Are infant feeding options that are recommended for mothers with HIV acceptable, feasible, affordable, sustainable and safe? Pregnant women's perspectives

Facilitators and Barriers of Wet Nursing from Antiquity to the Present: A Narrative Review with Implications for Emergencies

Background: If maternal breastfeeding is not possible, wet nursing allows infants to receive the nutrition and protection against disease that breastfeeding provides. Such protection may be particularly valuable in emergencies. However, while wet nursing is recommended in the Operational Guidance on Infant and Young Child Feeding in Emergencies it is underutilized. This narrative review aimed to develop an understanding of wet nursing practice across time and location, and why wet nursing is currently so little supported to inform interventions to support wet nursing in emergencies. Method: Medline and Embase were searched for "wet nursing," "cross-nursing," "shared breastfeeding," and "non-maternal nursing". Included articles were inductively analyzed to identify positive and negative factors associated with previous wet nursing practice. Results: This review included 74 records. Our analysis of the wet nursing literature includes historical and contemporary themes with milk kinship and wet nursing as risky being shared themes across time periods. Our analysis revealed that it is how wet nursing is undertaken that influences whether it benefits women, children, and societies or not. Facilitators and barriers to wet nursing in emergencies related to infant mortality rates, cultural and individual support for wet nursing, availability of wet nurses, and resources to support wet nursing. Conclusion: Understanding the conditions under which wet nursing has positive outcomes and what can be done to facilitate beneficial wet nursing practices will assist in enabling wet nursing to be more commonly implemented in emergencies.

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

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

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.

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.

HIV disclosure to partners and family among women enrolled in prevention of mother to child transmission of HIV program: implications for infant feeding in poor resourced communities in South Africa

The introduction of routine HIV counselling and testing (HCT) has increased the number of pregnant women being tested and receiving prevention of mother to child transmission of HIV (PMTCT) interventions in South Africa. While many women may enroll in PMTCT, there are barriers that hinder the success of PMTCT programmes. The success of the PMTCT is dependent on the optimal utilization of PMTCT interventions which require the support of the woman's partner, and other members of her family. We conducted focus groups interviews with 25 HIV-positive post-natal women enrolled in PMTCT, in the City of Tshwane, South Africa. The study explored HIV-positive status disclosure to partners and significant family members and assessed the effect of nondisclosure on exclusive infant feeding. Most women disclosed to partners while few disclosed to significant family members. Most women initiated mixed feeding practices as early as one month and reported that they were pressurized by the family to mix feed. Mixed feeding was common among women who had not disclosed their HIV-positive status to families, and women who had limited understanding of mother to child transmission of HIV. Women who disclosed to partners and family were supported to adhere to the feeding option of choice. Health providers have a critical role to play in developing interventions to support HIV pregnant women to disclose in order to avoid mixed feeding. Improving the quality of information provided to HIV-positive pregnant women during counselling will also reduce mixed feeding.

Promoting safe infant feeding practices - the importance of structural, social and contextual factors in Southern Africa

There has been significant progress towards the goal of eliminating vertical transmission of HIV by 2015. However, a question that remains is how we can most effectively prevent late postnatal transmission of HIV through infant feeding. Guidelines published by the World Health Organization in 2010 have been widely adopted. These guidelines place strong emphasis on exclusive breastfeeding, in some countries over-turning a prior emphasis on formula feeding. Where available, provision of antiretroviral treatment for HIV-positive mothers or prophylaxis for infants offers additional protection against vertical transmission through infant feeding. However, merely changing guidelines is not sufficient to change practice, particularly with regard to culturally sanctioned forms of feeding, such as mixed feeding. This commentary highlights structural, social and contextual barriers to effective implementation of the guidelines and suggests ways to address some of these barriers.

Individual and Community Perspectives, Attitudes, and Practices to Mother-to-Child-Transmission and Infant Feeding among HIV-Positive Mothers in Sub-Saharan Africa: A Systematic Literature Review

OBJECTIVES

International guidelines on infant feeding for HIV- positive mothers promote Exclusive Replacement Feeding (ERF) (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission of HIV and is strongly discouraged. However, little is known about the ability of women to adhere to recommended feeding strategies to prevent mother-to-child transmission (MTCT) of HIV from breast milk. The objective of this study was to assess the individual and community-level factors that affect perspectives, attitudes and practices of HIV-positive mothers on MTCT and infant feeding in sub-Saharan Africa as documented in peer-reviewed and grey literature.

METHODS

This work is based on an extensive review of peer-reviewed articles and grey literature from the period 2000-2012. The literature search was carried out using electronic databases like Medline Ovid, Google Scholar, PubMed and EBSCOhost. Both quantitative and qualitative studies written in English language on HIV and infant feeding with particular emphasis on Sub-Saharan Africa were included.

RESULTS

The review found low adherence to the chosen infant feeding method by HIV-positive mothers. The following factors emerged as influencing infant feeding decisions: cultural and social norms; economic conditions; inadequate counselling; and mother's level of education.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

Unless local beliefs and customs surrounding infant feeding is understood by policy makers and program implementers, Prevention of Mother-to-Child Transmission (PMTCT) programs will only be partially successful in influencing feeding practices of HIV-positive women. Hence programs should provide affordable, acceptable, feasible, safe and sustainable feeding recommendations that do not erode strong cultural practices. Advice to HIV-positive mothers should be based on local conditions that are acceptable to the community.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

BACKGROUND

Despite efforts to increase the uptake of prevention of mother to child transmission of HIV (PMTCT) services, coverage is still lower than desired in developing countries. A lack of male partner involvement in PMTCT services is a major barrier for women to access these services.

OBJECTIVES

To evaluate the impact of interventions which aim to enhance male involvement to increase women's uptake of PMTCT interventions in developing countries.

SEARCH METHODS

We searched the following databases from the year 2000 to November 2011: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, the WHO Global Health Library, ClinicalTrials.gov, Current Controlled Trials, AEGIS, CROI, IAS, IAC web sites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised controlled trials, quasi-randomised controlled trials, controlled before and after studies and interrupted time series studies assessing interventions to increase male involvement for improvement of uptake PMTCT services in low- and middle-income countries..

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched, screened, assessed study quality and extracted data. A third reviewer resolved any disagreement.

MAIN RESULTS

Only one study met the inclusion criteria, an RCT conducted in Tanzania between May 2003 and October 2004. Women in the intervention group (n=760) received a letter for their male partners, which invited them to return together to receive Couple Voluntary Counselling and Testing (CVCT) for HIV. Women in the control group (n=761) received individual HIV VCT during their first ANC visit and then usual care. The percentages of women who received HIV VCT and collected their results were 48%, 45% and 39% in the intervention group and 93%, 78% and 71% in the control group (p <0,001). Only 33% of women in the intervention group returned with their male partners and only 47% of them went through the whole CVCT process. The proportion of women who received HIV prophylaxis at delivery was not different between the two arms (27% in the intervention and 22% in the control group). The study had a high risk of bias.  

AUTHORS' CONCLUSIONS

We found only one eligible study that assessed the effectiveness of male involvement in improving women's uptake of PMTCT services, which only focused on one part of the perinatal PMTCT cascade. We urgently need more rigorously designed studies assessing the impact of male engagement interventions on women's uptake of PMTCT services to know if this intervention can contribute to improve uptake of PMTCT services and reduce vertical transmission of HIV in children.   

A review of evidence for transmission of HIV from children to breastfeeding women and implications for prevention

BACKGROUND

Child-to-breastfeeding woman transmission (CBWT) of HIV occurs when an HIV-infected infant transmits the virus to an HIV-uninfected woman through breastfeeding. Transmission likely occurs as a result of breastfeeding contact during a period of epithelial disruption, such as maternal skin fissures and/or infant stomatitis. Despite extensive epidemiologic and phylogenetic evidence, however, CBWT of HIV continues to be overlooked.

OBJECTIVE

This article summarizes the available evidence for CBWT from nosocomial outbreaks, during which nosocomially HIV-infected infants transmitted the virus to their mothers through breastfeeding. This article also explores the CBWT risk associated with HIV-infected orphans and their female caretakers, and the lack of guidance regarding CBWT prevention in infant feeding recommendations.

METHODS

We searched online databases including PubMed and ScienceDirect for English language articles published from January 1975 to January 2011 using the search terms "HIV," "perinatal," "child-to-mother" and "breastfeeding." The citations from all selected articles were reviewed for additional studies.

RESULTS

We identified 5 studies documenting cases of CBWT. Two studies contained data on the number of HIV-infected women, as well as the proportion breastfeeding. Rates of CBWT ranged from 40% to 60% among women reporting breastfeeding after their infants were infected.

CONCLUSIONS

Poor infection control practices, especially in areas of high HIV prevalence, have resulted in pediatric HIV infections and put breastfeeding women at risk for CBWT. Current infant feeding guidelines and HIV prevention messages do not address CBWT, and fail to provide strategies to help women reduce their risk of acquiring HIV during breastfeeding.

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.

Food insecurity is associated with attitudes towards exclusive breastfeeding among women in urban Kenya

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers (n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months.

The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers

Improving the nutritional status of infants and young children in developing countries depends to a significant extent on adoption of optimal nutrition-related practices within the context of the household. Most policies, research and programmes on child nutrition in non-Western societies focus narrowly on the mother-child dyad and fail to consider the wider household and community environments in which other actors, hierarchical patterns of authority and informal communication networks operate and influence such practices. In particular, the role and influence of senior women, or grandmothers, has received limited attention. Research dealing with child nutrition from numerous socio-cultural settings in Africa, Asia and Latin America reveals three common patterns related to the social dynamics and decision-making within households and communities. First, grandmothers play a central role as advisers to younger women and as caregivers of both women and children on nutrition and health issues. Second, grandmother social networks exercise collective influence on maternal and child nutrition-related practices, specifically regarding pregnancy, feeding and care of infants, young children and sick children. Third, men play a relatively limited role in day-to-day child nutrition within family systems. The research reviewed supports the need to re-conceptualize the parameters considered in nutritional policies and programmes by expanding the focus beyond the mother-child dyad to include grandmothers given their role as culturally designated advisers and caregivers.

Current knowledge and future research on infant feeding in the context of HIV: basic, clinical, behavioral, and programmatic perspectives

In 2008, between 129,000 and 194,000 of the 430,000 pediatric HIV infections worldwide were attributable to breastfeeding. Yet in many settings, the health, economic, and social consequences of not breastfeeding would have dire consequences for many more children. In the first part of this review we provide an overview of current knowledge about infant feeding in the context of HIV. Namely, we describe the benefits and risks of breastmilk, the evolution of recommended infant feeding modalities in high-income and low-income countries in the last two decades, and contextualize the recently revised guidelines for infant feeding in the context of HIV current knowledge. In the second section, we suggest areas for future research on the postnatal prevention of mother-to-child transmission of HIV (PMTCT) in developing and industrialized countries. We suggest two shifts in perspective. The first is to evaluate PMTCT interventions more holistically, to include the psychosocial and economic consequences as well as the biomedical ones. The second shift in perspective should be one that contextualizes postnatal PMTCT efforts in the cascade of maternal health services. We conclude by discussing basic, clinical, behavioral, and programmatic research questions pertaining to a number of PMTCT efforts, including extended postnatal ARV prophylaxis, exclusive breastfeeding promotion, counseling, breast milk pasteurization, breast milk banking, novel techniques for making breast milk safer, and optimal breastfeeding practices. We believe the research efforts outlined here will maximize the number of healthy, thriving, HIV-free children around the world.

"It is her responsibility": partner involvement in prevention of mother to child transmission of HIV programmes, northern Tanzania

BACKGROUND

Partner involvement has been deemed fundamental in prevention of mother to child transmission (PMTCT) programmes, but is difficult to achieve. This study aimed to explore acceptability of the PMTCT programme components and to identify structural and cultural challenges to male involvement.

METHODS

The study was conducted during 2007-2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, and included focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunization at five reproductive and child health clinics.

RESULTS

Routine testing for HIV of women at the antenatal clinic was highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place.

CONCLUSIONS

Deep-seated ideas about gender roles and hierarchy are major obstacles to male participation in the PMTCT programme. Empowering women remains a huge challenge. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritized for the PMTCT programme to achieve its potential.

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

OBJECTIVES

To evaluate the infant-feeding choices, practices and possible determinants among HIV-positive women enrolled in a prevention of mother-to-child transmission programme in Ibadan, Nigeria.

METHODS

A cross-sectional survey involving HIV-positive women who had received infant-feeding counselling prior to delivery. A structured questionnaire was administered at < or = 72 hrs and not > or = 6 weeks of delivery and was complemented with an in-depth interview.

RESULTS

A total of 241 women were studied. The choice of infant feeding was formula for 223 (93.5%) and in actual practice, 9 (3.7%) mothers admitted mixed feeding. There was no statistical significant difference between the feeding pattern and the socio-demographic characteristics. The major factor influencing the choice of infant feeding was "The desire to reduce the risk of transmission" which was recorded among 204 (84.6%) of the women. Greatest support in maintaining infant-feeding option was the spouse (36.1%). From the in-depth interview of 23 non-breastfeeding (infant formula) mothers, the major challenge faced was stigmatisation.

CONCLUSION

Despite the premium placed on breastfeeding in this locality, with infant-feeding counselling, most HIV-positive women chose and practiced formula feeding. It is necessary to address how best HIV-positive mothers could handle or overcome criticisms and stigmatisation by others.

Ways ahead: protecting, promoting and supporting breastfeeding in the context of HIV

The HIV epidemic coupled with the assumed benefits of infant formula for the children of all HIV-infected mothers have in complex ways changed public ideas about infant feeding and represents a threat to well established breastfeeding practices. In the wake of the confusion that postnatal prevention of mother to child transmission of HIV (PMTCT) interventions have created among HIV-infected mothers, infant feeding counsellors and the public at large, it is time to reinstate the principles of the Innocenti Declaration to protect, promote and support breastfeeding in the context of HIV. The challenge that lies ahead is a search for ways to restore the trust in breastfeeding as the normal and safest way to feed an infant. This requires continued research as well as concerted advocacy and action.

The difficulty with responding to policy changes for HIV and infant feeding in Malawi

BACKGROUND

When and how to wean breastfed infants exposed to HIV infection has provoked extensive debate, particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is global consensus on optimal infant-feeding practices in the form of guidelines, practices are sub-optimal in much of sub-Saharan Africa. Policy-makers and health workers face many challenges in adapting and implementing these guidelines.

METHODS

This paper is based on in-depth interviews with five policy-makers and 11 providers of interventions to prevent mother-to-child transmission (PMTCT) of HIV, participant observations during clinic sessions and site visits.

RESULTS

The difficulties with adapting the global infant-feeding guidelines in Malawi have affected the provision of services. There was a lack of consensus on HIV and infant-feeding at all levels and general confusion about the 2006 guidelines, particularly those recommending continued breastfeeding after six months if replacement feeding is not acceptable, feasible, affordable, sustainable and safe. Health workers found it particularly difficult to advise women to continue breastfeeding after six months. They worried that they would lose the trust of the PMTCT clients and the population at large, and they feared that continued breastfeeding was unsafe. Optimal support for HIV-infected women was noted in programmes where health workers were multi-skilled; coordinated their efforts and had functional, multidisciplinary task forces and engaged communities. The recent 2009 recommendations are the first to support antiretroviral (ARV) use by mothers or children during breastfeeding. Besides promoting maternal health and providing protection against HIV infection in children, the new Rapid Advice has the potential to resolve the difficulties and confusion experienced by health workers in Malawi.

CONCLUSIONS

The process of integrating new evidence into institutionalised actions takes time. The challenge of keeping programmes, and especially health workers, up-to-standard is a dynamic process. Effective programmes require more than basic resources. Along with up-to-date information, health workers need contextualized, easy-to-follow guidelines in order to effectively provide services. They also require supportive supervision during the processes of change. Policy-makers should ensure that consensus is carefully considered and that comprehensive perspectives are incorporated when adapting the global guidelines.

Mothers' knowledge and utilization of prevention of mother to child transmission services in northern Tanzania

BACKGROUND

More than 90% of children living with HIV have been infected through mother to child transmission. The aims of our present study were to: (1) assess the utilization of the prevention of mother to child transmission (PMTCT) services in five reproductive and child health clinics in Moshi, northern Tanzania, after the implementation of routine counselling and testing; (2) explore the level of knowledge the postnatal mothers had about PMTCT; and (3) assess the quality of the counselling given.

METHODS

This study was conducted in 2007 and 2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used. We interviewed 446 mothers when they brought their four-week-old infants to five reproductive and child health clinics for immunization. On average, the urban clinics included in the study had implemented the programme two years earlier than the rural clinics. We also conducted 13 in-depth interviews with mothers and nurses, four focus group discussions with mothers, and four observations of mothers receiving counselling.

RESULTS

Nearly all mothers (98%) were offered HIV testing, and all who were offered accepted. However, the counselling was hasty with little time for clarifications. Mothers attending urban antenatal clinics tended to be more knowledgeable about PMTCT than the rural attendees. Compared with previous studies in the area, our study found that PMTCT knowledge had increased and the counsellors had greater confidence in their counselling.

CONCLUSIONS

Routine counselling and testing for HIV at the antenatal clinics was greatly accepted and included practically every mother in this time period. However, the counselling was suboptimal due to time and resource constraints. We interpret the higher level of PMTCT knowledge among the urban as opposed to the rural attendees as a result of differences in the start up of the PMTCT programme and, thus, programme maturation. After comparison with earlier studies conducted in this setting, we conclude that when the programme has had time to get established, both its acceptance and the understanding of the topics dealt with during the counselling increases.

Predictors of breastfeeding cessation among HIV-infected women in Dar es Salaam, Tanzania

This paper examines predictors of breastfeeding cessation among a cohort of human immunodeficiency virus (HIV)-infected women. This was a prospective follow-up study of HIV-infected women who participated in a randomized micronutrient supplementation trial conducted in Dar es Salaam, Tanzania. 795 HIV-infected Tanzanian women with singleton newborns were utilized from the cohort for this analysis. The proportion of women breastfeeding declined from 95% at 12 months to 11% at 24 months. The multivariate analysis showed breastfeeding cessation was significantly associated with increasing calendar year of delivery from 1995 to 1997 [risk ratio (RR), 1.36; 95% confidence interval (CI) 1.13-1.63], having a new pregnancy (RR 1.33; 95% CI 1.10-1.61), overweight [body mass index (BMI) ≥25 kg m(-2) ; RR 1.37; 95% CI 1.07-1.75], underweight (BMI <18.5kg m(-2) ; RR 1.29; 95% CI 1.00-1.65), introduction of cow's milk at infant's age of 4 months (RR 1.30; 95% CI 1.04-1.63). Material and social support was associated with decreased likelihood of cessation (RR 0.83; 95% CI 0.68-1.02). Demographic, health and nutritional factors among women and infants are associated with decisions by HIV-infected women to cease breastfeeding. The impact of breastfeeding counselling programs for HIV-infected African women should consider individual maternal, social and health contexts.

Assessment of knowledge, attitudes and practices of infant feeding in the context of HIV: a case study from western Kenya

Guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialisation processes, gender dimensions and socio-economic status within communities should be considered in recommending feasible and sustainable options. The objective of this study was to assess the knowledge, attitudes and practices with regards to infant feeding in the context of HIV. A cross-sectional study was conducted between November 2003 and January 2004. The study was carried out in Kosirai Division, Nandi-North District, in western Kenya. The target population was community members aged 18 - 45 years and key informants aged 18 years and above. Structured questionnaires and in-depth interviews were used to collect data. Multistage and snowball sampling methods were used to identify study participants. Quantitative data were analysed using the SPSS statistical package for social scientists (Version 12). Cross-tabulations were calculated and Pearson's chi-square test used to test significance of relationships between categorical variables. Recorded qualitative data were transcribed and coded. Themes were developed and integrated. A generation of concepts was used to organise the presentation into summaries, interpretations and text. A total of 385 individuals participated in the survey, 50% of whom were women. There were 30 key informants. Farming was the main source of income but half of the women (49.7% ) had no income. Most of the respondents (85.5% ) knew of breastfeeding as a route of HIV transmission with sex (p=0.003) and age (p=0.000) being highly associated with this knowledge. Breastfeeding was the norm although exclusive breastfeeding was not practised. Cow's milk, the main breast milk substitute, was reported as being given to infants as early as two weeks. It was the most popular (93.5% ) infant feeding option in the context of HIV/AIDS. Heating expressed milk, wet nursing and milk banks were least preferred. Thus, the social, cultural and psychological complexity of infant feeding practices should be taken into account when advocating appropriate infant feeding options. Further research is required to determine the safety of using cow's milk as an infant feeding option. Community engagement, including education and awareness strategies, specific to the benefits of exclusive breastfeeding as a mechanism to reduce the risk of HIV transmission is urgently needed.

Perceived incentives and barriers to exclusive breastfeeding among periurban Ghanaian women

Focus group discussions were conducted to elicit the perceived incentives and barriers to exclusive breastfeeding in Ghana. Thirty-five breastfeeding women were recruited from the Manya and Yilo Krobo districts of the eastern region. Participants had a mean age of 27.5 years and had at least one child < 4 months old. Almost all of the participants believed that exclusive breastfeeding is the superior infant feeding method and should be practiced for the first 6 months postpartum. However, there was widespread belief that infants can be given water if it is clean. Mothers reported that exclusive breastfeeding was easier when breast milk began to flow soon after delivery. The main obstacles to exclusive breastfeeding identified were maternal employment, breast and nipple problems, perceived milk insufficiency, and pressure from family. Addressing the concerns put forward by these participants can be used to enhance exclusive breastfeeding promotion in this region.

Breast milk as the "water that supports and preserves life"--socio-cultural constructions of breastfeeding and their implications for the prevention of mother to child transmission of HIV in sub-Saharan Africa

OBJECTIVES

Complementary breastfeeding represents an important source of risk of HIV infection for infants born to HIV positive mothers. The World Health Organisation recommends that infants born to HIV positive mothers receive either replacement feeding or exclusive breastfeeding (EBF) followed by early weaning. Beyond the clinical and epidemiological debate, it remains unclear how acceptable and feasible the two options are for rural populations in sub-Saharan Africa. This qualitative study aims to fill this gap in knowledge by exploring both the socio-cultural construction and the practice of breastfeeding in the Nouna Health District, rural Burkina Faso.

METHODS

Information was collected through 32 individual interviews and 3 focus group discussions with women of all ages, and 6 interviews with local guérisseurs.

RESULTS

The findings highlight that breastfeeding is perceived as central to motherhood, but that women practice complementary, rather than exclusive, breastfeeding. The findings also indicate that women recognise both the nutritional value of breast milk and its potential to act as a source of disease transmission.

CONCLUSIONS

The findings suggest that given the socio-cultural importance attributed to breastfeeding and the prevailing poverty, it may be more acceptable and more feasible to promote EBF followed by early weaning than replacement feeding. A set of operational strategies are proposed to favour the prevention of mother to child transmission of HIV in the respect of the local socio-cultural setting.

Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice

OBJECTIVE

To examine infant feeding intentions of HIV-infected and uninfected women and the appropriateness of their choices according to their home resources; and to determine their adherence to their intentions in the first postnatal week.

METHODS

Feeding intentions of pregnant women were compared against four resources that facilitate replacement feeding: clean water, adequate fuel, access to a refrigerator and regular maternal income. First-week feeding practices were documented.

FINDINGS

The antenatal feeding intentions of 1253 HIV-infected women were: exclusive breastfeeding 73%; replacement feeding 9%; undecided 18%. Three percent had access to all four resources, of whom 23% chose replacement feeding. Of those choosing replacement feeding, 8% had access to all four resources. A clean water supply and regular maternal income were independently associated with intention to replacement feed (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI) 1.2-3.2; AOR 2.1, 95% CI: 1.2-3.5, respectively). Significantly more HIV-infected women intending to exclusively breastfeed, rather than replacement feed, adhered to their intention in week one (exclusive breastfeeding 78%; replacement feeding 42%; P<0.001). Of 1238 HIV-uninfected women, 82% intended to exclusively breastfeed; 2% to replacement feed; and 16% were undecided. Seventy-five percent who intended to exclusively breastfeed adhered to this intention postnatally, and only 11 infants (<1%) received no breast milk. The number of antenatal home visits significantly influenced adherence to feeding intention.

CONCLUSION

Most HIV-infected women did not have the resources for safe replacement feeding, instead choosing appropriately to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counselling and support, spillover of suboptimal feeding practices to HIV-negative women is minimal.

Making the choice: the translation of global HIV and infant feeding policy to local practice among mothers in Pune, India

In 2003, India had over 5.1 million infected individuals living with HIV/AIDS. The percentage of all HIV cases attributed to perinatal transmission has been increasing steadily from 0.33% of total cases in 1999 to 2.80% in 2004. Recent statistics indicate that over 130,000 infants have been infected through this route. Despite recent advances in reducing in utero and interpartum transmission with the use of antiretrovirals, there is a critical need to make infant feeding safer. Current UNAIDS/WHO/UNICEF recommendations stress avoidance of all breast-feeding if replacement feeding fulfills the key requirements of being affordable, feasible, acceptable, sustainable, and safe. In this paper, we examine how the UNAIDS/WHO/UNICEF recommendations have been actualized within the context of an urban government hospital in India. The documented patterns of infant feeding by HIV-positive mothers in Pune, India, from 2000 to 2004, highlight the complexities of making an informed and healthy choice under suboptimal conditions. The data indicate that interpersonal variations in the key requirements greatly influence the optimal practice to minimize mortality risks. Moreover, local information on health outcomes is crucial to tailoring policy recommendations to save lives. We propose the development of a decision-making algorithm that includes factors affecting mother-to-infant transmission, including site-specific data on health risks to the mother and the child. Such an algorithm would allow identification of the healthiest feeding choice and would minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.