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

Healthcare Workers' Knowledge of HIV-Exposed Infant Feeding Options and Infant Feeding Counseling Practice in Northern Nigeria

BACKGROUND

Despite the existence of evidence-based HIV-exposed infant feeding guidelines, infants in Africa still acquire HIV through inappropriate feeding practices.

OBJECTIVE

To identify predictors of HIV-exposed infant feeding knowledge and counseling practice among health care workers (HCW) in Nigeria.

METHODS

Structured, pretested questionnaires were administered to HCW (n=262) in a tertiary health facility in Kano, Nigeria. Multivariate logistic regression was used to determine predictors of HIV-exposed infant feeding knowledge and counseling practice.

RESULTS

Of 262 respondents, (58.0%, n=152) had good knowledge of recommended feeding options. Respondents listed exclusive breastfeeding (57.6%, n=151), human milk substitutes (45.4%, n=119), HIV-negative wet-nursing (37.0%, n=97), heated expressed human milk (20.6%, n=54) and mixed feeding (13.4%, n=35) as appropriate feeding choices. Over half (57.3%, n=150) of the respondents have ever counseled a HIV-positive mother on infant feeding. Knowledge was predicted by female sex (Adjusted Odds Ratio (AOR)=2.47, 95% Confidence Interval (CI):1.35-4.52), profession (physician vs. laboratory scientist, AOR=4.00, 95%CI:1.25-12.87; nurse/midwife vs. laboratory scientist, AOR=2.75, 95%CI:1.17-9.28), infant feeding counseling training (AOR=3.27, 95%CI:1.87-5.71), and number of children (2-4 vs. 0, AOR=1.75, 95%CI:1.23-3.92). Infant feeding counseling was predicted by female sex (AOR=2.85, 95%CI:1.39-5.85), age (>40 vs. <30 years, AOR=3.87, 95%CI:1.27-15.65), knowledge of infant feeding options (good vs. fair/poor, AOR=3.96, 95%CI:2.07-7.59), training (AOR=2.60, 95%CI:1.42-5.32), and profession (physician vs. laboratory scientist, AOR=10.7, 95%CI:2.85-40.54; nurse/midwife vs. laboratory scientist, AOR=4.8, 95%CI:1.26-18.02).

CONCLUSION

The practice of infant feeding counseling among HCW in Nigeria is associated with sex, knowledge, and profession. Our findings may inform the development of targeted training programs for HCW in similar settings.

Correlates of infant feeding practices among HIV-positive mothers and controls in northeast Nigeria

BACKGROUND

Despite the global decline in pediatric HIV infections, infants in sub-Saharan Africa still acquire HIV infection through inappropriate feeding.

OBJECTIVE

The aim of the study was to compare knowledge and predictors of infant feeding behavior between mothers living with HIV and controls of unknown HIV status in Gombe, northeast Nigeria.

METHOD

A cross-section of clinic-based samples of 84 HIV-positive mothers and 170 controls of unknown status were interviewed using validated questionnaires. Knowledge scores and self-reported infant feeding practices were analyzed. Multivariate logistic regression models were employed to determine predictors for infant feeding practices.

RESULTS

Transmission risk perception (95.2% vs. 65.3%) (p<0.05) and adequate knowledge of infant feeding (77.4% vs. 51.2%) (p<0.05) were higher among HIV-positive mothers. Compared to mothers of unknown status (56.5%), a higher proportion of HIV-positive mothers (84.5%) reported breastfeeding the infant exclusively for 6 months (p<0.05). In contrast, mixed feeding was more prevalent among controls (19.4% vs. 4.8%) (p<0.05). Further, over a third (39.3%) of HIV-positive mothers and 27.6% of controls weaned their infants at ≥12 months (p>0.05). Antenatal attendance, hospital delivery, knowledge and positive attitude predicted infant feeding practices in both groups. The predictive roles of education and parity were limited to HIV-positive mothers, while the effects of maternal age and infant death were restricted to controls.

CONCLUSION

Risk perception, knowledge, and exclusive breastfeeding rates were higher among mothers living with HIV. Antenatal care, hospital delivery, knowledge, and attitude predicted infant feeding practices in both groups. Girl child education, antenatal care, hospital delivery, and sustained promotion of exclusive breastfeeding with antiretroviral therapy are key to HIV-free infant survival.

Mother-to-Child Transmission of HIV and HIV-Free Survival in Swaziland: A Community-Based Household Survey

In Swaziland, no data are available on the rates of HIV infection and HIV-free survival among children at the end of the breastfeeding period. We performed a national crosssectional community survey of children born 18-24 months prior to the study, in randomly selected constituencies in all 4 administrative regions of Swaziland, from April to June 2015. Mother-to-child transmission (MTCT) of HIV and HIV-free survival rates were calculated for all HIV-exposed children. The overall HIV-free survival rate at 18-24 months was 95.9% (95% CI 94.1-97.2). The estimated proportion of HIV infected children among known HIV-exposed children was 3.6% (95% CI 2.4-5.2). Older maternal age, delivering at a health facility, and receiving antenatal antiretroviral drugs were independently associated with reduced risk for child infection or death. The Swaziland program for prevention of MTCT achieved high HIV-free survival (95.9%) and low MTCT (3.6%) rates at 18-24 months of age when Option A (infant prophylaxis) of the WHO 2010 guidelines was implemented.

HIV-1 transmission and survival according to feeding options in infants born to HIV-infected women in Yaoundé, Cameroon

Background

Evidence of 24-months survival in the frame of prevention of mother-to-child transmission (PMTCT) cascade-care is scare from routine programs in sub-Saharan African (SSA) settings. Specifically, data on infant outcomes according to feeding options remain largely unknown by month-24, thus limiting its breath for public-health recommendations toward eliminating new pediatric HIV-1 infections and improving care. We sought to evaluate HIV-1 vertical transmission and infant survival rates according to feeding options.

Methods

A retrospective cohort-study conducted in Yaounde from April 2008 through December 2013 among 1086 infants born to HIV-infected women and followed-up throughout the PMTCT cascade-care until 24-months. Infants with documented feeding option during their first 3 months of life (408 on Exclusive Breastfeeding [EBF], 663 Exclusive Replacement feeding [ERF], 15 mixed feeding [MF]) and known HIV-status were enrolled. HIV-1 vertical transmission, survival and feeding options were analyzed using Kaplan Meier Survival Estimate, Cox model and Schoenfeld residuals tests, at 5% statistical significance.

Results

Overall HIV-1 vertical transmission was 3.59% (39), and varied by feeding options: EBF (2.70%), ERF (3.77%), MF (20%), p = 0.002; without significance between EBF and ERF (p = 0.34). As expected, HIV-1 transmission also varied with PMTCT-interventions: 1.7% (10/566) from ART-group, 1.9% (8/411) from AZT-group, and 19.2% (21/109) from ARV-naïve group, p < 0.0001. Overall mortality was 2.58% (28), higher in HIV-infected (10.25%) vs. uninfected (2.29%) infants (p = 0.016); with a survival cumulative probability of 89.3% [79.9%–99.8%] vs. 96.4% [94.8%–97.9% respectively], p = 0.024. Mortality also varied by feeding option: ERF (2.41%), EBF (2.45%), MF (13.33%), p = 0.03; with a survival cumulative probability of 96% [94%–98%] in ERF, 96.4% [94.1%–98.8%] in EBF, and 86.67% [71.06%–100%] in MF, p = 0.04. Using Schoenfeld residuals test, only HIV status was a predictor of survival at 24 months (hazard ratio 0.23 [0.072–0.72], p = 0.01).

Conclusion

Besides using ART for PMTCT-interventions, practice of MF also drives HIV-1 vertical transmission and mortality among HIV-infected children. Thus, throughout PMTCT option B+ cascade-care, continuous counseling on safer feeding options would to further eliminating new MTCT, optimizing response to care, and improving the life expectancy of these children in high-priority countries.

Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review

BACKGROUND

To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets.

METHODS

Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU).

RESULTS

Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants.

CONCLUSION

Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.

Breastfeeding Education: Where Are We Going? A Systematic Review Article

BACKGROUND

UNICEF (United Nations International Children's Emergency Fund) and WHO estimate that if all babies were breastfed for at least the first six months of their lives, the rate of morbidity and malnutrition would significantly decrease all over the world. In this view, these two organizations promoted a worldwide campaign for breastfeeding, creating the Baby Friendly Hospital Initiative (BFHI) that encourages good practices for the promotion of breastfeeding in hospitals. The aim of our study was to review the available evidence regarding the positive effects of breastfeeding, in order to suggest to most appropriate strategy to support it.

METHODS

The main databases including Scopus, PubMed, MEDLINE, Google scholar and Science Direct were researched to obtain the original papers related to breastfeeding education. The main terms used to literature search were "Breastfeeding education", Breastfeeding support", and "Breastfeeding healthcare policy". The timeframe included the obtained articles was from 1980 to 2015.

RESULTS

Our analysis confirms that healthcare providers play a pivotal role in education and encouraging mothers to begin and continue breastfeeding. In this view, the adequate training of healthcare providers seems to be mandatory in order to support this practice. Moreover, adequate facilities are needed in order to promote and support breastfeeding.

CONCLUSION

Considering the available evidence, breastfeeding should be supported among all the mothers. Based on the positive data emerging from the public awareness campaign in different Countries of the world, we strongly encourage an accurate training for doctors and midwives and the implementation of adequate facilities in order to support breastfeeding.

Under-five mortality and maternal HIV status in Tanzania: analysis of trends between 2003 and 2012 using AIDS Indicator Survey data

Background

Mortality among children under five remains a significant health challenge across sub-Saharan Africa. HIV/AIDS is one of the leading contributors to the relatively slow decline in under-five mortality in this region. In Tanzania, HIV prevalence among under-five children is high and 90% of all infections are due to mother-to-child transmission.

Objectives

The study aimed to examine the association between maternal HIV-positive status and under-five mortality in Tanzania. It also aimed to estimate the proportions and trends of under-five mortality attributable to maternal HIV/AIDS in Tanzania between 2003 and 2012.

Design

Binomial logistic regression was used to analyze cross-sectional survey data from the Tanzania AIDS Indicator Surveys to examine the association between maternal HIV positivity and under-five mortality between 2003 and 2012.

Results

After controlling for confounders, the adjusted odds ratios were 1.5 (95% CI 1.1–1.9) in 2003–2004, 4.6 (95% CI 2.7–7.8) in 2007–2008, and 2.4 (95% CI 1.2–4.6) in 2011–2012. The maternal HIV-attributable mortality risk percent of under-five children was 3.7 percent in 2003–2004, 11.3 percent in 2007–2008 and 5.6% in 2011–2012.

Conclusion

Maternal HIV positivity is associated with under-five mortality in Tanzania, making maternal HIV serostatus a relevant determinant of whether a child will survive up to five years of age or not. The impact of maternal HIV/AIDS attributable mortality risk has a significant contribution to the overall under-five mortality in Tanzania. The continued monitoring of HIV and mortality trends is important for policy development and design of interventions.

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial

BACKGROUND

Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package.

METHODS

In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with ClinicalTrials.gov, number NCT01805752.

FINDINGS

Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per μL (IQR 268-606) in the intervention group and 314 cells per μL (245-406) in the control group (p<0·0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3·3, 95% CI 1·4-7·8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9·1, 5·2-15·9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10·3, 5·4-19·7) post partum.

INTERPRETATION

This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development and US National Institutes of Health.