Factors affecting breastfeeding cessation after discontinuation of antiretroviral therapy to prevent mother-to-child transmission of HIV

Perceptions of grandmothers and HIV-infected mothers on infant feeding practices in a rural South African district

Background

Despite enormous interventions aimed at preventing mother-to-child transmission (MTCT) of HIV, cultural practices on mixed infant feeding remain prevalent. Complementary food provision to infants seems to be the most common and acceptable form of infant feeding highly endorsed by grandmothers.

Aim

This study aimed to explore the perceptions of grandmothers and HIV-infected mothers on infant feeding practices in the context of prevention of mother-to-child transmission.

Setting

This study was undertaken in two primary healthcare facilities in the Mpumalanga province, South Africa.

Methods

A qualitative exploratory narrative design was used to conduct four focus group discussions with 32 purposefully selected grandmothers and 21 in-depth interviews with postnatal HIV-infected women in the two identified health facilities. Data were analysed using an interthematic inductive analysis approach, resulting in major themes and subthemes supported by participants’ excerpts.

Results

Four themes emerged showing (1) high mixed feeding endorsement because of the need to adhere to conventional practices, strengthen the umbilicus and have fuller, fat and calmer babies; (2) infant feeding fallacies and stigma reflected by exclusive breastfeeding period confusion, breastfeeding scepticism and infant feeding stigma; (3) breastfeeding endorsement for other disease prevention and family support for breastfeeding and (4) conflict between traditional and western infant feeding approaches.

Conclusion

Total elimination of MTCT of HIV in a rural context calls for targeted education for grandmothers addressing their perceptions and practices of infant feeding. The knowledge of the identified factors encouraging mixed infant feeding can assist in designing programmes to change community beliefs on infant feeding. Cultural, social and psychosocial factors should be addressed when making recommendations for exclusive breastfeeding for HIV-positive mothers.

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.

Can mother-to-child transmission of HIV be eliminated without addressing the issue of stigma? Modeling the case for a setting in South Africa

BACKGROUND

Stigma and discrimination ontinue to undermine the effectiveness of the HIV response. Despite a growing body of evidence of the negative relationship between stigma and HIV outcomes, there is a paucity of data available on the prevalence of stigma and its impact. We present a probabilistic cascade model to estimate the magnitude of impact stigma has on mother-to-child-transmission (MTCT).

METHODS

The model was parameterized using 2010 data from Johannesburg, South Africa, from which loss-to-care at each stage of the antenatal cascade were available. Three scenarios were compared to assess the individual contributions of stigma, non-stigma related barriers, and drug ineffectiveness on the overall number of infant infections. Uncertainty analysis was used to estimate plausible ranges. The model follows the guidelines in place in 2010 when the data were extracted (WHO Option A), and compares this with model results had Option B+ been implemented at the time.

RESULTS

The model estimated under Option A, 35% of infant infections being attributed to stigma. This compares to 51% of total infections had Option B+ been implemented in 2010. Under Option B+, the model estimated fewer infections than Option A, due to the availability of more effective drugs. Only 8% (Option A) and 9% (Option B+) of infant infections were attributed to drug ineffectiveness, with the trade-off in the proportion of infections being between stigma and non-stigma-related barriers.

CONCLUSIONS

The model demonstrates that while the effect of stigma on retention of women at any given stage along the cascade can be relatively small, the cumulative effect can be large. Reducing stigma may be critical in reaching MTCT elimination targets, because as countries improve supply-side factors, the relative impact of stigma becomes greater. The cumulative nature of the PMTCT cascade results in stigma having a large effect, this feature may be harnessed for efficiency in investment by prioritizing interventions that can affect multiple stages of the cascade simultaneously.

Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa)

OBJECTIVE

To investigate the association between feeding patterns and HIV-free survival in children born to HIV-infected mothers and to clarify whether antiretroviral (ARV) prophylaxis modifies the association.

METHODS

From June 2005 to August 2008, HIV-infected pregnant women were counseled regarding infant feeding options, and randomly assigned to triple-ARV prophylaxis (triple ARV) until breastfeeding cessation (BFC) before age 6 months or antenatal zidovudine with single-dose nevirapine (short-course ARV). Eighteen-month HIV-free survival of infants HIV-negative at 2 weeks of age was assessed by feeding patterns (replacement feeding from birth, BFC <3 months, BFC ≥3 months).

RESULTS

Of the 753 infants alive and HIV-negative at 2 weeks, 28 acquired infection and 47 died by 18 months. Overall HIV-free survival at 18 months was 0.91 [95% confidence interval (CI): 0.88-0.93]. In the short-course ARV arm, HIV-free survival (0.88; CI: 0.84-0.91) did not differ by feeding patterns. In the triple ARV arm, overall HIV-free survival was 0.93 (CI: 0.90-0.95) and BFC <3 months was associated with lower HIV-free survival than BFC ≥3 months (adjusted hazard ratio: 0.36; CI: 0.15-0.83) and replacement feeding (adjusted hazard ratio: 0.20; CI: 0.04-0.94). In the triple ARV arm, 4 of 9 transmissions occurred after reported BFC (and 5 of 19 in the short-course arm), indicating that some women continued breastfeeding after interruption of ARV prophylaxis.

CONCLUSIONS

In resource-constrained settings, early weaning has previously been associated with higher infant mortality. We show that, even with maternal triple-ARV prophylaxis during breastfeeding, early weaning remains associated with lower HIV-free survival, driven in particular by increased mortality.

Predictors of breastfeeding cessation among HIV infected mothers in Southern Ethiopia: a survival analysis

Background

Mother-to-child transmission (MTCT) of Human immunodeficiency virus (HIV) through breastfeeding remains the most significant route infection among children. Although the current guideline is recommending continued breastfeeding for HIV exposed infants, significant proportion of infants have been subjected to early weaning to prevent HIV transmission. However the predictors of breastfeeding cessation among HIV positive mothers were not documented in Ethiopia. Therefore the objective of this study was to determine the predictors of breastfeeding cessation among HIV-infected women in Southern Ethiopia.

Methods

A facility based cross sectional study was conducted in Southern Ethiopia. The samples were selected by cluster sampling technique. The Kaplan-Meier curve was used to describe the survival time of breastfeeding and a step-wise multivariable Cox-proportional hazards regression model were used to identify the predictors of breastfeeding cessation. Both crude and adjusted hazard ratio were determined and p<0.05 was considered as statistically significant.

Result

The mean duration of breastfeeding among HIV positive mothers was 13.79 [95% CI: (12.97–14.59)] months. The Kaplan-Meier estimate showed that proportions of women who were breastfeeding at 6, 9, 12 and 17 months were 89.3%, 75.3%, 66% and 17%, respectively. Those mothers having a monthly income of ≤500 ETB [AHR = 0.16, 95% CI :(0.03–0.76)], having a family size of three and below [AHR = 0.12, 95%CI: (0.02–0.68), four and above [AHR = 0.07, 95%CI: (0.01–0.35)] and bottle feeding [AHR = 3.95, 95%CI: (1.64–9.51)] were also independent factors associated with breastfeeding cessation.

Conclusion

Above one third of HIV positive mothers stopped breastfeeding before 12 months. Monthly income, bottle feeding and family size were the independent predictors of breastfeeding cessations. Strengthening the current counseling and promotion modality on avoidance of bottle feeding and continued breastfeeding is recommended for improved HIV free survival.

The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women's ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights.

HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this "PMTCT cascade". Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

A review of reproductive health research, guidelines and related gaps for women living with HIV

The study of pregnancy and motherhood in women living with HIV (WLWH) has concentrated on the health of the unborn baby and the prevention of mother-to-child transmission, whereas consideration of the broader aspects of women's reproductive health has been largely overlooked. The rights of WLWH with respect to their reproductive health should be exactly the same as non-HIV-positive women, however, inequalities exist due to discrimination and also because the treatment guidelines used in the care of women are often based on insufficient evidence. The purpose of this article is to review the available literature on reproductive health issues for WLWH and to identify gaps requiring further investigation. Our review indicates that further research is warranted into a number of aspects of reproductive health among WLWH. Currently, access to the relevant reproductive health resources and services, such as advice on contraception and fertility services, for WLWH is far from optimal in many developed countries and most developing countries. More data are needed on the most appropriate family planning options with the consideration of drug interactions between contraceptives and antiretroviral therapy and the risk of HIV transmission. Also, more research is needed to improve understanding of the maternal health challenges facing WLWH. Similarly, our understanding of the impact of HIV on the physical and emotional health of pregnant women and new mothers is far from complete. Answering these questions and countering these inequalities will help to ensure the reproductive health and child-bearing intentions of WLWH become an integral part of HIV medicine.

Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding--the Kisumu Breastfeeding Study, Kenya: a clinical trial

BACKGROUND

Effective strategies are needed for the prevention of mother-to-child HIV transmission (PMTCT) in resource-limited settings. The Kisumu Breastfeeding Study was a single-arm open label trial conducted between July 2003 and February 2009. The overall aim was to investigate whether a maternal triple-antiretroviral regimen that was designed to maximally suppress viral load in late pregnancy and the first 6 mo of lactation was a safe, well-tolerated, and effective PMTCT intervention.

METHODS AND FINDINGS

HIV-infected pregnant women took zidovudine, lamivudine, and either nevirapine or nelfinavir from 34-36 weeks' gestation to 6 mo post partum. Infants received single-dose nevirapine at birth. Women were advised to breastfeed exclusively and wean rapidly just before 6 mo. Using Kaplan-Meier methods we estimated HIV-transmission and death rates from delivery to 24 mo. We compared HIV-transmission rates among subgroups defined by maternal risk factors, including baseline CD4 cell count and viral load. Among 487 live-born, singleton, or first-born infants, cumulative HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were 2.5%, 4.2%, 5.0%, 5.7%, and 7.0%, respectively. The 24-mo HIV-transmission rates stratified by baseline maternal CD4 cell count <500 and ≥500 cells/mm(3) were 8.4% (95% confidence interval [CI] 5.8%-12.0%) and 4.1% (1.8%-8.8%), respectively (p = 0.06); the corresponding rates stratified by baseline maternal viral load <10,000 and ≥10,000 copies/ml were 3.0% (1.1%-7.8%) and 8.7% (6.1%-12.3%), respectively (p = 0.01). None of the 12 maternal and 51 infant deaths (including two second-born infants) were attributed to antiretrovirals. The cumulative HIV-transmission or death rate at 24 mo was 15.7% (95% CI 12.7%-19.4%).

CONCLUSIONS

This trial shows that a maternal triple-antiretroviral regimen from late pregnancy through 6 months of breastfeeding for PMTCT is safe and feasible in a resource-limited setting. These findings are consistent with those from other trials using maternal triple-antiretroviral regimens during breastfeeding in comparable settings.