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.

Background

Globally, of the 33.3 million individuals infected with HIV,^[1] 22.5 million live in sub-Saharan Africa (SSA).^[1,2] Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for approximately 69 per cent of people living with HIV globally.^[3] Over the past decade, HIV prevalence among women attending antenatal clinics has unprecedentedly risen leading to an increase in HIV-positive children born to HIV-infected mothers' worldwide.^[4] According to Illiff and colleagues, 30-50% of women will pass the virus to their infants; and more than a third of all transmissions will occur during breastfeeding without appropriate interventions.^[5]

In 2010, an estimated 390,000 [340,000-450,000] children were newly infected with HIV of which more than 90% were living in Sub-Saharan Africa.^[3] In 2008, of the 430,000 paediatric HIV infections worldwide, between I29,000 and I94,000 were attributable to breastfeeding.^[4] In the absence of any interventions, the rate of Mother to Child Transmission (MTCT) in developing countries can be as high as 45 per cent with prolonged breastfeeding of up to 24 months.^[5] Post-natal transmission of HIV, predominantly through breastfeeding accounts for approximately half of all MTCT in Sub-Saharan Africa where breastfeeding is prolonged.^[5] In this region, HIV/AIDS accounted for 7.7 per cent of deaths of children under five years.^[6]

Several studies have tried to estimate the net effect of HIV/AIDS on child mortality in Africa.^[7-10] One of such studies by Adetunji in 2000, provided an overview by comparing point estimates of under-five mortality in the late 1980's and early 1990's, using published estimates from Demographic and Health Surveys (DHS). The study found that in Africa, HIV mortality accounted from 13% to 6I% of under-five mortality depending on the country, demonstrating that the HIV/AIDS epidemic is reversing many of the gains made in child survival.^[8]

Over the past decade, the WHO in partnership with other UN agencies has issued several guidelines in relation to the PMTCT and infant feeding. While each successive guideline has varied in light of evidence, a common recommendation for the prevention of transmission has been the avoidance of breastfeeding and replacement with infant formulae when possible and considered adequately safe, and discouraging of mixed feeding (combining breastfeeding with other fluids and solids). While this has clearly been successful in developed countries, this is often not been the case in developing countries and much of Sub-Saharan Africa,^[11] more specifically, with regards to infant feeding. Although formula is the recommended infant feeding option for HIV-infected mothers in developed countries, this may not be a feasible or preferred choice for women in resource-poor communities and developing countries for many reasons. These include the prohibitive cost, poor infrastructure to ensure consistent availability and cultural beliefs that may compel mothers to continue breastfeeding. These socially and culturally embedded practices need to be understood and taken into account when designing and implementing infant feeding programs in the context of MTCT of HIV.

Breastfeeding is the norm in most of the world, and for good reasons such as the best nutrition for babies, protection against deadly childhood diseases, delay return to fertility, being costless, and promotion of bonding and social/emotional development in babies.^[12-14] Other benefits of the promotion of Exclusive Breastfeeding (EBF) include: a healthful behavior for HIV-unexposed infants and their mothers, requires minimal preparation, is not dependent upon outside materials^[4] and among other benefits which are incalculable. Yet, in today's society, breastfeeding is often thought of as unnecessary due to diseases. 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.^[15] The rise in HIV/AIDS cases puts new focus on breastfeeding as a route of transmission from mother to child especially in Africa.

Infants across all regions of the world are breastfed, although not always exclusively and there is significant variation in the percentage of infants who are ever breastfed among regions and among countries within a region.^[16] According to Young and colleagues, current rates of EBF are well below targeted levels in both HIV-affected and unaffected populations around the world though increasing rates of EBF is one of the most powerful interventions to save child lives.^[4] The promotion of breastfeeding could prevent 13-15% of child deaths in low-income countries.^[17] In Sub-Saharan Africa, the issue of HIV transmission through breastfeeding is of public health importance particularly in countries where HIV affects significant proportion of the population and where breastfeeding is the cultural norm.^[18] Studies have confirmed that about a third of HIV transmission from mother to child occurs through breastfeeding.^[19,5] This is as a result of inappropriate infant feeding practices.

According to WHO, appropriate feeding practices play a crucial role in preventing mortality and in achieving optimal health outcomes for infants and young children during the first 6 months of life.^[20] Despite, the many advantages of EBF and ERF, a woman's initial decision to EBF or ERF can be hindered by a range of societal, household, and individual factors. In light of the gap between policy and practice, the purpose of this review is to deepen our understanding of why this gap exists. We examined the evidence in terms of factors affecting perspectives, attitudes and practices of HIV-positive mothers and communities on mother-to-child-transmission and infant feeding in Sub-Saharan Africa region.

Methods

This work is based on an extensive review of peer-reviewed articles and grey literature based on the aim and objectives of the study, covering the period 2000-2012 (12 years). The literature search for peer-reviewed articles were carried out using electronic databases like, Medline Ovid, Google scholar, Pubmed and EBSCOhost, keeping in mind the fact that different authors use different terminologies. Key words and phrases like “HIV” “HIV and infant feeding”, “infant feeding practices,” “influence of breastfeeding duration,” “replacement feeding or alternative feeding”, “international infant feeding guidelines”, “WHO infant feeding guidelines”, “developing countries”, “low-income countries”, “middle-income countries”, “sub-Saharan Africa”, “resource poor settings”, “socio-economic status”, “educational status”, “counseling”, “cultural norms and practices”, “stigma” PMTCT, were used to identify the relevant literature after which duplicate records and irrelevant titles were removed. Both quantitative and qualitative studies on HIV and infant feeding with particular emphasis on sub-Saharan Africa were included. Only papers written in English which met the inclusion criteria were selected for this review.

In all, a total of 215 articles were identified through the searching. After articles excluded based on region, study subjects and year of publication, 34 articles both quantitative and qualitative English language studies met the inclusion criteria. Figure 1 presents a flowchart representing the overall selection process for the studies reviewed in this paper. This paper is based on a review of existing literature and did not require ethical approval.

Close

Figure 1.

Process for searching the relevant literature.

Export to PPT

Results

For the review, 34 articles comprising of 9 qualitative, 18 quantitative and 7 both quantitative and qualitative studies were analyzed. The results were categorized based on the following attributes: socio-economic, PMTCT and infant feeding counseling and cultural and social norms. Based on information gathered from the study findings, we developed a conceptual framework (Figure 2) that demonstrated the interrelationships between the attributes that affect breastfeeding among mothers who are positive for HIV/AIDS. These factors influence considerations of and the relative importance of affordability, feasibility, acceptability, and sustainability of feeding options recommended for HIV-Positive mothers and the decision by the mother to adopt a particular option or combination thereof.

Close

Figure 2.

Conceptual framework

Export to PPT

Discussion

From this review, it is clear that in many African settings breastfeeding initiation is near universal, and early mixed feeding patterns are deeply entrenched. Adopting either EBF or ERF represents departures from the social norms. While counseling is important and a necessary condition for improved feeding choices for HIV-positive mothers, the impact of counseling about breastfeeding risks and alternative feeding methods has also not been adequate. Furthermore, the influence of socio-economic factors, family and community members often result in women not being able to adhere to the recommended infant feeding options.^[49,53]

Infant feeding represents a great challenge in the prevention of MTCT of HIV in Sub-Sahara Africa. Based on the review of the literature, we hypothesized that decisions by HIV-positive mothers with regards to infant feeding is influenced by three important sets of factors. These include knowledge of the feeding guidelines for infants born to HIV-positive mothers, socio-economic status of HIV-positive mothers and cultural norms and practices. Not only that, but also influences by their spouses/partners, family members and the community at large. These factors are linked to the issues of affordability, availability, acceptability, and sustainability of different feeding options and finally the decision by the mother to adopt a particular option or combination thereof.

Socio-economic status of HIV-positive mothers more specifically is determined by a range of factors including the mothers' and their spouses' professional status, Socio-economic status of her family^[37-39] and educational levels.^[41] Education also impacts positively on employment and income with implications for issues of affordability.^[24,55] Mothers with higher educational levels are more likely to be socio-economically better off, are more likely to adopt healthy infant feeding practices.^[56] It is not surprising then that infant feeding options which often include financial considerations (e.g. cost of formula) and require access to clean water and sanitation need to be considered as important influences on the decision-making process of HIV-positive mothers. It is obvious that the socio-economic position of HIV-positive women is an important factor which influences the infant feeding decision-making process and can often explain why women who indicate their intention to replacement feed, change their decisions postpartum because of the financial challenges they face. This underscores the importance of counseling and support which extends beyond the antenatal period. In a global context of widespread impoverishment especially in developing countries, there is the need for countries to re-examine their infant-feeding policies in relation to broader socioeconomic issues and realities facing women and families.^[57]

From this review, it is clear that infant feeding counseling is an important intervention for the prevention of PMTCT of HIV PMTCT interventions include HIV testing and counseling, antiretroviral prophylaxis or treatment for mother and infant, modified obstetric practices, and support for infant-feeding practices.^[5] The World Health Organization advises that HIV-positive mothers should be offered nondirective counseling on various infant feeding options that are feasible, affordable, safe, sustainable, and effective in the local context. Comprehensive PMTCT of HIV programs have nearly eliminated MTCT in developed countries.^[58] However, progress in implementing PMTCT interventions in resource-limited countries has been slow.^[59] It is against this background that Coutsoudis and colleagues recommend investments in high-quality, widely available HIV counseling support for choice of feeding methods for HIV-positive mothers.^[60]

Clearly, counseling in the context of MTCT calls for adequate training of health workers and lay counsellors in infant feeding counseling skills, followed by monitoring and supervision which can lead to effective support to mothers in areas of high HIV prevalence. Such efforts have resulted in reduced mixed feeding and increased EBF and ERF. Counseling approaches need to effectively guide women to informed choices with support available to make these choices viable and sustainable. Reducing transmission of HIV through breast milk is dependent on the knowledge and understanding of these mothers and the quality of counseling information given to them by PMTCT counsellors or health workers. Poor quality of counseling is likely to reduce the effectiveness of these programs on infant feeding interventions in the context of HIV/ AIDS. Therefore it is important that HIV-positive mothers are provided with correct information during counseling on infant feeding options to enable them choose a feeding option and adhere to it. To support counseling on HIV and infant feeding as a routine part of Maternal and Child Health, health workers and PMTCT counsellors need to be trained to provide culturally compatible counseling support that improves self-esteem and confidence and corresponds with the social norms and perceptions of mothers.

As noted earlier in this review, mixed-feeding and not exclusive breast-feeding is the norm in many cultures across the sub-Saharan Africa region. These practices are also embedded within cultural norms where communities, husbands and other significant family members play a decisive role in infant feeding decisions. Understanding and addressing local beliefs and customs can help counsellors to provide more culturally appropriate counseling about breastfeeding. Therefore, unless local beliefs and customs surrounding infant feeding and the socio-cultural aspects of HIV/AIDS is understood by policy makers and program implementers, PMTCT programs will only be partially successful in influencing feeding practices of HIV-positive women.

Conclusion and Global Health Implication

In conclusion, guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialization processes, gender dimensions and socio-economic status within communities and families should be considered in recommending feasible and sustainable options. Hence, the need to take into account the social, cultural and psychological complexity of infant feeding practices when advocating appropriate infant feeding options. The need for further research into infant feeding in the context of HIV to ascertain the safety of using animal's milk (cow's milk), expressed heat-treated human milk and wet-nursing as infant feeding options. Finally, development of appropriate, locally produced, feasible, sustainable and affordable local nutritive foods for children in Sub-Saharan Africa.