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FACTORS INFLUENCING CHOICE OF INFANT FEEDING METHODS, AMONG HIV POSITIVE MOTHERS, ATTENDING PMTCT CLINIC IN PLATEAU STATE SPECIALIST HOSPITAL, JOS.
SUMMARY
The method of infant feeding to adopt for the newborn is a major decision to make for the HIV Positive mother. This is made more difficult by the socio - cultural influences these women have to contend with in making these decisions.
A longitudinal prospective study of the factors influencing the choice of infant feeding, among HIV Positive mothers attending PMTCT clinic in Plateau State Specialist Hospital, Jos was done.
HIV Positive Mothers between 20years and 40years of age were enrolled following their informed consent. One hundred and seventy nine mothers were enrolled and 152 of the eligible mothers participated and completed the study. These mother-infant pairs were followed up at six weeks of birth.
Many factors were found to influence the choice of infant feeding among the HIV Positive mothers; these included the fear of stigmatization, the fear of HIV transmission, the cost of infant formula and infant feeding counselling by health workers.
In the actual practice of infant feeding, these mothers faced various challenges ranging from family pressures and stigmatization, to cost of infant formula and health worker influence. These challenges forced some mothers to change their initial method of infant feeding to other forms, with attendant consequences.
From the foregoing, there is a need to identify which infant feeding options, under individual and local circumstances would save the most lives, be the most feasible, be the least costly to the society, and have the fewest negative effects. It is therefore necessary to intensify counselling in order to meet cultural needs and prevent
stigmatization.
TABLE OF CONTENTS
Title Page - - - - - - - - - - - - - - - - i
Declaration - - - - - - - - - - - - - - - ii
Certification - - - - - - - - - - - - - - iii
Dedication - - - - - - - - - - - - - - iv
Acknowledgement - - - - - - - - - - - - - v
Table of contents - - - - - - - - - - - - - - vi
List of Tables and figures - - - - - - - - - - - ix
Abbreviations - - - - - - - - - - - - - - x Summary - - - - - - - - - - - - - - - 1
CHAPTER ONE
1.0 Introduction - - - - - - - - - - - - - 2
1.1. Scope of the HIV and AIDS Pandemic - - - - - - - 2
1.1.1 HIV Transmission - - - - - - - - - - - - 3
1.1.2 HIV and Pregnancy - - - - - - - - - - - - 5
1.1.3 HIV in Children - - - - - - - - - - - - 5
1.1.4 Prevention of Mother to Child Transmission (PMTCT) of HIV - 8
1.1.5 Background of HIV and Infant Feeding - - - - - - 9
1.1.6 To Breastfeed or not to Breastfeed? - - - - - - - 10
1.2 Statement of the Problem - - - - - - - - - - 11
1.3 Rationale of the Study - - - - - - - - - - - 11
1.4 Aim and Specific Objectives - - - - - - - - - 12
CHAPTER TWO
2.0 Literature Review - - - - - - - - - - - - 13
2.1 Historical Overview of Infant Feeding - - - - - - - 13
2.2 The Human Breast milk - - - - - - - - - - 14
2.3 Artificial Milk - - - - - - - - - - - - 16
2.4 Other Sources of Milk - - - - - - - - - - - 17
2.5 Infant Feeding in the Context of HIV - - - - - - - 17
2.5.1 Infant Feeding Options Among HIV Positive Mothers - - - 21
2.5.1.1 Exclusive Breastfeeding - - - - - - - - - - 21
2.5.1.2 Exclusive breastfeeding with early Cessation - - - - - - 23
2.5.1.3 Safer Breast-milk Feeding - - - - - - - - - - 23
2.5.1.4 Replacement Feeding - - - - - - - - - - - 26
2.5.1.5 Mixed Feeding - - - - - - - - - - - - 29
2.5.2 Official Policies on Infant Feeding - - - - - - - - 31
2.5.3 Infant Feeding and HIV-free Survival - - - - - - - 34
2.5.4 Adherence to Recommended Infant Feeding Methods - - - 37
2.5.5 Factors Influencing Choice of Infant Feeding Methods, Among HIV
Positive Mothers - - - - - - - - - - - - - - - 38
2.5.6 Growth Pattern of HIV-Exposed Infants - - - - - - - 45
2.5.7 Support for Women’s Choice of Infant Feeding - - - - - 46
2.5.8 Infant Feeding Counselling for HIV Infected Mothers - - - 48
CHAPTER THREE
3.0 Methodology - - - - - - - - - - - - - 51
3.1 Study Environment - - - - - - - - - - - - 51
3.2 Study Site - - - - - - - - - - - - - - 52
3.3 Study Population - - - - - - - - - - - - 53
3.4 Inclusion Criteria - - - - - - - - - - - - 53
3.5 Exclusion Criteria - - - - - - - - - - - - 53
3.6 Study Design - - - - - - - - - - - - - - 53
3.7 Sampling Method - - - - - - - - - - - - - 54
3.8 Ethical Clearance - - - - - - - - - - - - - 54
3.9 Method of Data Collection - - - - - - - - - - - 54
3.10 Prophylactic Treatments - - - - - - - - - - - - 55
3.11 Method of Data Analysis- - - - - - - - - - - - 56
3.12 Sample Size - - - - - - - - - - - - - - 56
CHAPTER FOUR
4.0 Results - - - - - - - - - - - - - - - - 57
4.1 Socio-demographic characteristics - - - - - - - - - - 59
4.2 Disclosure of HIV Status - - - - - - - - - - - 60
4.3 Infant characteristics - - - - - - - - - - - - - 61
4.4 Choice and Practice of Infant Feeding - - - - - - - - - 62
4.5 Pattern of Growth/Infant Illness - - - - - - - - - - 70
4.6 Factors influencing infant feeding choice - - - - - - - - 72
4.7 Challenges in the practice of infant feeding - - - - - - - - 73
CHAPTER FIVE
5.0 Discussion - - - - - - - - - - - - - - - 75
5.1 Limitations - - - - - - - - - - - - - - - 85
5.2 Conclusion and Recommendations - - - - - - - - - - 86 References - - - - - - - - - - - - - - - - - - 88
CHAPTER ONE
1.0 INTRODUCTION
1.1. Scope of the HIV and AIDS Pandemic
Human immunodeficiency virus (HIV) infection, the cause of acquired immune deficiency syndrome (AIDS) is a global pandemic1. In 2003, it was described by the World Health
Organisation (WHO) as a global health emergency1. The number of people living with HIV/AIDS (PLWHA) worldwide has continued to increase over the years1,2. By 2008, it was estimated that up to 33.4 million people were living with HIV, 2.7 million new infections occurred, while 2 million deaths were recorded1. This translated to 7400 daily new HIV infections in 20081. Forty-eight percent of daily infections were said to occur among women and 40% of cases among young people 15-24years of age1,3. Among children less than 15 years of age, it was estimated that 2.1 million were living with HIV while 280,000 died from AIDS in 2008 alone1.
More than 97% of HIV infected individuals are said to live in low- and middle income countries4. The epidemic is especially severe in sub-Saharan Africa. Sub-Saharan Africa accounts for 12% of the global population, but carries 68% of the global HIV burden and 90% of global HIV infection in children1,4.
In Nigeria, the number of PLWHA is the second largest in the world (after South Africa). The 2008 National HIV seroprevalence was 4.6%. About 220,000 Nigerian children were said to be infected with HIV5.
1.1.1. HIV Transmission
The demographics of HIV transmission have varied greatly among different regions of the world and is influenced by social, behavioural and cultural factors1. Despite the fact that HIV can be isolated from a wide range of tissues and body fluids, the majority of infections are transmitted via semen, cervical secretions and blood1,2. The character of the epidemic in different regions of the world has been influenced by the relative frequencies of each of the routes of transmission2.
Globally, heterosexual intercourse accounts for the vast majority of HIV infection. All sexually active men, women and adolescents are at risk of the infection1-3. Pregnant women are at higher risk of HIV infection than non-pregnant women1. This is due to hormonal changes and decreased immune response associated with pregnancy1. Transmission of HIV appears to be more efficient from men to women and to the passive partner in anal intercourse than vice versa1. In Central and sub-Saharan Africa, the transmission of HIV has always been by heterosexual route and more than half of the infected adults are women1,2.
Mother-to-child transmission (MTCT), also known as vertical transmission, is the most common route of HIV infection in children3. If no alternatives are in place to reduce or prevent MTCT, an estimated 5-10% of HIV transmission will occur during pregnancy, 1015% during labour and delivery and 5-20% through breastfeeding3. If a pregnant woman is HIV positive, her risk of transmitting HIV to her baby is reduced if she stays as healthy as possible1-3. Factors that increase mother-to-child transmission of HIV include smoking, substance abuse, vitamin A deficiency, malnutrition, infections such as STD’s, clinical stage of HIV(including viral load), factors related to labour and birth, and breastfeeding1,3,4.
Breastfeeding has been shown to increase the rate of HIV transmission to up to 25-44%2,3. A combination of interventions, that include the use of antiretroviral therapy for both mother and baby, and safe delivery practices, have been shown to reduce the rate of MTCT of HIV, to as low as 2% in the presence of breastfeeding4.
Other routes of HIV transmission include transfusion of unscreened blood and blood products, sharing of contaminated needles and syringes1. There is no evidence that HIV is spread by social or household contacts, or by blood sucking insects such as mosquitoes or bed bugs1.
The progression from initial infection with HIV to end-stage AIDS varies among people and can take more than 15 years1. Disease progression in children is more varied and less predictable. HIV progresses more rapidly in infected children than in adults. Some children will show signs of HIV infection within a few months of birth. Without antiretroviral therapy, HIV progresses to symptomatic disease and AIDS1.
1.1.2. HIV and Pregnancy
The HIV/AIDS pandemic is one of the major factors challenging women’s health globally. There are 20 million women globally living with the virus and more than 2 million pregnancies occur annually in HIV seropositive women5. The infection has thus become a major problem complicating the management of pregnancy5,6.
In Africa, HIV prevalence varies considerably, with most countries in southern Africa having more than one in five pregnant women infected3,5,7. In a few sub-Saharan African countries, median HIV prevalence in antenatal clinics in 2003 exceeded 10%3. As at 2005 HIV seroprevalence in Nigeria was 4.4% and by the end of 2006, it was estimated that there were 2.99 million Nigerians living with HIV8. Only 5-10% of HIV infected pregnant women in Nigeria are on antiretroviral drugs for PMTCT8.
Most women in sub-Saharan Africa have their HIV status diagnosed during pregnancy because of HIV testing available through programs for the PMTCT of HIV8. The program commenced in Nigeria in 2001, and has since undergone several scale-up both in scope and coverage, mainly in secondary and tertiary health facilities8.
1.1.3. HIV in Children
Each day, some 1200 children under the age of 15 years become infected with HIV9. Ninety percent of these children are said to live in sub-Saharan Africa9,10. Most of these HIV infected children acquired the virus in-utero, during childbirth or while being breastfed9-11; these are ways of contracting HIV that can be prevented9,10.
For many children infected with HIV, the chances of survival are slim10,11. Worldwide, AIDS now accounts for 3% of deaths in children under 5 years of age10. It accounts for 6% deaths in under-fives in sub-Saharan Africa, where AIDS has become one of the major killers of young children10. One in seven people dying from HIV-related illness, worldwide, is a child under 15 years of age10. This is largely due to failure of introduction of PMTCT programs on the scale needed9,10.
Without HIV care, including antiretroviral therapy (ART), the progression of HIV infection in children is particularly aggressive12. In hard-hit countries such as Botswana and Zimbabwe, HIV is the underlying cause of more than one-third of deaths among children under the age of 5 years10. HIV infection is however, almost entirely preventable9-12. It has been virtually eliminated in high-income countries, where the ready availability of HIV prevention, testing and treatment services has lowered mother-to-child-transmission (MTCT) rates to less than 2% and boosted the survival rates of HIV-infected infants9,10.
In sub-Saharan Africa, more than 95% of HIV infected infants acquire HIV through MTCT1,9,10. A small fraction of HIV infection in children are caused by unsafe injections, transfusion of infected blood or blood products, sexual abuse, sexual intercourse and
scarification10,11.
Between 25-30% of children who acquire HIV from their mothers die before their first birthday10. More than half of the infected children develop symptoms early in life, and in the absence of timely diagnosis and effective treatment, die before they are 2 years old10. In a study of 3500 children enrolled in seven perinatal trials in sub-Saharan Africa, 35% of HIV-infected children had died by the age of one year and 53% had died by 2 years of age10.
The definitive diagnosis of HIV infection in children at any age requires diagnostic testing
that confirms the presence of HIV6,12. Serological antibody testing identifies HIV antibodies5,12. However, maternal antibodies transferred passively during pregnancy can persist for as long as eighteen months in HIV-exposed children12. The interpretation of antibody test results is therefore difficult in children below this age12. In order to make a definite diagnosis of HIV in children under 18 months of age, assays that detect the virus or its components (virological tests) are therefore required12. Polymerase chain reaction (PCR) has now become the gold standard for diagnosing HIV infection in children12. The use of Dried Blood Spot (DBS) technology for both HIV-RNA and HIV-DNA testing and p24 antigen assay has proved robust and reliable12. Polymerase chain reaction and p24 antigen assays can respectively detect HIV in blood as early as six weeks and three weeks after
birth12.
A breastfeeding infant remains at risk of acquiring HIV infection throughout the
breastfeeding period6-12. Consequently, a negative virological test in a breastfeeding infant does not rule out HIV infection12. The WHO advises that virological test assays to detect HIV infection can be conducted at least six weeks or more after complete cessation of breastfeeding12.
In children aged eighteen months and above, HIV antibody testing as performed in adults, can be reliably used to make a definite diagnosis of HIV infection5,12.
1.1.4. Prevention of Mother to Child Transmission (PMTCT) of HIV
The most efficient and cost effective way to tackle paediatric HIV worldwide is to reduce mother-to-child transmission2,6,10. Pregnant women must have access to HIV testing and counselling5,9,10. This will help them to learn about their HIV status and make informed decisions about pregnancy, delivery and infant feeding options1,5,9,10. Mothers that are HIVpositive should have access to a package of services that can enable safe delivery, and ensure safe postnatal care and support for both baby and mother10. These PMTCT interventions, which includes the use of antiretroviral (ARV) drugs, concurrently with feeding adjustments, have proven to be effective in reducing MTCT of HIV3,4. The successful implementation of these programs is dependent on the effective implementation of appropriate feeding regimen2,4,6. With current available technology, widespread, effective services for PMTCT could prevent an estimated 315,000 paediatric HIV infections annually10. The use of ARV drugs, for treating the HIV-positive mother and preventing infection in the baby, has become the standard of care10. Antiretroviral therapy has proven to be highly effective in children including those in resource-poor settings9,10,12.In countries where it has been successfully introduced, antiretroviral therapy has substantially changed the face of HIV infection10. Infants and children infected with HIV now survive to adolescence and adulthood12. The challenges that confront HIV care have therefore evolved to become those of chronic as well as acute care12. Rapid initiation of treatment restores and preserves immune functions, promotes normal growth and development and prolongs life10.
1.1.5. Background of HIV and Infant Feeding
Since the mid-1980s, there has been great improvement in the understanding of the risks associated with different types of infant feeding. In 1985, Australian doctors reported the first case of an HIV positive mother, whose baby became infected presumably through breastfeeding6. Later in the year it was announced that HIV had been isolated from breast milk6. Soon afterwards, the Centre for Disease Control and prevention (CDC), stated that American women with HIV should be advised against breastfeeding6. With greater accuracy in HIV diagnosis, following the development of polymerase chain reaction (PCR), UNICEF stated that breastfeeding was not a significant means of transmitting HIV. They therefore encouraged continued breastfeeding, irrespective of HIV status, where effective use of alternative feeding methods was not possible3,6. By 1992, the World Health Organization (WHO) resolved that, “where infectious diseases and malnutrition are the main causes of infant deaths, breastfeeding should be the usual advice given to women, including those with HIV”3,6. Few months later, meta-analysis of studies conducted around the world, estimated a transmission rate of 14-29% through breastfeeding6.
By 1998, the WHO published new infant feeding guidelines. They advised that all mothers should be counselled about possible feeding options and allowed to make their own
decisions6,7. By 2001, the acceptability, feasibility, affordability, sustainability and safety
(AFASS) criteria for exclusive formula feeding (EFF), otherwise called replacement feeding (RF), was introduced6. In 2002, UNICEF decided to stop procuring and distributing free infant formula as it became obvious that it could not sustain it.
Doctor Jean Humphrey et al, in a study conducted in Zimbabwe, in 2005, reported that babies given a mixed diet were much more likely to become infected with HIV, than those who were exclusively breastfed6.
In 2007, a study of about 3000 mothers in South Africa confirmed that mixed feeding carries a higher risk of HIV transmission than exclusive breastfeeding (EBF)6. The team that conducted the research suggested that the WHO guidelines on infant feeding be revised in favour of EBF6.
1.1.6. To Breastfeed or not to Breastfeed?:
For most babies, it is documented that breastfeeding is the best way to be fed 4,6,8. Unfortunately, breastfeeding can also transmit HIV1,2. In Africa, between one-third and half of infant HIV infections are due to breastfeeding6.
For any HIV positive mother, the dangers of not breastfeeding must be weighed against the threat of HIV transmission. This results in a painful dilemma for millions of women in developing countries for whom there are no easy options1,6.
Many factors have been observed to influence the infant feeding choices made by HIV positive mothers. These include awareness and/or disclosure of HIV status, stigmatization, pressure from relatives, cost of infant formula, advice from health workers etc.
1.2 Statement of the Problem
The 2008 National HIV seroprevalence Sentinel survey estimated a 4.6% HIV prevalence, in pregnant women, registered for antenatal care in Nigeria13. Studies have shown that, even where HIV transmission is reduced through interventions, including exclusive formula feeding practices, infant mortality rate is still on the increase and similar to that seen in exclusively breastfed infants8.
Studies in Botswana9 and South Africa3 have established that adherence to EBF is as low as 10% at three months of age3,9. Even where EFF is predominant due to free supply of formula, adherence is suboptimal as less than 80% of mothers maintain this feeding method for the first few weeks post-delivery3,7.
In Plateau State Specialist Hospital (PSSH), free infant formula is not provided, but routine counselling on infant feeding is given to all mothers at the antenatal clinics and at delivery. It has been observed in this centre (PSSH) that, despite this routine counselling on infant feeding, some HIV positive mothers still fail to adhere to their initially chosen infant feeding method. While some change from one feeding method to another, others resort to mixed feeding with attendant complications among the infants.
1.3 Rationale of Study
The rationale behind this study lies in the need to examine the characteristics of HIV positive mothers and their infants that inform the mothers’ choice of infant feeding. This will determine their success or otherwise, in adhering to their intended infant feeding option.
This study therefore seeks to find out why HIV infected mothers make the infant feeding choices they make, and the problems they encounter in actual practice.
1.4 Aim and Specific Objectives
Aim
To determine the factors influencing choice of infant feeding methods, among HIV positive mothers attending PMTCT clinic, in Plateau State Specialist Hospital.
Specific Objectives
- To determine the types of infant feeding methods chosen among the study population.
- To determine factors responsible for the choice of infant feeding method.
- To determine the challenges faced in the practice of chosen infant feeding option.
- To compare the pattern of growth among the exposed infants at six weeks of age, with respective feeding choices.
FACTORS INFLUENCING CHOICE OF INFANT FEEDING METHODS, AMONG HIV POSITIVE MOTHERS, ATTENDING PMTCT CLINIC IN PLATEAU STATE SPECIALIST HOSPITAL, JOS.
