Breastfeeding and Complementary Feeding Practices among HIV-Exposed Infants in Coastal Tanzania

Infant and Young Child Feeding in the Context of HIV: An Exploration of Barriers in Exclusive Breastfeeding Practice in Dar Es Salaam, Tanzania

Background

Ensuring optimal nutrition through early breastfeeding is vital for infant mental development and overall health. HIV infections complicate decisions regarding exclusive breastfeeding, jeopardizing effective infant and young child feeding, which affects nutrition and health outcomes. Recognizing the lack of evidence on barriers to infant feeding in the context of HIV in Tanzania, this study was conducted to explore individual, household, and community obstacles in the Ilala district, Dar es Salaam.

Methods

The study used a hospital-based qualitative approach, focusing on HIV-positive mothers with infants aged 3-6 months in Dar es Salaam city. This involved reviewing mothers' files, conducting interviews with them, and interviewing Reproductive and Child Health clinics (RCH) and community healthcare providers. In total, 27 In-depth interviews were conducted until data saturation was reached, and thematic analysis was used to analyze collected data.

Findings

The study identified various barriers to exclusive breastfeeding, encompassing individual factors like work schedules, postpartum depression, and breast conditions. On the household level, barriers included limited access to resources, family influence, and HIV status disclosure reluctance due to stigma. In the community, low retention in the Prevention of Mother-to-Child Transmission (PMTCT) programs plays a pivotal role in hindering exclusive breastfeeding support for HIV-positive mothers.

Conclusion and Recommendations

HIV-positive mothers face diverse barriers ranging from individual, household, and community-based barriers. Policies supporting breastfeeding, early detection of postnatal depression and breast problems, and peer support for young mothers are of paramount importance. Food insecurity and HIV stigma should be tackled through income-generating activities, family involvement in PMTCT programs, and awareness campaigns. Community-based counselors play a crucial role in supporting HIV-positive mothers in their exclusive breastfeeding journey to improve PMTCT care retention.

Adherence to Optimal Breastfeeding Practices Among HIV-Positive Mothers in Kilimanjaro, Tanzania

Purpose

We sought to assess how HIV-positive mothers enrolled in the PMTCT program adhere to breastfeeding recommendations concerning early initiation of breastfeeding (EIBF), ie, within one hour of birth, pre-lacteal feeds, exclusive breastfeeding until six months (EBF), and continued breastfeeding to one year of age. This study was designed to assess the practices in response to changing recommendations for breastfeeding in HIV, which have differed drastically over the years.

Patients and Methods

We recruited 524 mother-child pairs from 37 PMTCT clinics across Kilimanjaro, Tanzania. The 5 clinics with the highest patient load in each of the 7 districts of Kilimanjaro were chosen, plus the zonal and municipal referral hospitals. The children were below two years of age and currently in the PMTCT program. We administered a questionnaire to assess the mother's practices in feeding the child. We used multiple logistic regression models to determine factors associated with EIBF, EBF, and continued breastfeeding.

Results

EIBF was achieved for 73.1% of babies. Cesarean delivery, low birth weight, and partner disclosure of HIV status were significant risk factors for not achieving EIBF. About 19% of children did not breastfeed exclusively. Of the 247 children ≥12 months old, 43.3% had stopped breastfeeding before 12 months. Counseling on ARV, having had >2 pregnancies while HIV-positive and EBF were associated with breastfeeding until 12 months old. Using ART for more than two years decreased the odds of EBF and continued breastfeeding to 12 months of age.

Conclusion

Adherence to breastfeeding recommendations for HIV-positive women is suboptimal, particularly in aspects of recent changes in recommendations such as continuing breastfeeding for one year. There is a missed opportunity for interventions such as counseling, which has shown to favor adherence. Health education and counseling are needed for providers and mothers to keep them abreast with the frequently changing recommendations.

Barriers and facilitators for early and exclusive breastfeeding in health facilities in Sub-Saharan Africa: a systematic review

BACKGROUND

Sub-Saharan Africa carries a disproportionate burden of under-five child deaths in the world and appropriate breastfeeding practices can support efforts to reduce child mortality rates. Health facilities are important in the promotion of early and exclusive breastfeeding. The purpose of this review was to examine facility-based barriers and facilitators to early and exclusive breastfeeding in Sub-Saharan Africa.

METHODS

A systematic search was conducted on Medline, Web of Science, CINAHL, African Journals Online and African Index Medicus from database inception to April 29, 2021 and primary research studies on breastfeeding practices in health facilities in Sub-Saharan Africa were included in the review. We assessed qualitative studies with the Critical Appraisal Skills Programme Qualitative Checklist and quantitative studies using the National Heart, Lung, and Blood Institute tool. The review protocol was registered to Prospero prior to conducting the review (CRD42020167414).

RESULTS

Of the 56 included studies, relatively few described health facility infrastructure and supplies-related issues (5, 11%) while caregiver factors were frequently described (35, 74%). Facility-based breastfeeding policies and guidelines were frequently available but challenged by implementation gaps, especially at lower health service levels. Facilitators included positive caregiver and health worker attitudes, knowledge and support during the postpartum period. Current studies have focused on caregiver factors, particularly around their knowledge and attitudes, while health facility infrastructure and supplies factors appear to be growing concerns, such as overcrowding and lack of privacy during breastfeeding counselling that lowers the openness and comfort of mothers especially those HIV-positive.

CONCLUSION

There has been a dramatic rise in rates of facility births in Sub-Saharan Africa, which must be taken into account when considering the capacities of health facilities to support breastfeeding practices. As the number of facility births rise in Sub-Saharan Africa, so does the responsibility of skilled healthcare workers to provide the necessary breastfeeding support and advice to caregivers. Our review highlighted that health facility infrastructure, supplies and staffing appears to be a neglected area in breastfeeding promotion and a need to strengthen respectful maternity care in the delivery of breastfeeding counselling, particularly in supporting HIV-positive mothers within the context of Sub-Saharan Africa.

Exclusive breastfeeding among HIV exposed infants from birth to 14 weeks of life in Lira, Northern Uganda: a prospective cohort study

Background

Breastfeeding is important for growth, development and survival of HIV exposed infants. Exclusive breastfeeding reduces the risk of morbidity, mortality and increases HIV free survival of infants. Evidence on risk factors for inappropriate breastfeeding in Northern Uganda is limited.

Objective

This study determined the risk factors for non-exclusivity of breastfeeding in the first 14 weeks of life.

Methods

This prospective cohort study was conducted among 466 mother-infant pairs between August 2018 and February 2020 in Lira district, Northern Uganda. HIV infected pregnant women were enrolled and followed up at delivery, 6- and 14- weeks postpartum. We used a structured questionnaire to obtain data on socio-demographic, reproductive-related, HIV-related characteristics and exclusive breastfeeding. Data were analysed using Stata version 14.0 (StataCorp, College Station, Texas, USA.). We estimated adjusted risk ratios using modified Poisson regression models.

Results

The proportion of HIV exposed infants that were exclusively breastfed reduced with increasing age. Risk factors for non-exclusive breastfeeding included infants being born to HIV infected women who: were in the highest socioeconomic strata (adjusted risk ratio = 1.5, 95%CI: 1.01– 2.1), whose delivery was supervised by a non-health worker (adjusted risk ratio = 1.6, 95%CI: 1.01– 2.7) and who had not adhered to their ART during pregnancy (adjusted risk ratio = 1.3, 95%CI: 1.01– 1.7).

Conclusions

HIV infected women: with highest socioeconomic status, whose delivery was not supervised by a health worker and who did not adhere to ART were less likely to practice exclusive breastfeeding. We recommend ART adherence and infant feeding counselling to be emphasised among HIV infected women who are at risk of having a home delivery, those with poor ART adherence and those of higher socioeconomic status. We also recommend integration of these services into other settings like homes, community and work places instead of limiting them to hospital settings.

Abbreviations

HIV: Human Immunodeficiency Virus; ART: Antiretroviral therapy; HEI: HIV exposed infant; PMTCT: Prevention of mother-to-child transmission of HIV; MTCT: Mother-to-child transmission of HIV; AFASS: Acceptable, Feasible, Affordable, Sustainable and Safe; LRRH: Lira regional referral hospital; CI: confidence interval; ARR: Adjusted risk ratio; SD: Standard deviation; PCA: Principal component analysis

Prevalence of vertical HIV infection and its risk factors among HIV exposed infants in East Africa: a systematic review and meta-analysis

Background

Human immunodeficiency virus (HIV) is one of the most important global health problems. More than one and half million of children are living with HIV in the world, and majority of them are found in sub-Saharan Africa. There are primary fragmented study findings, and no review was conducted with regard to vertical HIV infection in East Africa. Therefore, this review aimed to assess the prevalence of vertical HIV infection and its risk factors among HIV-exposed infants in East Africa.

Main body

Eligible studies were retrieved by relevant search terms in CINHAL, Pub-MED, Google Scholar, EMBASE, Web of Science, SCOPUS, Cochrane, African Journals Online databases, and Ethiopian University research repositories. Data were extracted with Microsoft Excel and analyzed with Stata version 11 software. The random effect model was used to estimate the pooled prevalence of vertical HIV infection in East Africa. The variation between studies was quantified with an I ² statistic test. Furthermore, sub-group and meta-regression analyses were done to identify the sources of heterogeneity between the studies. The publication bias was assessed by Egger test. This systematic review and meta-analysis have included a total of 33 research articles. The overall pooled prevalence of vertical HIV infection in East Africa was 7.68% with a 95% confidence interval [CI]: (6.23, 9.12) with a heterogeneity of I ² = 86.8 with a p value < 0.001. In subgroup analysis, the pooled prevalence of vertical HIV infection in cross-sectional studies was 6.58%, while in cohort studies were 9.37%. Mixed feeding, AOR = 6.22 (1.02, 11.41); home delivery, AOR = 2 (1.01, 3); mothers took ART less than 4 weeks, AOR = 1.92 (1.79, 2.06); and infants who have not received ARV prophylaxis, AOR = 2.02 (1.05, 2.98) were the associated factors for vertical HIV infection for exposed infants.

Conclusions

The pooled prevalence of the mother to child transmission of HIV is way more than the desired target of the World Health Organization, which is less than 5% in breastfeeding populations. Thus, strengthening the prevention of vertical HIV transmission, promotion of exclusive breastfeeding, timely initiation of ART prophylaxis for HIV exposed infants, encouragement of hospital delivery, and the start of ART at the time of diagnosis of every HIV-positive person may all reduce the transmission of vertical HIV infection.

Determinants of infant feeding practices among mothers living with HIV attending prevention of mother to child transmission Clinic at Kiambu Level 4 hospital, Kenya: a cross-sectional study

BACKGROUND

Human immunodeficiency virus infection and acquired immune deficiency syndrome is global pandemic with around 150,000 children infected with HIV in 2015. In Kenya, it is estimated that 11,000 children who are under 15 years old were infected. Safe infant feeding practices are the major important determinants of the prevention of mother to child transmission. The decision to breastfeed or not is considered a very tough choice for mothers living with HIV. This study assessed the infant feeding practices and its determinants among mothers living with HIV with infants 0-12 months old.

METHODS

This was a mixed methods cross-sectional study adopting qualitative and quantitative data collection procedures. A sample of 180 systematically selected mothers living with HIV with infants 0-12 months old attending prevention of mother to child transmission clinic participated in the study.

RESULTS

Exclusive breastfeeding rate was 71.4%, mixed feeding (18.2%) and replacement feeding (10.4%). Complementary feeding with continued breastfeeding rate was 63.1%. Similarly, qualitative results showed that exclusive breastfeeding was the most preferred feeding method by mothers living with HIV. Age (Adjusted Odds Ratio (AOR) 0.19; (95% Confidence Interval (CI) 0.41, 0.85; p = 0.030) and infant feeding practice knowledge (AOR 0.20; 95% CI 0.06, 0.64; p = 0.007) were determinants of exclusive breastfeeding. Education AOR 0.17; 95% CI 0.03, 0.85; p = 0.002) and occupation (AOR 3.91; 95% CI 1.24, 12.32; p = 0.020) were determinants of complementary feeding with continued breastfeeding.

CONCLUSION

Exclusive breastfeeding is attainable in this population. However, poor infant feeding practice knowledge led to non-adherence to safe infant feeding practices such as exclusive breastfeeding. Socio-demographic factors such as age, education and occupation were established as determinants of infant feeding practices among mothers living with HIV. Ministry of Health should come up with strategies on infant feeding counseling that are aligned to a local context, to allow mothers to understand the importance of recommended infant feeding options for HIV-exposed infants.

Infants and young children feeding practice and associated factors among HIV positive mothers of children 0-23 months in health centers of Gulele sub-city, Addis Ababa, Ethiopia

Objective

A health facility based cross sectional study design was conducted among 358 randomly selected HIV positive mothers attending at four health centers from February 1 to 28, 2018. Magnitude of HIV positive mothers’ child feeding practice and associated factors was assessed according to WHO recommendation. Data were collected using structured pretested questionnaire and entered into EPI data version 3.1 and exported to SPSS version 20 computer software for analysis.

Result

The magnitude of recommended way of infant feeding practice among HIV positive mothers attending public health centers in Gulele sub-city is 37.4%, 95% CI (32.26–42.67). Statistically significant correlates of HIV exposed infant feeding practice of mothers in this study were knowledge of mother on HIV exposed infant feeding practice (AOR = 1.80 (95% CI 1.04–3.01)), head of family being father (AOR = 0.17 (95% CI 0.03–0.87)), having family (relatives) support (AOR = 2.05 (95% CI 1.00–4.18)) and information on HIV exposed infant feeding, practice (AOR = 1.77 (95% CI 1.07–2.93)).

Increasing trend of exclusive breastfeeding over 12 years period (2002-2014) among women in Moshi, Tanzania

BACKGROUND

The World Health Organization has recommended that all infants under 6 months should be exclusively breastfed. An understanding of the trend of exclusive breastfeeding (EBF) over years and over smaller geographical areas is crucial to monitor the progress made in improving the proportions of infants' EBF.

METHODS

Data on infant feeding practices on 2315 mother-infant pairs from 2002 to 2014 were extracted from cohorts of women who delivered in the Moshi Municipality. Descriptive statistics were used to establish the trend of EBF up to 1, 3 and 6 months across waves (2002/2004 = wave I, 2005/2012 = wave II and 2013/2014 = wave III), to relate EBF up to 6 months to wealth quintiles and to HIV status of mothers.

RESULTS

The number of mothers in waves I, II and III were 1656 (71.5%), 256 (11.1%) and 403(17.4%) respectively. The percentages of EBF up to 6 months increased from 5.5, 13.7 to 16.9% from wave I to III. Overall, across the waves, the proportion of EBF up to 6 months among the mothers in the low wealth quintile was 4, 9 and 42%, and 7, 26 and 15% for the ones in the highest wealth quintile. The proportion of EBF up to 6 months has been increasing among HIV positive mothers while fluctuating among their counterparts across the waves.

CONCLUSION

The proportion of EBF up to 6 months has been increasing in the Moshi municipality but is below the national average. While establishing trends of EBF at the national level is commendable, research to establish trends over smaller geographical areas is needed to provide a true picture that may otherwise be masked.

Feeding practices according to the WHO- recommendations for HIV exposed children in northwest Ethiopia: A cross-sectional study

BACKGROUND

Malnutrition is a major problem for HIV exposed children, which is mainly caused by inappropriate feeding practice. Hence, the study aimed to assess adherence to optimal complementary feeding practices recommended by the WHO and associated factors among HIV exposed infants and young children aged 6-18 months in selected Amhara Regional Hospitals, northwest Ethiopia.

METHODS

An institution based cross-sectional study was conducted from March 10 to April 30, 2017. Systematic random sampling was employed to select study participants. A 24hr dietary recall was used to assess compliance with child optimal complementary feeding practice. Children were considered to have received optimal complementary feeding when they fulfill the criteria of the timely introduction of solid, semi-solid or soft foods, and minimum acceptable diet. Both bi-variable and multivariable binary logistic regression analysis were applied to identify factors associated with optimal complementary feeding practice.

RESULTS

In this study, about 25.5% of HIV exposed children received optimal complementary feeding. More than two thirds, (70.7%), and more than a third, (36.9%), of the children received the recommended meal frequency and minimum acceptable diet, respectively. Father's education; primary (AOR = 2.39; 95%CI: 1.18, 4.88) and higher (AOR = 2.44; 95%CI: 1.37, 4.34), rich household wealth status (AOR = 2.08; 95%CI: 1.13, 3.82), and satisfactory media exposure (AOR = 1.70; 95%CI: 1.04, 2.78), and mothers disclosing that they have HIV (AOR = 1.78; 95%CI: 1.07, 2.98) were positively associated with optimal feeding practices.

CONCLUSION

Optimal complementary feeding practice was not at the level recommended by the WHO. Household wealth status, mother's HIV disclosure, and paternal educational status were positively associated with optimal complementary feeding practices among HIV exposed children. Therefore, a social safety net program for HIV positive mothers is recommended. In addition, strengthening maternal counseling about disclosure of HIV status and increased media promotion of optimal child feeding is important to achieve the recommended feeding goals.

HIV status disclosure among postpartum women in rural Tanzania: predictors, experiences and uptake of a nurse-facilitated disclosure intervention

HIV status disclosure is a key support strategy to start and maintain HIV care and treatment and to reduce HIV transmission. We explored the patterns and correlates of disclosure and described the effectiveness of nurse-facilitated disclosure among HIV-infected mothers of infants in coastal Tanzania. We enrolled 400 HIV positive women in an observational longitudinal study in 2011, interviewed them about maternal sociodemographic and economic characteristics, maternal and child health and history of HIV disclosure experiences and offered nurse-facilitated HIV disclosure at enrolment or at follow-up 1 month later. Mothers frequently disclosed their status to husbands and/or female relatives and experienced predominantly positive reactions. Economically vulnerable women disclosed more often to elderly female relatives, indicating that Infant and Young Child Feeding counseling given to HIV positive women should garner the support of elderly female relatives for implementing appropriate feeding practices. Nurse-facilitated disclosure was feasible in this low resource setting and was used by patients to help them with both first-time disclosure and disclosure to new persons.

Infant and Young Child Feeding Counseling, Decision-Making, and Practices Among HIV-Infected Women in Malawi's Option B+ Prevention of Mother-to-Child Transmission Program: A Mixed Methods Study

This study examined infant and young child feeding (IYCF) counseling, decision-making, and practices among HIV-infected women with children 0-23 months participating in Malawi's Option B+ prevention of mother-to-child transmission (PMTCT) program. We conducted 160 survey interviews, 32 in-depth interviews, and 32 observations of PMTCT visits. Surveys indicated that exclusive breastfeeding was common (75 %) among children <6 months, while minimum dietary diversity (41 %) and minimum acceptable diet (40 %) for children 6-23 months occurred less often. In-depth interviews supported these findings. Most women felt comfortable with current breastfeeding recommendations, but chronic food insecurity made it difficult for them to follow complementary feeding guidelines. Women trusted IYCF advice from health workers, but mainly received it during pregnancy. During observations of postnatal PMTCT visits, health workers infrequently advised on breastfeeding (41 % of visits) or complementary feeding (29 % of visits). This represents a missed opportunity for health workers to support optimal IYCF practices within Option B+.