers should therefore put the coping strategies in context during counselling of mothers in this category.

HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy-motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.