Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme

Understanding the uptake and determinants of prevention of mother-to-child transmission of HIV services in East Africa: Mixed methods systematic review and meta-analysis

BACKGROUND

Prevention of mother-to-child transmission (PMTCT) of HIV service is conceptualized as a series of cascades that begins with all pregnant women and ends with the detection of a final HIV status in HIV-exposed infants (HEIs). A low rate of cascade completion by mothers' results in an increased risk of HIV transmission to their infants. Therefore, this review aimed to understand the uptake and determinants of key PMTCT services cascades in East Africa.

METHODS

We searched CINAHL, EMBASE, MEDLINE, Scopus, and AIM databases using a predetermined search strategy to identify studies published from January 2012 through to March 2022 on the uptake and determinants of PMTCT of HIV services. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A random-effects model was used to obtain pooled estimates of (i) maternal HIV testing (ii) maternal ART initiation, (iii) infant ARV prophylaxis and (iv) early infant diagnosis (EID). Factors from quantitative studies were reviewed using a coding template based on the domains of the Andersen model (i.e., environmental, predisposing, enabling and need factors) and qualitative studies were reviewed using a thematic synthesis approach.

RESULTS

The searches yielded 2231 articles and we systematically reduced to 52 included studies. Forty quantitative, eight qualitative, and four mixed methods papers were located containing evidence on the uptake and determinants of PMTCT services. The pooled proportions of maternal HIV test and ART uptake in East Africa were 82.6% (95% CI: 75.6-88.0%) and 88.3% (95% CI: 78.5-93.9%). Similarly, the pooled estimates of infant ARV prophylaxis and EID uptake were 84.9% (95% CI: 80.7-88.3%) and 68.7% (95% CI: 57.6-78.0) respectively. Key factors identified were the place of residence, stigma, the age of women, the educational status of both parents, marital status, socioeconomic status, Knowledge about HIV/PMTCT, access to healthcare facilities, attitudes/perceived benefits towards PMTCT services, prior use of maternal and child health (MCH) services, and healthcare-related factors like resource scarcity and insufficient follow-up supervision.

CONCLUSION

Most of the identified factors were modifiable and should be considered when formulating policies and planning interventions. Hence, promoting women's education and economic empowerment, strengthening staff supervision, improving access to and integration with MCH services, and actively involving the community to reduce stigma are suggested. Engaging community health workers and expert mothers can also help to share the workload of healthcare providers because of the human resource shortage.

Factors influencing exclusive breast feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study

Only about 39% of infants in low- and middle-income countries are exclusively breast-fed for the first six months. In particular, human immunodeficiency virus (HIV) positive women report confusion about the best feeding methods. Exclusive Breastfeeding (EBF) practices in HIV positive mothers are sub-optimal in Ethiopia. This study aimed to identify the main factors influencing EBF among HIV positive breast-feeding mothers. A facility based cross-sectional study was carried out from September 2017 to June 30 2018 among HIV positive mothers with infants aged 6–23 months. Thirteen public health facilities (7 health centers and 6 hospitals) that provided anti-retroviral treatment (ART) and Prevention of mother-to-child transmission (PMTCT) services, found in three districts of West, East and Kellem Wollega Zones, were randomly selected. Respondents were recruited by systematic random sampling techniques from these facilities using client registers as a sampling frame. Data were collected using face to face interviews with a pre-tested questionnaire. Data were entered into EPI info Version 3.5.1 and analyzed using SPSS Version 20 for windows. Candidate variables for the final multi-variable model were selected considering P≤ 0.05 at bivariable analysis. Associations were declared at P≤ 0.05 by assuming Confidence Intervals did not cross ‘1’with corresponding 95%. A total of 218 HIV positive mothers were included in this study. Of these, only 122 (56.0%) practiced EBF in the first six months. The proportion of study participants who initiated EBF within the first hour of delivery was 134 (61.8%). Mean age of study participants was 28.6years with SD ± 4. Mothers’ having received advice on EBF [AOR 3, 95% CI (1.2–6.7)], disclosure of HIV status to someone close to them including their husband [AOR 6, 95% CI (1.2–29.6)] and believing HIV can be transmitted during delivery [AOR 5.2, 95% CI (1.1–24.0)] were found to increase the likelihood of EBF practices among the study participants (P-value ≤ 0.05). In this study, only just over half of the mothers practiced EBF for the first six months. Care providers should continue to encourage mothers to practice EBF in the first six months and to disclosure of HIV status to someone close to them including their partner. Efforts should be in place to curb the risk of HIV/AIDS transmission during delivery. Continues advise for mothers to practice EBF in the first 6 months is still needed.

Factors Associated with Infant Feeding Choices Among Women with HIV in Botswana

INTRODUCTION

In resource-constrained settings, infant feeding decisions among women with HIV (WHIV) must balance the risk of infant HIV acquisition from breastfeeding with increased mortality associated with formula feeding. WHO guidelines recommend countries principally promote a single feeding method for WHIV, either breastfeeding or formula feeding. In 2016, Botswana revised its policy of formula feeding for infants born to WHIV, instead promoting exclusive breastfeeding during the first 6 months of life.

METHODS

We sought to understand factors influencing infant feeding choices among WHIV by administering a questionnaire to pregnant and postpartum WHIV (2013-2015) participating in a clinical trial in Botswana (the Mpepu Study). Logistic regression analyses were used to identify factors associated with infant feeding choices.

RESULTS

Of 810 surveyed participants, 24.0% chose breastfeeding and 76.0% chose formula feeding. Women were more likely to choose formula feeding if advised by a health worker to formula feed (aOR 1.90; 95% CI 1.02-3.57) or if they harboured doubts about the potency of antiretroviral treatment (ART) to prevent infant HIV acquisition (aOR 9.06; 95% CI 4.78-17.17). Women who reported lack of confidence in preparing infant formula safely (aOR 0.09; 95% CI 0.04-0.19) or low concerns about infant HIV acquisition (aOR 0.35; 95% CI 0.22-0.55) were significantly less likely to formula feed.

DISCUSSION

Perceptions about ART effectiveness, social circumstances and health worker recommendations were key influencers of infant feeding choices among WHIV. Health system factors and maternal education interventions represent ideal targets for any programmatic actions aiming to shape informed decision-making towards HIV-free survival of infants.

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.

HIV-Related Stigma Among Black Mothers in Two North American and One African Cities

HIV-related stigma is a negative attitude or behaviour towards persons living with HIV, and is detrimental to effective care, management, and treatment of HIV. Using a revised 10-item stigma scale, we compared levels of HIV-related stigma and its correlates among Black women living with HIV in Ottawa, Canada, and Miami, FL, USA, with those in Port Harcourt, Nigeria. HIV-related stigma scores were calculated, with a maximum score of 10 and averaged 4.71 in Ottawa, 5.06 in Miami, and 3.78 in Port Harcourt. No significant difference in HIV-related stigma scores between Ottawa and Miami. HIV-related stigma was significantly (p < 0.05) higher among women in the North American cities compared with women in the African city. Hierarchical linear modelling shows that psychosocial variables contributed to variations in HIV-related stigma in Ottawa (22.3%), Miami (36.3%), and Port Harcourt (14.1%). At p < 0.05, discrimination was a significant predictor of increased HIV-related stigma in Ottawa (β = 0.077), Miami (β = 0.092), and Port Harcourt (β = 0.068). Functional social support had a significant diminishing effect on HIV-related stigma in Miami (β = - 0.108) and Port Harcourt (β = - 0.035). Tackling HIV-related sigma requires sociocultural considerations within specific regional and national contexts.

Knowledge, attitudes, and practices regarding exclusive breastfeeding among HIV-positive mothers in Uganda: A qualitative study

BACKGROUND

In Uganda, the prevalence of human immunodeficiency virus (HIV) in pregnant women was estimated at 6.1% in 2009, and in 2011, mother-to-child transmission (MTCT) of HIV resulted in 20 600 new paediatric HIV infections. A total of 50% of MTCT of HIV in Uganda occurs after birth, and this is partially attributable to poor adherence to infant feeding (IF) guidelines. Poor IF practices contribute to approximately 1.4 million deaths in children aged younger than five. In 2011, Uganda's rate of exclusive breastfeeding (EBF) was 62% for infants aged 0 to 5 months. Identifying barriers provides information on how to improve support for HIV-positive mothers' adherence to EBF, which may take the form of targeted interventions.

AIM

This study explores the knowledge, attitudes, and practices of HIV-positive mothers in Kampala, Uganda, regarding EBF of infants aged younger than 6 months.

METHODS

Five focus group discussions, each consisting of five HIV-positive mothers, were carried out at Kawempe Home Care using a semi-structured guide. Thematic content analysis was used to analyse the data.

RESULTS

The study findings showed that the main barriers to HIV-positive mothers practising EBF include a lack of IF counselling, fear of HIV transmission through breast milk, returning to work, and breastfeeding difficulties. The main factors influencing HIV-positive mothers' decisions regarding IF are IF counselling and partners' and families' recommendations.

CONCLUSION

This study recommends increasing access to couples-based HIV testing at antenatal clinics and couples-based IF counselling, while ensuring that it addresses breastfeeding difficulties.

Determinants of Infant Feeding Practices Among HIV-Infected Mothers in Urban Kano, Nigeria

BACKGROUND

Despite advances in prevention of mother-to-child HIV transmission, infants in Africa remain at risk of HIV acquisition from inappropriate feeding practices.

RESEARCH AIMS

To assess maternal knowledge and predictors of appropriate infant feeding practices among HIV-infected mothers attending a tertiary facility in Kano, Nigeria.

METHOD

A cross section of 203 HIV-positive mothers were interviewed using structured, pretested survey questionnaires. Knowledge scores and infant feeding practices were analyzed. Multivariate logistic regression was employed to ascertain independent correlates of infant feeding practices in the study sample.

RESULTS

Over a third (37.4%) of the participants were aware of the risk of HIV transmission through breastfeeding. The proportion of participants with good, fair, and poor knowledge of recommended feeding options for HIV-exposed infants was 4.4%, 73.4%, and 22.2%, respectively. About three in four participants (73.9%) breastfed their index infants exclusively for the first six months. Approximately 7.4% of respondents practiced mixed feeding (breastfeeding plus infant formula). Counseling on infant feeding (Adjusted Odds Ratio [AOR] = 2.16, 95% Confidence Interval [CI] = [1.58, 4.15]) and hospital delivery (AOR = 3.02, 95% CI = [2.67, 7.84]) predicted appropriate infant feeding practice.

CONCLUSION

Appropriate infant feeding practices were significantly associated with prior infant feeding counseling and delivery in a hospital setting. HIV-infected mothers in this setting should receive counseling on infant feeding early in their pregnancy and be educated on the importance of hospital delivery.

A realist review of infant feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa: what works for whom and in what contexts

BACKGROUND

The most recent World Health Organization (WHO) guidelines on Human Immunodeficiency Virus (HIV) and infant feeding promotes exclusive breastfeeding (EBF) in resource limited settings for the prevention of mother to child transmission (PMTCT) of HIV. Literature reveals poor uptake of WHO feeding guidelines, with mixed feeding being a regular practice. In light of the limited success in EBF promotion, a realist review was conducted, analysing the use of feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa, where the majority of HIV childhood infections occur. We considered what mechanisms were at play, for whom and in what circumstances they led to exclusive breastfeeding.

METHODS

Because infant feeding counselling is a complex social intervention with a non-linear causal pathway for preventing mother to child HIV transmission, a realist methodology was chosen for this study. Using Pawson's five stage sequence for conducting realist reviews, the results are presented as a set of identified and refined context-mechanism-outcome (CMO) configurations. These CMO configurations were used to show how particular outcomes occurred in specific contexts due to a generative mechanism and were developed through identifying a review question and program theory, searching for primary studies, quality appraisal, data extraction and data synthesis.

RESULTS

From an initial 1010 papers, 27 papers met the inclusion criteria and were used to refine the program theory. Exclusive breastfeeding occurred when a woman was motivated regarding motherhood, had correct learning and understanding about infant feeding practices through counselling, no fear of breastfeeding or the impact of opposing feeding related cultural beliefs, and the support from others to be assertive about their feeding choices when faced with pressure to mix-feed. An additional CMO configuration was added during the refinement of the program theory identifying that mothers needed to not just understand but also prioritize EBF advice over cultural beliefs and stigma.

CONCLUSION

The intended audience for this review are researchers and health care workers in PMTCT, particularly sub-Saharan Africa, who may benefit from the work that has been done to identify contexts for the success and failures of EBF.

Perception and practice of breastfeeding among HIV positive mothers receiving care for prevention of mother to child transmission in South-East, Nigeria

Background

Although the risk of HIV transmission through breastfeeding is reduced considerably with the use of antiretroviral therapy, infant feeding by HIV positive mothers remains controversial. Weighing risks against benefits generates intense debate among policymakers, program managers and service providers in sub-Saharan Africa, considering that the major causes of infant death of malnutrition and infectious diseases, could be prevented if mothers breastfeed their babies. Whereas breastfeeding involves some risk of HIV transmission, not breastfeeding poses considerable risk to infant survival. This study investigated perceptions and practice of breastfeeding of HIV-exposed infants among HIV positive mothers.

Methods

A cross-sectional descriptive study was conducted in Enugu metropolis among HIV positive mothers receiving care for prevention of mother-to-child transmission of HIV from two public and two private hospitals. Interviewer-administered questionnaire survey was done with 550 participants as they exited the final point of service delivery. Descriptive statistics of perception and practice variables and cross tabulation of selected variables was performed.

Results

Most mothers knew that HIV could be transmitted through breast milk. The majority perceived any type of breastfeeding as beneficial to the infant: 230 (83.6%) in private facilities, and 188 (68.4%) public facilities. Over three-quarters of the mothers breastfed their infants and their reasons for breastfeeding included personal choice, cultural norms, fear of HIV status being disclosed and pressure from family members. A statistical significant association was found between; (i) practice of breastfeeding and marital status, (p < 0.01), and (ii) practice of breastfeeding and household income provider (p = 0.02). However, neither marital status (AOR 1.4; 95% CI 0.3, 6.8) nor being the household income provider (AOR 4.9; 95% CI 0.6, 12.9) is a significant predictor of breastfeeding of HIV-exposed infants.

Conclusions

Breastfeeding remains a common trend among HIV positive women and it is associated with economic independence of women and social support. Fear of stigma negatively affects practice of breastfeeding. Hence, HIV positive mothers need economic independence and the support of family members to practice recommended infant feeding options.

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.

Infant feeding practices among HIV-exposed infants less than 6 months of age in Bomet County, Kenya: an in-depth qualitative study of feeding choices

BACKGROUND

In children, HIV can be acquired from the mother during pregnancy, delivery and through breast milk. The WHO recommends exclusive breast feeding or exclusive replacement feeding for the first 6 months after birth for HIV-exposed infants. Barriers such as HIV-related stigma, inadequate resources, lack of access to safe water and negative cultural beliefs have been shown to influence infant feeding among HIV-exposed infants in some settings. In Kenya, there is limited literature on the barriers. The purpose of this study was to identify barriers to optimal feeding among HIV-exposed infants 0-5 months of age attending a mission hospital in Bomet County, Kenya.

METHODS

A cross-sectional qualitative study was conducted at a referral mission hospital in Bomet County, Southwest Kenya. Four focused group discussions were conducted among mothers/caregivers of HIV-exposed infants aged 0-5 months in accordance with their infant feeding practices, while two key informant interviews were also held with healthcare workers. All sessions were audio recorded and later transcribed verbatim. Content analysis was performed, and conclusions were made based on identified themes.

RESULTS

Factors influencing the infant feeding choices were: financial constraints, cultural beliefs and practices, HIV-related stigma and conflicting knowledge among mothers/caregivers and healthcare workers on the recommendations for feeding HIV-exposed infants 0-5 months of age.

CONCLUSIONS

Health worker retraining in and reinforcement of WHO guidance on feeding HIV exposed/infected infants will clarify misconceptions around feeding HIV exposed/infected infants, though there remain social and economic barriers to full implementation.

Adherence to Exclusive Breastfeeding and Associated Factors in Mothers of HIV-Exposed Infants Receiving Care at Kilimanjaro Christian Medical Centre, Tanzania

Background:

More than 90% of HIV in children occurs through mother-to-child transmission. Breastfeeding is one of several factors associated with transmission of HIV, and, because of this, infant feeding practice is one of the cornerstones in the effort to reduce HIV transmission in children. World Health Organization guidelines from 2012 recommend exclusive breastfeeding to all infants for first 6 months of life. However, many factors contribute to the adherence of mothers to exclusive breastfeeding (EBF) recommendations. The aim of this study was to determine what factors likely influence adherence to exclusive breastfeeding in mothers of HIV-exposed infants receiving care at Kilimanjaro Christian Medical Centre.

Methods:

A cross-sectional hospital-based study was conducted from September 2012 to March 2013 at Kilimanjaro Christian Medical Centre in Moshi. All mothers of HIV-exposed infants aged 6 to 12 months receiving care at child-centred family care clinic who consented to participate in the study were included. Data were collected using a pretested structured questionnaire and analysed using SPSS version 16.0 statistical package.

Results:

Of the 128 mothers of HIV-exposed infants enrolled in the study, 71 (55.5%) adhered to EBF for 6 months. No statistical significance was seen between adherence status and maternal characteristics in bivariate analysis (P>.05). The mean age and standard deviation of initiating other foods by mothers who did not adhere was 3.32 months ± 1.24. Of 57 (44.5%) non-adherent mothers, one-tenth of them practised mixed breastfeeding and the rest stopped breastfeeding completely. Fear of postnatal transmission of HIV through breastfeeding and inadequate breast milk production were the most common reasons for non-adherence to EBF.

Conclusion:

Adherence to the recommended duration for EBF by mothers to their HIV-exposed infants is still a challenge. Ongoing intensive feeding counselling and education on EBF may increase the number of mother who can adhere to EBF in our society.

Intervening factors in the feeding of infants vertically-exposed to HIV: an integrative review

Objective

To evaluate the available scientific literature on factors that may intervene in the adequate feeding of infants vertically-exposed to HIV.

Methods

This was an integrative review of the literature, performed on the LILACS, PubMed and Scopus databases in February 2017. The search was guided by the question "What are the factors involved in feeding infants vertically-exposed to HIV." Selected studies met the inclusion criteria of being research articles published in English, Portuguese, or Spanish. Articles excluded were those on exclusive breastfeeding. There was no need to perform a temporal cut off of the studies.

Results

In all, the 32 primary studies selected showed that intervening factors were of three types: individual, such as maternal feelings and desires, beliefs, and practical difficulties; social, such as socioeconomic conditions, social support, and stigma; and political, such as health services structure and organization, supplies, health care guidance, and the knowledge and attitudes of health care professionals.

Conclusions

The factors that interfere with feeding infants vertically-exposed to HIV may be independent or associated with each other. To reduce the risk of inadequate nutrition and its associated diseases, actions must be taken to identify and minimize these factors, guaranteeing a better quality of life and reduction of infant morbidity and mortality.

Promotion of exclusive breastfeeding among HIV-positive mothers: an exploratory qualitative study

Background

Exclusive breastfeeding has the potential to reduce infant and under-five mortality, but research shows the practice is not widespread in resource-poor settings of sub-Saharan Africa. We explored factors influencing the decision to exclusively breastfeed among HIV-positive mothers accessing interventions for prevention of mother-to-child transmission of HIV in selected sites of Zambia.

Methods

This exploratory qualitative study was embedded in research conducted on: HIV and infant feeding; choices and decision-outcomes in the context of prevention of mother-to-child transmission among HIV-positive mothers in Zambia. Thirty HIV-positive mothers and six key informants were recruited from two health facilities providing mother-to-child HIV transmission prevention services. A semi-structured guide was used to conduct interviews, which were digitally recorded and simultaneously transcribed. Data coding and analysis was done with the support of QRS Nvivo 10 version software.

Results

Despite the known benefits of exclusive breastfeeding, gaps in understanding and potential for behaviour change remained. We found that information promoting exclusive breastfeeding may have been understood by mothers as instructions from the health care workers indicating how to feed their HIV-exposed babies rather than as an option for the mothers’ own informed-decision. This understanding influenced a mother’s perceptions of breast milk safety while on antiretroviral medicine, of the formula feeding option, and of the baby crying after breastfeeding. The meanings mothers attached to exclusive breastfeeding thus influenced their understanding of breast milk insufficiency, abrupt weaning and mixed feeding in the context of preventing mother-to-child transmission of HIV.

Conclusion

In order to enhance feeding practices for HIV-exposed infants, our study suggests a broader health campaign supporting all mothers to exclusively breastfeed.

"I did not feel like a mother": the success and remaining challenges to exclusive formula feeding among HIV-positive women in Brazil

Exclusive and safe formula feeding can eliminate the risk of vertical HIV transmission due to breastfeeding. Therefore, many countries advise all HIV-positive women to avoid breastfeeding their infants. However, little research explores the experiences of women attempting to exclusively formula feed in countries with free and universal access to highly active antiretroviral therapy (HAART). This article examines the success of Brazil in supporting HIV-positive women as engage in exclusive formula feeding (EFF). We conducted in-depth interviews with 30 HIV-positive women receiving care at the primary facility for HIV/AIDS in Salvador, Brazil about their attitudes and practices related to EFF as well as challenges with adhering to EFF. All interviews were recorded, professionally transcribed and translated, and then analyzed. Our results showed that one woman reported both breastfeeding and formula feeding her infant; all others reported EFF. Postpartum counseling regarding the risk of HIV transmission through breastfeeding was the primary motivation for EFF. Challenges included difficulty reconciling their perceptions that breastfeeding is an important maternal responsibility, trouble accepting that breastfeeding can cause potential to harm their infants, confronting HIV-related stigma associated with EFF, and unexpected financial burdens due to EFF. We conclude that HIV-positive women adhered to national guidelines recommending EFF; this phenomenon has likely contributed to declining rates of vertical transmission in Brazil. Despite this success, many women experienced challenges with EFF. Greater support services may enhance Brazil's success in empowering HIV-positive women and eliminating vertical HIV transmission via breastfeeding.

HIV-free survival according to the early infant-feeding practices; a retrospective study in an anti-retroviral therapy programme in Makurdi, Nigeria

Background

In Nigeria, reports of the outcomes of prevention of mother to child transmission of HIV (PMTCT) interventions had been limited to the MTCT rates of HIV, with no information on HIV-free survival (HFS) in the HIV-exposed infants over time.

Methods

A retrospective study between June 2008 and December 2011 at the Federal Medical Centre, Makurdi, Nigeria comparing HFS rates at 3 and 18 months according to the infant feeding pattern at the 6th week of life. HFS was assessed by Kaplan-Meier analysis and association of maternal and infant variables and risk of HIV acquisition or death was tested in a Cox regression analysis.

Results

801 HIV uninfected infants at 6 weeks of life were studied in accordance with their reported cumulative feeding pattern. This includes 196 infants on exclusive breast feeding (EBF); 544 on exclusive breast milk substitute (EBMS) feeding and 61 on mixed feeding (MF). The overall HFS was 94.4% at 3 months and this declined significantly to 87.1% at the 18 months of age (p-value = 0.000). The infants on MF had the lowest HFS rates of 75.7% at 3 months and 69.8% at 18 months. The HFS rate for infants on EBF was 97.4% at 3 months and 92.5% at 18 month whilst infants on EBMS had HFS of 99.1% at 3 months and 86.2% at 18 months. A higher and significant drop off in HFS at the two time points occurred between infants on EBMS (12.9%) compared to infants on EBF (4.9%), p-value of 0.002, but not between infants on MF (5.9%) and EBMS, p-value of 0.114 and those on MF and EBF, p-value of 0.758. In Cox regression multivariate analyses; MF, gestational age of ˂ 37 weeks, and a high pre-delivery maternal viral load were consistently associated with HIV infection or death at 3 months and 18 months (p ˂0.05).

Conclusion

For a better HFS in our setting; MF must be avoided, efforts to deliver babies at term in mothers with reduced viral load are advocated and EBF must be promoted as the safest and the most feasible mode of infant-feeding.

Socio-cultural factors influencing the prevention of mother-to-child transmission of HIV in Nigeria: a synthesis of the literature

Background

Currently, Nigeria alone accounts for 30% of the burden of mother-to-child transmission of HIV. This review explores the socio-cultural factors influencing prevention of mother-to-child transmission of HIV (PMTCT) service uptake in Nigeria.

Methods

Using the PEN-3 cultural model as a guide, we searched electronic databases and conducted a synthesis of empirical studies conducted from 2001 to 2013 that reported the perceptions people have towards PMTCT, the enablers/resources that influence PMTCT service uptake, and the role of nurturers/family or community in shaping actions and decisions towards PMTCT service uptake.

Results

A total of 42 articles meeting the search criteria were retained in this review. Thirty-six (36) were quantitative cross-sectional surveys; three were mixed methods, while three were qualitative studies. The findings highlight that there are perceptions, ranging from positive to negative that influence PMTCT service uptake in Nigeria. Furthermore, lack of available, accessible, acceptable, and affordable resources negatively influence decisions and actions towards PMTCT. Finally, family contexts matter with decisions and actions towards PMTCT service uptake in Nigeria particularly with disclosure and non-disclosure of sero-positive status, fertility intentions and infant feeding choices.

Conclusion

As ambitious goals are established and unprecedented resources deployed towards the elimination of mother-to-child transmission of HIV globally by 2015, there is clearly a need to develop effective family-oriented, culture-centered community-based PMTCT programs in Nigeria so as to improve the low uptake of PMTCT services.

Trends of early infant feedings practices after counseling in infant born to HIV positive women in Yaoundé, Cameroon

The objective is to describe the trends of infant feedings choices in HIV context after infant feeding counseling. Descriptive retrospective study: Infant feeding counseling (IFC) sessions were offered to HIV pregnant women by the same team of counselors from April 2008 to December 2012. Counseling content was promoting either exclusive breastfeeding (EBF) or exclusive formula feeding (EFF) prior to 2010. Later on, versus EBF+ antiretroviral (ARV) drug given either to the mother or the infant or EFF was the gold standard. Mixed feeding was prohibited. Infants feeding were practices recorded at the first post natal visit. Main measurement: rate of EBF/ EFF per year and period. We included a total of 1114 live-born babies. During the five year the overall rate of EBF and EFF stood at 41% and 59% respectively. The rate of EBF/EFF was recorded as follow: varies from 25/75% in year one to 52/48% in year five(p≤0.001). The rate of mixed was virtually cancelled during the same period, 3/237 (1.2%) in year one to period 1/165 (0.6%) in the latest period. In conclusion, in Yaoundé, there is a slight increase in breastfeeding rate among HIV exposed infants during the first two months of life. Further investigations are required to confirm this tendency and analyze the new features of breastfeeding practices.

Commonalities and differences in infant feeding attitudes and practices in the context of HIV in sub-Saharan Africa: a metasynthesis

Exclusive breastfeeding (EBF) has been identified as a key intervention to promote infant health and to reduce the vertical transmission of HIV. Despite this knowledge and increased resources to promote EBF, the practice in sub-Saharan Africa (SSA) remains low among HIV+ women. Although a number of qualitative studies have been conducted throughout SSA, the influences on and consequences of infant feeding choices of HIV+ mothers' findings have not been regarded systematically. Therefore, our objective was to identify overarching themes, commonalities, and differences in infant feeding choices among qualitative studies with HIV+ mothers in SSA. Sixteen qualitative studies of infant feeding practices in the context of HIV were identified. Noblit and Hare's seven-step metasynthesis methodology was used to analyze the experiences of HIV+ women and those who provide infant feeding services/counseling. Data were available from approximately 920 participants (i.e., 750 HIV+ mothers, 109 health-care providers, and 62 family members) across 13 SSA countries from 2000 to 2011. From these data, five themes emerged within which 3-4 overarching key metaphors were identified. The consistency of key metaphors across a variety of geographic, economic, and cultural settings suggest the importance of approaching infant feeding holistically, within the context of maternal knowledge, health-care support, family resources, and cultural expectations. EBF campaigns in SSA are more likely to successfully support optimal health for infants and a safe supportive environment for their mothers when the impact of infant feeding decisions are evaluated across these themes.

Knowledge, attitudes and practices regarding infant feeding among HIV-infected pregnant women in Gaborone, Botswana: a cross-sectional survey

OBJECTIVES

To assess knowledge, attitudes and practices regarding infant feeding among HIV-positive pregnant women in Gaborone, Botswana, and factors that influence their infant feeding choices.

DESIGN

A cross-sectional study.

METHODS AND STUDY SETTING

A questionnaire survey of 96 HIV-positive pregnant women attending four public infectious disease control clinics in Gaborone, Botswana.

RESULTS

Only about half of the study participants had knowledge about prevention of mother-to-child transmission (PMTCT) services related to breastfeeding, and very few (19.8%) chose to breastfeed their infants exclusively. Results of multiple logistic regression analysis showed that receiving infant feeding counselling as part of the PMTCT programme was significantly associated with a decision to exclusively breastfeed (OR (95% CI) 5.38 (1.83 to 15.81)). Similarly, HIV-positive pregnant women who received breastfeeding counselling through the PMTCT programme had higher knowledge of PMTCT practices related to appropriate infant feeding (OR (95% CI) 5.91 (1.06 to 34.31)). Women who did not express concern about HIV stigma had significantly higher knowledge of PMTCT practices related to infant feeding (OR (95% CI) 5.91 (1.69 to 15.56)). Knowledge of PMTCT practices related to breastfeeding was negatively associated with the belief that breastfeeding could transmit HIV to the baby (OR (95% CI) 9.73 (3.37 to 28.08)).

CONCLUSIONS

Knowledge, attitudes and practices related to breastfeeding among HIV-positive pregnant women need further improvement, and the PMTCT programme should strengthen infant feeding counselling services to assist HIV-positive mothers in making informed and appropriate decisions regarding infant feeding.

Development of an AFASS assessment and screening tool towards the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa--a Delphi survey

Background

The rate of mother-to-child transmission of HIV, occurring during pregnancy, delivery/labour and breastfeeding, still remains high in Sub-Saharan Africa (SSA). The World Health Organization recommends HIV infected mothers exclusively breastfeed their infants, unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). Health care workers are responsible for providing counselling to mothers on the risks and benefits of infant feeding options allowing mothers to make an ‘informed choice’, but this role is challenging and mostly subjective. The aim of this study was to develop and content validate an AFASS assessment tool that could be used for infant feeding counselling in SSA.

Methods

An AFASS assessment tool was developed based on the evidence and tools available regarding why replacement feeding is not AFASS in SSA (15 questions). Fifty seven experts involved in PMTCT programmes in five SSA countries were approached to participate as members of the Delphi expert panel (purposive sampling and snowballing). A web-based survey, utilising a 4-point Likert scale, was employed to gain consensus (>75% agreement) from the expert panel following the Delphi technique.

Results

A final panel of 15 experts was obtained. Thirteen of the 15 questions in the tool achieved consensus agreement. Experts suggested some additional questions, and that double-barrelled questions were split. Consensus was achieved regarding the applicability and appropriateness of the tool within a SSA context. Experts all agreed that the tool will be useful for the purpose for which it was designed. Suggestions made by the expert panel were incorporated into the revised tool.

Conclusions

The findings of this study confirm that this AFASS counselling tool may be appropriate and useful for SSA. Ideally the revised tool should be tested by providers of infant feeding advice with the aim of adoption into routine PMTCT programmes in SSA. Within the context of the 2010 WHO guidelines which advocate a public health rather than an individualised approach, it may inform the WHO process of improving counselling tools for health care workers involved in PMTCT programmes.

Infant feeding practice and associated factors of HIV positive mothers attending prevention of mother to child transmission and antiretroviral therapy clinics in Gondar Town health institutions, Northwest Ethiopia

Background

It has been estimated that 430,000 children under 15 years of age were newly infected with HIV in 2008, and more than 71% are living in sub-Saharan Africa. In the absence of intervention to prevent mother-to-child transmission, 30-45% of infants born to HIV-positive mothers in developing countries become infected during pregnancy, delivery and breastfeeding. The aim of this study was to assess infant feeding practice and associated factors of HIV positive mothers attending prevention of mother to child transmission and antiretroviral therapy clinics of Northwest Ethiopia.

Methods

Institution based cross sectional study was conducted from January to May 2011 among all HIV positive mothers with less than two years old child attending prevention of mother to child transmission and antiretroviral therapy clinics in Gondar Town health institutions. A structured pre-tested questionnaire using interview technique was used for data collection. The data was entered and analyzed using SPSS version 16 statistical package.

Results

A total of 209 HIV positive mothers were included in the study. Of these, 187 (89.5%) had followed the recommended way of infant feeding practice while significant percentage (10.5%) had practiced mixed breast feeding. In multivariate analysis, disclosure of HIV status with their spouse, insufficient breast milk and occupational status were found to be independently associated (p-value of < 0.05) with recommended infant feeding practice. Lack of resource, stigma of HIV/AIDS, and husband opposition were also obtained as factors that influenced choice of infant feeding options by respondents.

Conclusions

Higher proportion of respondents used the recommended way of infant feeding practice by WHO as well as by Ethiopian Ministry of Health. However, mixed feeding in the first 6 months of age, an undesirable practice in infant feeding, were reported in this study. Infant feeding education that is aligned to national policy should be strengthened in primary health care, particularly in situations where prevention of mother to child transmission of HIV is prioritized.