Experiences of breastfeeding and vulnerability among a group of HIV-positive women in Durban, South Africa

Vulnerability in maternal, new-born, and child health in low- and middle-income countries: Findings from a scoping review

Objectives

To identify and synthesise prevailing definitions and indices of vulnerability in maternal, new-born and child health (MNCH) research and health programs in low- and middle-income countries.

Design and setting

Scoping review using Arksey and O’Malley’s framework and a Delphi survey for consensus building.

Participants

Mothers, new-borns, and children living in low- and middle-income countries were selected as participants.

Outcomes

Vulnerability as defined by the authors was deduced from the studies.

Results

A total of 61 studies were included in this scoping review. Of this, 22 were publications on vulnerability in the context of maternal health and 40 were on new-born and child health. Definitions used in included studies can be broadly categorised into three domains: biological, socioeconomic, and environmental. Eleven studies defined vulnerability in the context of maternal health, five reported on the scales used to measure vulnerability in maternal health and only one study used a validated scale. Of the 40 included studies on vulnerability in child health, 19 defined vulnerability in the context of new-born and/or child health, 15 reported on the scales used to measure vulnerability in child health and nine reported on childhood vulnerability indices. As it was difficult to synthesise the definitions, their keywords were extracted to generate new candidate definitions for vulnerability in MNCH.

Conclusion

Included studies paid greater attention to new-born/ child vulnerability than maternal vulnerability, with authors defining the terms differently. A definition which helps in improving the description of vulnerability in MNCH across various programs and researchers was arrived at. This will further help in streamlining research and interventions which can influence the design of high impact MNCH programs.

Scoping review registration

The protocol for this review was registered in the open science framework at the registered address (https://osf.io/jt6nr).

Validation of the Bayley Infant Neurodevelopmental Screener Among HIV-Exposed Infants in Rural South Africa

INTRODUCTION

Screening for developmental delays during critical periods of infant development is essential for early detection and intervention. Among high-risk infants in resource-limited settings, including those who are HIV exposed, there is a greater need for screening. This study expanded on previous analyses of the Bayley Infant Neurodevelopmental Screener (BINS) by providing psychometric properties to evaluate the appropriateness of using the BINS in a sample of HIV-exposed infants in rural South Africa.

METHOD

A total of 160 mothers with HIV, their infants, and their male partners were recruited. The BINS was administered to the infants, and their weights were recorded. Mothers completed measures of depression, intimate partner violence, male involvement, and adherence. Male partners reported their own involvement in perinatal care.

RESULTS

Results demonstrated support for a 5-factor structure consistent with previous transcultural adaptations of the BINS, demonstrating construct validity, and adequate reliability. Convergent validity was partially supported, as shown by associations with intimate partner violence and male involvement as reported by men and women and maternal adherence, although not with birth weight or maternal depression. The BINS showed adequate discriminating power, with only a few low-performing items.

CONCLUSION

In rural South Africa, a resource-limited setting, the BINS seems to be an adequate screening tool for developmental delays in children that may be used to identify those in need of intervention. Considering the high prevalence of delays identified in this study, antiretroviral therapy-exposed and HIV-exposed infants may benefit from further assessment to determine a need for intervention in community-based clinics.

Translating new evidence into clinical practice: a quasi-experimental controlled before-after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa

OBJECTIVES

We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding.

DESIGN

Quasi-experimental controlled before-after study.

SETTING

Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa.

PARTICIPANTS

All HWs providing infant feeding counselling in selected facilities were invited.

INTERVENTIONS

Three 1-2 hours, on-site workshops over 3-6 weeks.

PRIMARY OUTCOME MEASURES

Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level.

RESULTS

In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups.

CONCLUSION

A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

BACKGROUND

In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.

OBJECTIVES

The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.

METHODS

We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.

RESULTS

From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.

CONCLUSIONS

From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

'If nurses were in our shoes would they breastfeed their own babies?' A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe

BACKGROUND

The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the challenges faced by breastfeeding mothers on the PMTCT programme.

METHOD

Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme.

RESULTS

The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others.

CONCLUSION

HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.

Infant feeding practices among HIV-positive mothers at Tembisa hospital, South Africa

Background

Despite the nutritional, physiological and emotional benefits of breastfeeding, HIV-positive mothers cannot practise exclusive breastfeeding for six months because of a range of influences on their feeding choice – thereby creating a caveat for morbidity in infants.

Aim

This study explored factors influencing the infant feeding choice of HIV-positive mothers at a peri-urban hospital in Tembisa, South Africa.

Methods

This study was qualitative and was conducted among 30 purposefully selected postnatal HIV-positive mothers at Tembisa hospital, Gauteng, from May to June 2011. In-depth interviews were conducted mainly in isiZulu and Sepedi which were then transcribed into English. An open coding system of analysis was used for thematic analysis.

Results

Nurses significantly influenced the feeding choices of new mothers – sometimes with inconsistent information. The grandmothers of infants also influenced the new mothers’ feeding options, in some cases with the new mother coming under duress. Other relatives like the sisters and aunts of mothers appeared to significantly affect feeding choices. The time frames expressed for the initiation of a supplementary diet were as follows: before 1 month, at 1 month and at 4 months. The main reason was the belief that infants required more than breast milk as sustenance during this period.

Conclusion

In the postnatal hospital setting of this study, the feeding choices of mothers were influenced by nursing personnel. Nursing personnel could marry the influential ‘authority’ they have with correct and consistent information, in order to change feeding behaviour. Significant ‘others’ like grandmothers and other relatives also influenced decisions on infant feeding. As such, family dynamics need to be considered when encouraging breastfeeding.

Mapping the existing body of health policy implementation research in lower income settings: what is covered and what are the gaps?

This article uses 85 peer-reviewed articles published between 1994 and 2009 to characterize and synthesize aspects of the health policy analysis literature focusing on policy implementation in low- and middle-income countries (LMICs). It seeks to contribute, first, to strengthening the field of LMIC health policy analysis by highlighting gaps in the literature and generating ideas for a future research agenda and, second, to thinking about the value and applicability of qualitative synthesis approaches to the health policy analysis field. Overall, the article considers the disciplinary perspectives from which LMIC health policy implementation is studied and the extent to which the focus is on systems or programme issues. It then works with the more specific themes of the key thrusts of the reviewed articles, the implementation outcomes studied, implementation improvement recommendations made and the theories used in the reviewed articles. With respect to these more specific themes, the article includes explorations of patterns within the themes themselves, the contributions of specific disciplinary perspectives and differences between systems and programme articles. It concludes, among other things, that the literature remains small, fragmented, of limited depth and quite diverse, reflecting a wide spectrum of health system dimensions studied and many different suggestions for improving policy implementation. However, a range of issues beyond traditional 'hardware' health system concerns, such as funding and organizational structure, are understood to influence policy implementation, including many 'software' issues such as the understandings of policy actors and the need for better communication and actor relationships. Looking to the future, there is a need, given the fragmentation in the literature, to consolidate the existing body of work where possible and, given the often broad nature of the work and its limited depth, to draw more explicitly on theoretical frames and concepts to deepen work by sharpening and focusing concerns and questions.

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.

Barriers to implementing WHO's exclusive breastfeeding policy for women living with HIV in sub-Saharan Africa: an exploration of ideas, interests and institutions

The vertical transmission of HIV occurs when an HIV-positive woman passes the virus to her baby during pregnancy, delivery or breastfeeding. The World Health Organization's (WHO) Guidelines on HIV and infant feeding 2010 recommends exclusive breastfeeding for HIV-positive mothers in resource-limited settings. Although evidence shows that following this strategy will dramatically reduce vertical transmission of HIV, full implementation of the WHO Guidelines has been severely limited in sub-Saharan Africa. This paper provides an analysis of the role of ideas, interests and institutions in establishing barriers to the effective implementation of these guidelines by reviewing efforts to implement prevention of vertical transmission programs in various sub-Saharan countries. Findings suggest that WHO Guidelines on preventing vertical transmission of HIV through exclusive breastfeeding in resource-limited settings are not being translated into action by governments and front-line workers because of a variety of structural and ideological barriers. Identifying and understanding the role played by ideas, interests and institutions is essential to overcoming barriers to guideline implementation.

Empowering women in human immunodeficiency virus prevention

Women comprise one-half of people infected with the human immunodeficiency virus in the world, and about 70% of them live in sub-Saharan Africa. Advancing, untreated HIV disease in women has resulted in substantial declines in fertility rates, life expectancy and infant mortality rates, and an increased burden of tuberculosis. Three decades into the pandemic, our knowledge of HIV acquisition in women remains sparse, as are options of what women can use to reduce their risk of acquiring HIV. Here, we describe the role of pre-HIV responses to venereal diseases and then discuss unwanted pregnancies, early perceptions of the HIV epidemic in setting prevention priorities, and the history of microbicide development. Opportunities to reduce HIV risk in women through sexual reproductive health services are highlighted. Women are key to turning the tide of the HIV pandemic. Microbicides provide an opportunity to ensure survival of women while addressing the power disparities that underpin women's vulnerability to HIV.

A descriptive qualitative review of the barriers relating to breast-feeding counselling

The purpose of this review was to describe barriers in breast-feeding counselling considering it from the viewpoint of health professionals. CINAHL, MEDLINE and Cochrane databases were searched from 1950 to 2008. In total, 40 scientific research articles in English, Swedish or Finnish related to breast-feeding counselling were included and analysed using thematic analysis. The quality of the studies was also assessed. The main barriers were deficits in knowledge, resources, counselling skills and the counsellor's negative attitude. Conflicting advice, lack of guidelines, sufficiency of counselling and perceiving of the personal education needs were examples of the indicated barriers. The most commonly described barriers in breast-feeding counselling were limitations in breast-feeding knowledge. Developing of the measurements to assess the barriers in breast-feeding counselling is needed.

Poisonous milk and sinful mothers: the changing meaning of breastfeeding in the wake of the HIV epidemic in Addis Ababa, Ethiopia

Background

Breastfeeding remains normative and vital for child survival in the developing world. However, knowledge of the risk of Human Immunodeficiency Virus (HIV) transmission through breastfeeding has brought to attention the controversy of whether breastfeeding can be safely practiced by HIV positive mothers. Prevention of mother to child transmission (PMTCT) programs provide prevention services to HIV positive mothers including infant feeding counseling based on international guidelines. This study aimed at exploring infant feeding choices and how breastfeeding and the risk of HIV transmission through breastfeeding was interpreted among HIV positive mothers and their counselors in PMTCT programs in Addis Ababa, Ethiopia.

Methods

The study was conducted in the PMTCT clinics in two governmental hospitals in Addis Ababa, Ethiopia, using qualitative interviews and participant observation. Twenty two HIV positive mothers and ten health professionals working in PMTCT clinics were interviewed.

Results

The study revealed that HIV positive mothers have developed an immense fear of breast milk which is out of proportion compared to the evidence of risk of transmission documented. The fear is expressed through avoidance of breastfeeding or, if no other choice is available, through an intense unease with the breastfeeding situation, and through expressions of sin, guilt, blame and regret. Health professionals working in the PMTCT programs seemed to largely share the fear of HIV positive mother's breast milk, and their anxiety was reflected in the counseling services they provided. Formula feeding was the preferred infant feeding method, and was chosen also by HIV positive women who had to beg in the streets for survival.

Conclusions

The fear of breast milk that seems to have developed among counselors and HIV positive mothers in the wake of the HIV epidemic may challenge a well established breastfeeding culture and calls for public health action. Based on strong evidence of the risks when infants are not exclusively breastfed, there is a great need to protect breastfeeding from pressures of replacement feeding and to promote exclusive breastfeeding as the best infant feeding option for HIV positive and HIV negative mothers alike.

Rethinking HIV/AID disclosure among women within the context of motherhood in South Africa

This qualitative study explored whether motherhood plays a role in influencing decisions to conceal or reveal knowledge of seropositive status among women living with HIV/AIDS in 2 South African communities: Gugulethu and Mitchell's Plain. Using the PEN-3 cultural model, we explored how HIV-positive women disclose their status to their mothers and how HIV-positive mothers make decisions about disclosure of their seropositive status. Our findings revealed 3 themes: the positive consequences of disclosing to mothers, how being a mother influences disclosure (existential role of motherhood), and the cost of disclosing to mothers (negative consequences). The findings highlight the importance of motherhood in shaping decisions to reveal or conceal knowledge of seropositive status. Implications for interventions on HIV/AIDS prevention, care, and support are discussed.

Importance of strategic management in the implementation of private medicine retailer programmes: case studies from three districts in Kenya

Abstract

The "work" of women when considering and using interventions to reduce mother-to-child transmission (MTCT) of HIV

This paper explores HIV-infected women's experiences of considering and using recommended interventions during pregnancy and postpartum to reduce mother-to-child transmission of HIV. Data were collected from 45 HIV-infected women aged 18-44 years living in Melbourne, Australia. A semi-structured interview was used to collect qualitative information on women's reproductive experience and intentions. The 15 women who had their children after their HIV diagnosis engaged in significant work including surveillance and safety work to minimise stigma and infection, information work to inform decisions and actions, accounting work to calculate risk and benefit, hope and worry work concerning a child's infection status and impact of interventions, work to redefine an acceptable maternal identity, work to prepare an alternative story to counter the disclosure effect of the intervention and emotional work to reconcile guilt when considering these interventions. This study provides a framework to help clinicians understand the real and on-going "work" that women engage in when they are considering interventions recommended by their physicians to reduce transmission of HIV. Even in circumstances where access to and acceptance of interventions are high, women continue to engage in this work even after they have a made a decision about a particular intervention.

"Peer but not peer": considering the context of infant feeding peer counseling in a high HIV prevalence area

Postnatal transmission of HIV through breastfeeding remains an unsolved problem in resource poor settings, where refraining from breastfeeding is neither feasible nor safe. This study describes how women experienced infant-feeding peer counseling within a community-based intervention trial in 3 settings in South Africa. In total, 17 interviews and 10 observations were done with HIV-infected and uninfected women. The findings raise questions on the concept of "peer." Some women feared the peer counselor visits and questioned their intentions. Others, especially HIV-infected women, valued peer counseling for the emotional support provided. Being HIV infected with limited or no network of support appeared stressful for most women. The effects of data collection on the delivery and uptake of peer counseling are discussed. The findings underline the contextual barriers facing peer counselors and show that these challenges could have important implications for the effectiveness of infant-feeding counseling in high HIV prevalence countries.

The prevention of mother-to-child HIV transmission programme in Lilongwe, Malawi: why do so many women drop out

Mother-to-child transmission of HIV constitutes a substantial burden of new HIV infections in sub-Saharan Africa, and losses to follow-up continue to undermine prevention of mother-to-child transmission of HIV (PMTCT) programmes. This qualitative study sought to clarify why some women who were enrolled in a PMTCT programme in Lilongwe, Malawi, did not fully participate in follow-up visits in the first six months after testing HIV-positive. Twenty-eight women, 14 who participated fully in the programme and 14 who dropped out, were purposively selected for in-depth interview at two clinics. Focus group discussions with 15 previously interviewed and 13 newly recruited women were also conducted. Discussions with 12 of the women's husbands were also carried out. Although the proportion of women being tested has reportedly increased, losses to follow-up have shifted and are occurring at every step after testing. Major emerging themes associated with dropping out of the PMTCT programme within six months after delivery were to avoid involuntary HIV disclosure and negative community reactions, unequal gender relations, difficulties accessing care and treatment, and lack of support from husbands. The whole approach to the delivery of the PMTCT programme and home visits must be reconsidered, to improve confidentiality and minimise stigmatization. Women need to be empowered economically and supported to access HIV treatment and care with their partners, to benefit their whole family.

Evaluating nurses' implementation of an infant-feeding counseling protocol for HIV-infected mothers: The Ban Study in Lilongwe, Malawi

A process evaluation of nurses' implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study's outcomes.

Factors influencing teen mothers' enrollment and participation in prevention of mother-to-child HIV transmission services in Limpopo Province, South Africa

In this article, we examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission (PMTCT) services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. We used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into PMTCT. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counselor dynamics during pretest counseling were pivotal in determining uptake and participation, and counselor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to PMTCT recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labor and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Preventing Mother-to-Child HIV Transmission Among South African Adolescents

Although prevention of mother-to-child HIV transmission (PMTCT) programs are predicated on maternal behavior change, little is known about sociocultural factors affecting maternal—child care practices in this arena. The authors used narrative methods (key informant workshops, questionnaires, focus groups, and case study analysis) to explore how sociocultural context shapes adolescent mothers' ability to adhere to programmatic recommendations in rural and urban South Africa. The study aims were to understand the extent to which mothers' decisions are borne out in PMTCT-related practices and to identify contextual elements that affect the link between individual resolutions and action. The results revealed rural adolescents as less likely than urbanites to successfully implement most PMTCT-related practices. HIV stigma, family decision making, and cultural norms surrounding infant feeding hampered mothers' efforts to implement practices that would decrease the risk for infant infection. Barriers to behavior change were analyzed along four domains: history, culture, gender, and power. Methodological aspects and programmatic implications are discussed.

Infant feeding and HIV in Sub-Saharan Africa: what lies beneath the dilemma?

The debate over how to best guide HIV-infected mothers in resource-poor settings on infant feeding is more than two decades old. Globally, breastfeeding is responsible for approximately 300,000 HIV infections per year, while at the same time, UNICEF estimates that not breastfeeding (formula feeding with contaminated water) is responsible for 1.5 million child deaths per year. The largest burden of these infections and deaths occur in Sub-Saharan Africa. Using this region as an example of the burden faced more generally in other resource-poor settings, we contrast the evolution of the clinical standard of care for infant feeding with HIV-infected mothers in high-income countries to the current international clinical guidelines for HIV-infected mothers and infant feeding in resource-poor settings. While the international guidelines of exclusive breastfeeding for a 6-month period seem to offer the least-worst strategy for reducing mother-to-child transmission of HIV during infancy while conferring some immunity through breastfeeding post-6 months, we argue that the impact of the policy on mothers and healthcare workers on the ground is not well understood. The harm reduction approach on the level of health policy translates into a complicated, painful moral dilemma for HIV-positive mothers and those offering them guidance on infant feeding. We argue that the underlying socio-economic disparities that continue to fuel the need for a harm reduction policy on infant feeding and the harm to women and children justify: (1) that higher priority be given to solving the infant feeding dilemma with improved data on safe feeding alternatives, and (2) support of innovative, community-driven solutions that address the particular economic and cultural challenges that continue to result in HIV-transmission to children within these communities.

Primiparous mothers' knowledge about mother-to-child transmission of HIV in Lusaka, Zambia

OBJECTIVE

to learn what primiparous mothers in Lusaka, Zambia know about human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), mother-to-child transmission (MTCT) of HIV, and breast feeding.

DESIGN

qualitative interviews analysed by thematic manifest content analysis.

SETTING

postnatal wards at Lusaka University Teaching Hospital.

PARTICIPANTS

14 primiparous mothers were interviewed.

FINDINGS

1 year after implementation of the prevention of MTCT programme in Zambia, the majority of the women interviewed lacked basic knowledge about MTCT. They did not know that HIV is present in breast milk and that it is a source of transmission. Few mothers had been informed about breast feeding, correct attachment and ways of avoiding breast infection. The mothers seemed to be uncertain about what HIV actually is, and they preferred to talk about MTCT and safe breast feeding rather than HIV/AIDS in general, which was the main reason for their participation in the study. According to the mothers, the most effective way of preventing transmission of HIV to the unborn baby was a single dose of nevirapine. Many believed that treatment is equal to cure and gives the baby full protection. The overall feeling of mothers was that they had not received information and support from the antenatal clinics and postnatal wards. The more traditional women preferred not to discuss these issues with their friends, their husbands or their families, which may make it more difficult to spread information and encourage couples to make decisions about their and their baby's future.

CONCLUSION

these findings suggest that primiparous mothers and their families need more education about MTCT of HIV. The mothers also need basic education about breast feeding and how to avoid breast injuries. The main reason for mothers' poor knowledge may be that health workers do not have the necessary information. There seems to be a need for training in breast-feeding and baby-feeding counselling in the context of HIV in order to promote exclusive and safe breast feeding. As such, further research about health workers' knowledge and methods of teaching is required.

HIV and infant feeding counselling: challenges faced by nurse-counsellors in northern Tanzania

BACKGROUND

Infant feeding is a subject of worry in prevention of mother to child transmission (pMTCT) programmes in settings where breastfeeding is normative. Nurse-counsellors, expected to counsel HIV-positive women on safer infant feeding methods as defined in national/international guidelines, are faced with a number of challenges. This study aims to explore the experiences and situated concerns of nurses working as infant feeding counsellors to HIV-positive mothers enrolled in pMTCT programmes in the Kilimanjaro region, northern Tanzania.

METHODS

A qualitative study was conducted using in-depth interviews and focus group discussions (FGDs) with 25 nurse-counsellors at four pMTCT sites. Interviews were handwritten and FGDs were tape-recorded and transcribed, and the programme Open Code assisted in sorting and structuring the data. Analysis was performed using 'content analysis.'

RESULTS

The findings revealed a high level of stress and frustration among the nurse-counsellors. They found themselves unable to give qualified and relevant advice to HIV-positive women on how best to feed their infants. They were confused regarding the appropriateness of the feeding options they were expected to advise HIV-positive women to employ, and perceived both exclusive breastfeeding and exclusive replacement feeding as culturally and socially unsuitable. However, most counsellors believed that formula feeding was the right way for an HIV-positive woman to feed her infant. They expressed a lack of confidence in their own knowledge of HIV and infant feeding, as well as in their own skills in assessing a woman's possibilities of adhering to a particular method of feeding. Moreover, the nurses were in general not comfortable in their newly gained role as counsellors and felt that it undermined the authority and trust traditionally vested in nursing as a knowledgeable and caring profession.

CONCLUSION

The findings illuminate the immense burden placed on nurses in their role as infant feeding counsellors in pMTCT programmes and the urgent need to provide the training and support structure necessary to promote professional confidence and skills. The organisation of counselling services must to a larger extent take into account the local realities in which nurses construct their role as counsellors to HIV-positive childbearing women.

Investigating the decision-making needs of HIV-positive women in Africa using the Ottawa Decision-Support Framework: Knowledge gaps and opportunities for intervention

OBJECTIVE

To examine HIV-positive women's decision making in the context of pregnancy and HIV/AIDS and to explore interventions that may enhance and develop women's decision-making capacity in the sub-Saharan African context.

METHODS

The Ottawa Decision-Support Framework was used to assemble evidence of women's decision-making needs. Several electronic databases were searched and an Internet search of the World Wide Web was conducted to search grey literature sources. An evidence-based approach to assessing benefits, harms and current practices was employed.

RESULTS

Several gaps in our knowledge about women's decision making in the context of pregnancy and HIV were identified. The availability of evidence varied for each decision; however, significant gaps included: evidence around testing for ones status, advanced directives for self and child, disclosure (specifically, the impact of), others perceptions of antiretroviral use and data on termination of pregnancies.

CONCLUSION

Decision making as a concept was generally not addressed in the MTCT literature. Evidence regarding the perceptions of women and others regarding the various decisions was often not available and subsequently an important aspect of MTCT interventions neglected.

PRACTICE IMPLICATIONS

Incorporating a multi-disciplinary decision-support framework may prove useful to promote women's autonomy and involvement in MTCT-related decision making.

Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi

BACKGROUND

To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers.

METHODS

As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi.

RESULTS

Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workers had concerns about early cessation of breastfeeding.

CONCLUSION

Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions.

Social consequences of HIV-positive women's participation in prevention of mother-to-child transmission programmes

Approximately two-third of the worlds HIV/AIDS cases are found in sub-Saharan Africa. The rate of mother-to-child-transmission (MTCT) has been found to lie between 15 and 40%. The aim of this study was to explore the social consequences affecting the experience HIV-positive women have when taking part in a prevention of mother-to-child-transmission programme (PMTCT). Few studies have investigated this earlier. A cross section of 52 participating women enrolled into a PMTCT programme were randomly selected and interviewed, using a structured questionnaire. There were three main findings. The most important consequence of participating was the difficulty associated with the breast-feeding issue. For the women who because of a wish to prevent MTCT are employing formula feeding, this causes suspicion and prejudice amongst people in the local community. Few people influence a woman's decision to take part, as they tend to keep their HIV status to themselves. More information to the general public about HIV and PMTCT programmes will enhance acceptance to HIV, and generate an environment conducive towards participation in PMTCT programmes.

Use of population-specific infant mortality rates to inform policy decisions regarding HIV and infant feeding

Mother-to-child transmission of HIV occurs during pregnancy, at the time of delivery, and through breastfeeding (BF). WHO recommends avoidance of all BF when replacement feeding (RF) is affordable, feasible, acceptable, sustainable, and safe. Otherwise, exclusive breastfeeding (EBF) followed by early BF cessation is recommended. Governments are currently scaling up programs to prevent infant HIV infection. Few data exist to guide policy decisions about the allocation of resources to prevent postnatal HIV transmission while minimizing the non-HIV-related risks of these policies. This paper presents an analysis of the impact of WHO infant feeding recommendations in different settings characterized by infant mortality rate (IMR). Mathematical simulation modeling is used to estimate the effects on HFS (HFS) through 24 mo of 3 intervention scenarios: RF from birth by HIV-positive mothers (RF24), EBF up to 6 mo followed by early BF cessation (EBF6), and the default scenario where there is no postnatal intervention (BF24). This analysis differs from earlier reports in that it uses the most recent data on risks of postnatal HIV transmission for mixed and exclusive BF. These simulations suggest that in settings where IMR is <25/1000 live births, RF24 results in the greatest HFS to 24 mo; EBF6 produces the best outcome where IMR > 25/1000 live births. RF24 results in lower HFS than no postnatal intervention where IMR >/= 101/1000. IMR-based analyses can help to guide government policy decisions about which infant feeding strategies to invest in and emphasize for HIV-positive mothers in different settings.

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

OBJECTIVE

To investigate pregnant women's views on infant feeding options recommended for HIV-infected women.

DESIGN

A structured interview survey complemented with focus group discussions.

SETTING

Antenatal clinics in Moshi urban and rural districts of Tanzania.

SUBJECTS

Five hundred pregnant women participated in the interview survey and 46 pregnant women participated in six focus group discussions.

RESULTS

Participating women reported that they would change to an alternative infant feeding method if they were found to be HIV-infected and were advised to do so. Cow's milk was regarded as the most feasible infant feeding method for local HIV-infected mothers. Infant feeding formula was regarded as too costly, but if recommended by health workers and distributed free of charge, the majority of the women (82%) were confident that they would then choose this option. In the focus group discussions, women were less optimistic and expressed great concern for the social consequences of not breast-feeding. The safety of exclusive breast-feeding was questioned. Less common infant feeding methods, such as expressed heat-treated breast milk and wet-nursing, were not regarded as viable options. Several social barriers to replacement feeding were identified in the focus group discussions, including possible lack of support from partner and potential negative reactions from the community.

CONCLUSION

Future research on infant feeding options should include the broader cultural context and the psychological stress that HIV-infected women face when choosing infant feeding methods.

Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study

OBJECTIVE

To find out why pregnant women who receive HIV-1 positive test results and are offered short course antiretroviral prophylaxis to prevent transmission of HIV from mother to child do not participate in necessary follow up visits before starting prophylaxis.

DESIGN

Qualitative interview study.

SETTING

A programme aiming to prevent transmission of HIV from mother to child at a public antenatal clinic in Abidjan, Côte d'Ivoire.

PARTICIPANTS

Purposive sample of 27 women who had received HIV-1 positive test results and were invited to return for monthly follow up visits before starting prophylaxis with zidovudine at 36 weeks' gestation, but who had either refused or discontinued the visits. None of the women started prophylaxis.

RESULTS

Most of the women explained their non-participation in follow up visits by referring to negative experiences that they had had while interacting with programme staff or to their views about the programme. Additional reasons concerned their disbelief of HIV positive test results and personal factors.

CONCLUSIONS

Difficulties experienced by women during their contacts with staff working on the prevention programme and negative views that they have about the programme can contribute to their non-participation in prophylaxis. Training and supervision of programme staff may increase the likelihood of positive interactions between staff and clients, thereby facilitating women's participation in preventing transmission of HIV from mother to child. Outreach and mobilisation in communities that are served by prevention programmes may complement these measures at programme level by contributing to increased social support for women's efforts to prevent transmission of HIV from mother to child.

Transmission of HIV in the dental clinic and elsewhere

This review focuses on the risk of transmission of HIV in dental practice in developed and developing countries; and as a result of oral sex, perinatal transmission and breast feeding. Postexposure prophylaxis (PEP) and practical measures to control cross-infection with TB are also discussed. There are few data from resource-poor countries where prevalence of HIV and risk of infection are higher--issues that deserve priority. Available information indicates that the risk of HIV transmission in the dental office is very low. Transmission of HIV from three healthcare workers to patients has been confirmed, including a dentist who infected six patients. There are >300 reports (102 confirmed) of occupational transmission to healthcare workers, including nine dental workers (unconfirmed). Exposure to HIV has been reported by 0.5% dentists/year. The risk of HIV infection after percutaneous exposure (0.3%) can be reduced by 81% with zidovudine PEP. However, risk assessment is required to assess the need and appropriate regimen. The risk of HIV transmission associated with orogenital sex exists, but is considered extremely low: barrier protection is recommended. Conversely, the proportion of babies who acquire HIV from untreated HIV-seropositive mothers is 15-25% in developed countries and 25-45% in developing countries. The frequency of HIV transmission attributable to breastfeeding is 16%. Airborne transmission of TB can be avoided by the prompt referral of known/suspected cases of active TB for chemotherapy, deferral of elective procedures until patients are not infectious, and the use of appropriate standard/isolation precautions including adequate ventilation of treatment areas.

Counsellors' perspectives on antenatal HIV testing and infant feeding dilemmas facing women with HIV in northern Tanzania

This study investigated the infant feeding advice that counsellors were giving HIV-infected pregnant women in Moshi, Tanzania, the factors they thought had an impact on women's infant feeding choices and their role in influencing these decisions. The data are drawn from in-depth interviews with 16 nurses working as counsellors in their spare time in an antenatal trial of prevention of mother-to-child transmission, five local HIV/AIDS counsellors and two medical doctors, whose counselling experience ranged from less than six months to nine years. Informed choice of infant feeding method by HIV-infected women, as recommended by UNAIDS/WHO/UNICEF Guidelines, was seriously compromised by the actual advice given, directive counselling, lack of time to cope with a positive HIV test result, and lack of follow-up support, regardless of socio-economic status. Infant feeding options were not always accurately explained, but counsellors believed most women had little choice but to breastfeed and were unlikely to exclusively breastfeed, despite advice. It was apparent that the risks and benefits of the options open to HIV-infected women were complicated for the counsellors, not only the women. Counsellors needed additional training in non-directive counselling and infant feeding options to ensure a better quality of advice-giving and support to follow-up women at home.