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

"Discrimination is harder to live with than the disease": an interview study of the perceptions and experiences of sexual and reproductive health and rights among women living with HIV in Sweden

Around 40% of people living with human immunodeficiency virus (HIV) in Sweden are women. However, little is known about their experiences, particularly those related to sexual and reproductive health and rights (SRHR). This study aims to explore perceptions and experiences of SRHR among women living with HIV (LWH). Twelve interviews were conducted with women LWH from September to October 2019 and analysed using thematic analysis. The central theme describing participants' experiences of social relationships, intimate encounters and reproductive life, "Discrimination is harder to live with than the disease itself", is based on three themes that contain subthemes. Theme 1 describes how participants reconsider and reorient their sexual and reproductive life after diagnosis. Theme 2 highlights how (mis)perceptions of HIV affect sexual and reproductive life and lead to abusive treatment and internalisation. Theme 3 describes a paradoxical shift of responsibilities where participants experience being compelled to take greater responsibility in some situations and stripped of the right to decide in others. This study suggests that despite notable progress in HIV treatment, stigma and discrimination stemming from outdated beliefs and (mis)conceptions, ambiguous policies and guidelines, and unequal access to information affect SRHR experiences of women LWH more than the virus itself. The results emphasise the need to: update knowledge within healthcare settings and among the public; clarify ambiguous legislations and guidelines; ensure equal access to information to enable all women LWH to take informed decisions, make fully informed choices and realise their SRHR; and consider the diversity of women LWH and enable shared decision-making.

"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.

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.

Determinants of Adherence to National Infant Feeding Guidelines by Black Mothers Living with HIV

Objective

Worldwide, 160,000 children were newly infected with HIV in 2018; half of these were infected through breastfeeding. Infant feeding guidelines are distinct depending on each country's resources and national or sub-national guidelines. Because of divergent guidelines, the best infant feeding approach to prevent mother-to-child transmission can become unclear. The purpose of this study was to examine the sociocultural and psychosocial factors related to adherence to infant feeding guidelines through a city-level, North-South comparison of Black mothers living with HIV in Nigeria, Canada, and the United States.

Design

Using a cross-sectional multi-country survey, a convenience sample of 690 mothers were recruited from June 2016 - December 2019. Socio-cultural and psychosocial factors influencing infant feeding practices were measured.

Results

Using binary logistic regression, infant feeding attitudes (OR = 1.10), motherhood experiences (OR = 1.08), low hyper-vigilance score (OR = .93), paternal support (OR = 1.10) and perception that the health care provider supported adherence to infant feeding guidelines (OR = 2.43) were associated with guideline adherence. Mothers who had cultural beliefs that were inconsistent with infant feeding guidelines and mothers with low incomes (OR = 2.62) were less likely adherent with their country's guidelines.

Conclusion

City-level factors were not found to influence adherence to infant feeding guidelines; however, socio-cultural and psychosocial factors at community, family and individual levels were significant. Policy formulation and targeted interventions must be cognizant of cultural expectations of motherhood and mindful of psychosocial determinants of adherence to infant feeding guidelines.

Qualitative evidence synthesis of values and preferences to inform infant feeding in the context of non-HIV transmission risk

Background

Breastfeeding is recommended by many organisations, but feeding choices can take on complexity against a backdrop of a transmissible infection risk. The aim of this synthesis is to explore what is known about the values and preferences of pregnant women, mothers, family members and health practitioners, policy makers and providers (midwives) concerning feeding when there is a risk of Mother-to-Child transmission [MTCT] of an infectious disease (other than HIV/AIDS) to infants (0–2 years of age).

Methods

A qualitative evidence synthesis and GRADE CERQual assessment of relevant studies of values and preferences regarding infant feeding options in the context of non-HIV MTCT risk.

Results

The synthesis included eight qualitative studies. Four studies focussed on human T-cell lymphotropic virus type 1 (HTLV-1), three studies on Ebola, and one study on influenza vaccination. Mothers reported feeling sadness and guilt at not breastfeeding, while recognising that it was important for the health of their baby not to breastfeed. Mothers were reportedly appreciative of the provision of appropriate facilities, and the advice of those health professionals who knew about the diseases, but felt other professionals lacked knowledge about the transmission risk of conditions such as HTLV-1. All groups expressed concerns about social perceptions of not breastfeeding, as well as the alternatives. The evidence was coherent and relevant, but there were serious concerns about adequacy and methodological limitations, such as potential social desirability bias in some studies.

Conclusions

This synthesis describes the reported values and preferences of pregnant women, mothers, and others concerning feeding when there is a risk of Mother-to-Child transmission (MTCT) of an infectious disease (other than HIV/AIDS) to an infant when breastfeeding. However, the evidence in the peer-reviewed literature is limited both in quality and quantity.

Infant feeding guideline awareness among mothers living with HIV in North America and Nigeria

Background

WHO guidelines recommend breastfeeding for mothers living with HIV adherent to antiretroviral therapy in countries where formula is not accessible. In Canada and the US, guidelines for mothers living with HIV recommend exclusive formula feeding. Awareness of national infant feeding guidelines and socio-cultural factors influence infant feeding choices that may result in an increased risk of vertical transmission of HIV. The purpose of this paper is to present factors associated with awareness of guidelines among Black mothers living with HIV. Data were derived from a survey conducted as part of a recent international study that examined infant feeding practices among Black women living with HIV in Ottawa, Canada; Port Harcourt, Nigeria; and Miami, Florida.

Methods

Participants (n = 690) from Port Harcourt (n = 400), Miami (n = 201), and Ottawa (n = 89) were surveyed on their awareness of infant feeding guidelines for mothers living with HIV. Data were collected between November, 2016 and March, 2018.

Results

Participants’ mean ages were 34.3 ± 5.9 years. Across all sites, 15.4% (95% CI 13.2, 7.7) of mothers were NOT aware of their country’s infant feeding guidelines. Cultural beliefs (OR = 0.133, p = 0.004, 95% CI 0.03, 0.53) and functional social support influenced infant feeding choices (OR = 1.1, p = 0.034, 95% CI 1.01, 1.20) and were statistically significant predictors of guideline awareness (Χ² = 38.872, p < .05) after controlling for age, years of formal education, marital status, and country of residence. As agents of functional social support, family members and health workers (e.g., nurses, physicians, social workers, other health care workers) influenced participants’ awareness of infant feeding guidelines and guided them in their infant feeding choices.

Conclusions

Among participants, awareness of national infant feeding guidelines was associated with functional social support and cultural beliefs influenced infant feeding choices. Therefore, culturally adapted messaging via social supports already identified by mothers, including family relationships and health workers, is an appropriate way to enhance awareness of infant feeding guidelines. Ultimately, contributing to the global health goals of maternal health and reduced infant mortality.

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.

HIV-Infected Mothers Who Decide to Breastfeed Their Infants Under Close Supervision in Belgium: About Two Cases

Introduction: In most industrialized countries, human immunodeficiency virus (HIV) infection remains a formal contraindication to breastfeeding. However, for the past 9 years, the World Health Organization (WHO) has recommended, for developing countries, that mothers infected with HIV and treated by combined antiretroviral therapy (cART) should breastfeed their infants. HIV-infected women coming from developing countries and living in industrialized settings are increasingly expressing their natural desire to breastfeed. To avoid uncontrolled breastfeeding practices and reduce the risk of mother-to-child transmission of the virus, there is an urgent need to consider the wishes of these women. Discussion: We report two cases in which specific guidelines were implemented in order to support the mothers' choice to breastfeed in Belgium. As a result of different prophylactic measures including antiretrovirals in mothers and infants and close follow-up, none of the infants were infected. Conclusions: National or international recommendations for HIV-infected mothers who choose to breastfeed in industrialized countries remain unclear and discordant. There is an unmet need for experts to address this emerging issue and to develop an international consensus for the monitoring and prophylactic management of exposed-infants.