Choice Of Alternative Breast Feeding Among HIV Positive Mothers

Project and Seminar Material for Nursing (Science)

Choice Of Alternative Breast Feeding Among HIV Positive Mothers


This work seems to investigate the choice of alternative feeding among HIV mothers. This was done related to their knowledge attitude and adherence because this three factors influence choice. A prospective study of seventy-four mothers was designed to assess impact of HIV infection on infant feeding practices and nutritional status of children born to HIV positive mothers’ aged zero to six months. The study carried out in Ahmadu Bello University Teaching Hospital-Zaria, from birth to six months, with the objectives of assessing the impact of HIV infection on infant feeding practice among HIV infected mothers, assessing the effect of feeding practices on the nutritional status of infants of HIV infected mothers, and assessing the impact of education, on infant feeding practicing among HIV positive mothers. Data collection involved administration of semi-structured questionnaire, taking anthropometric measurement of their babies and their folders were used to collect more information that could not be obtained from the caregivers directly such as CD4+ count. Data was analyzed using WHO Anthro. Maternal knowledge on Mother to Child Transmission of HIV was high and is reflected in maternal choice of infant feeding practice where 95.95% practiced alternatives to breastfeeding. On the other hand, level of formal education attained has no association on choice of infant feeding practice while exposure to other information received through health talks and or counselling from health workers or media influenced their choices. Despite high level of maternal knowledge on Prevention of Mother to Child Transmission of HIV, few respondents practiced mixed infant feeding before 6 months. The exposed children were moderately undernourished because, in all the indexes; none was below -2 Z-score, with values revolving between -1 Z-score and -2 Z-scores. In conclusion, the choice of infant feeding practice is significantly associated (p<0.05) with level of maternal knowledge of PMTCT of HIV as seen in the Chi-square value calculated compared to the tabulated value, while commonly used infant feeding option among the mothers is alternatives to breast feeding.

Chapter One


1.1 Background of the Study

Infant and Young Child Feeding (IYCF) is very critical for child survival, especially in the presence of HIV. While HIV has direct effect on childhood nutrition, the choice of Infant and Young Child Feeding in the context of HIV has significant effect on optimal child growth, survival and development. Hiv/AIDs is one of the world’s most serious public health and developmental challenges. It was first reported in 1981 and primarily affects those in their most productive years 15-29years. Hiv not only affects the health of individuals, it affects households, communities, the development and economic growth of countries. Many of the countries hardest hit by HIV also suffer from other infectious diseases, food insecurity and other serious problems.

Globally, in 2015, there were 36.7 million people living with HIV, up from 33.3million in 2010 which is partly due to new infections, people living longer and general population growth (Abiona, T. C., Onayade, A. A). About 70% of people living with HIV/AIDS were in Sub-Saharan Africa of these 51% but only constitute 13% of the world population.1,2,3 were women. As at December 2015 there were 1.8million children under the age of 15 living with Human Immunodeficiency Virus (HIV).

In Nigeria, the epidemiology of HIV is mainly informed by two national surveys, the Antenatal clinic (ANC) survey conducted among pregnant women and the National HIV/AIDS Reproductive Health Survey (NARHS) which is a general population-based survey. The national HIV and syphilis sero prevalence sentinel survey among pregnant women attending ANC in Nigeria 2014 reported a national prevalence of 3.0%.4 The national prevalence of HIV is 3.0% with over 3.2 million people living with HIV/AIDS and about 58% are women. The 2010 mode of transmission study for HIV in Nigeria reported Mother to Child Transmission route as 10%, and Sexual route for 80%.More than 90 percent of HIV infections in children are as a result of mother-to-child transmission, where the virus is passed from a mother living with HIV to her baby during pregnancy, childbirth or during breastfeeding. While the precise mechanisms for viral transmission during pregnancy are incompletely understood, the risk of this form of transmission increases in direct relation to the severity of the mother’s HIV infection.5 Without intervention to prevent mother-to-child transmission, 30-45% of infants born to HIV-positive mothers become infected during pregnancy, delivery and breastfeeding. Breastfeeding for women living with HIV can be made safer by providing antiretroviral drugs throughout this period.

Despite over decades of fight against the HIV/AIDS epidemic, Nigeria still has a high burden of HIV/AIDS, second only to South Africa by global ranking. Although Nigeria’s current HIV prevalence rate among pregnant women is 3.0%, a decline from the peak of 5.8% in 2001,7 the number of new infections remains unacceptably high.
The 2013 Nigeria demographic and Health survey reported the child mortality rate was 64 per 1000 children surviving to age 12 months and under –five mortality rates was 128 per live birth.8 This implies that 1 in 15 Nigerian children die before their first birthday and 1 in 8 die before their fifth birth day. About 70 percent of under-five deaths are caused by preventable and curable diseases such as typhoid, malaria, pneumonia, diarrhoea, measles and HIV/AIDS. Malnutrition is another cause of morbidity and mortality in Nigeria, it accounts for at least 50 percent of children’s deaths8. The HIV among children is mainly through Mother to Child Transmission. Globally, Nigeria contributes the highest number of vertically transmitted childhood HIV infections, accounting for 30% of the global burden.7 The latter is partly due to the large number of people living with HIV (PLHIV) in Nigeria of whom 58% are women. Most of these women do not know that they are HIV positive and therefore do not receive intervention during pregnancy, labour and breastfeeding to prevent vertical transmission of HIV to their infants. In Nigeria, it is estimated that there are 5.3million births annually. In 2014, 3.1million pregnant women were tested for HIV and 63,350 HIV positive pregnant women received ART to reduce Mother to Child Transmission (MTCT).9
Management of Pregnant women living with HIV/AIDS and Children Born to women living with HIV/AIDS

The management of pregnant women living with HIV and AIDS include Antenatal HIV testing and counselling, provision of ARVs for women and children, Nutrition and Breast feeding counselling and support and Integrated Management of Childhood Illnesses (IMCI). The National guideline on Prevention of Mother to child transmission of HIV in Nigeria recommended alternatives to breast feeding with extended ARV given to the mother or infant up to 12-months of age. This is in line with the WHO global recommendation

1.2 Statement of the Problem

In 2014, it was estimated that 380,000 children were living with HIV/AIDS in Nigeria, with 250,000 of them requiring antiretroviral therapy. Only about 20% was accessing ART. There was an unmet paediatric HIV treatment gap of 80%, which is partly due to low early infant diagnosis (9%) in 2014, National HIV and syphilis zero-prevalence ANC sentinel survey 2014. Linkage to HIV care and treatment is poor. Among the 33,499 children (<15years) diagnosed with HIV/AIDS only 52% were linked to care. The paediatric ART coverage was 20.7% in ANC sentinel survey, 2014.

This means that the child can benefit from the choice of alternative breastfeeding with very little risk of becoming infected with HIV as supported by the WHO-led Kesho Bora study which found 42% reduced risk of transmission to infants11. Furthermore, it has been reported that only 17% of children under six months were exclusively breastfed with a median duration of 18.3 months. However, breastfeeding still remains the recommended feeding options for improving child survival. The UNAIDS has estimated that more than half of HIV transmission from mother to infants occurred during breastfeeding and reported that Nigeria carries the highest burden of new HIV infections among children and home to a quarter of all new HIV infections among children in 2013, which is approximately 51 000 cases. This is because Nigeria, has placed greater emphasis on antiretroviral drugs during pregnancy and delivery, linked with antenatal care, but less emphasis on postnatal follow up for retention in care during breastfeeding.

Poverty is very high in Nigeria with nearly 61% of the population living below the poverty line and 60.9% in absolute poverty.13 Between 70% and 85% of Nigeria households encounter food shortages every year. The scale of this problem has created a situation where young children are being fed foods that are available (that may not be balanced diet). While choosing alternatives to breast feeding is a challenge regardless of HIV status, an estimated though with its risk that’s why most people despite the economic hardship opt for alternative choice of alternatives to breast feeding. 29% of Nigeria under-five children are currently underweight, 18% are wasted and 37% are stunted.

The risk of transmission depends on many factors, including the timing of maternal infection, maternal viral load, nutritional status of both the woman and baby, antiretroviral (ARV) use, duration of any breastfeeding, and presence of oral lesions in the infant among others. In the absence of interventions to prevent transmission, 5–10% of infants born to HIV-positive mothers become infected with HIV during pregnancy and 10–20% become infected around the time of delivery), with additional 5% risk during breastfeeding. Estimates of the risks of HIV infection via alternatives to breast feeding have varied due to the multi-factorial nature of risk of transmission.

1.3 Objective of the Study

To assess Choice of alternative breastfeeding among HIV positive mothers

HIV positive mothers in Kaduna.

  1. To determine knowledge and attitude of HIV positive mothers towards HIV and alternative Breast feeding options.
  2. To determine HIV positive mothers level of adherence to recommended choice of alternative Breast feeding option.
  3. To determine factors influencing adherence by HIV positive mothers to recommended choice of alternative Breast feeding at neonatal follow-up clinic in Kaduna.

1.4 Research Questions

  1. What is the knowledge and Attitude of HIV positive mothers on HIV and alternative choice of Breast feeding?
  2. What is the level of adherence of HIV positive mothers towards HIV and recommended choice of alternatives to breast feeding options?
  3. What are the factors affecting adherence by HIV positive mothers to recommended choice of alternative Breast feeding options in Kaduna?

1.5 Significance of the study

The HIV prevalence in Kaduna among pregnant women is 5.8% compared with the national prevalence of 3.0%. The HIV prevalence in Kaduna municipal, Birnin Gwari and Karshi are 10.0%, 5.0% and 5.4% respectively reported in National HIV and Syphilis Sero Prevalence Sentinel Survey among Pregnant women attending ANC, 2014.Given the high prevalence of HIV in the Zaria and poor Breast feeding practices‟ contributing to child mortality, it is important to support alternative choice of alternatives to breast feeding among mothers living with HIV/AIDS. The United Nations member organizations have offered guidance in the development, adoption and or adaptation of HIV and infant-feeding guidelines in way to address these challenges and emphasis has been given to available new scientific evidence. In developed countries, use of Highly Active Antiretroviral Therapy (HAART) have lowered the levels of MTCT to as low as below 2%.Finding the optimal infant-feeding strategy for women with HIV in developing countries like Nigeria, where there is often limited access to HAART, remains a challenge. In such settings, clinical guidelines have fluctuated between exclusive formula feeding, alternatives to breast feeding in the first six months of life, and most recently, providing antiretroviral (ARV) drugs to either the mother or the child until one week after exposure to alternatives to breast feeding has ended. In addition to the aforementioned challenges related to replacement feeding, alternatives to breast feeding has also proved difficult to adhere to even though most mothers breastfeed for nearly two years.

More than half transmission of HIV from infected mother to her unborn child occur during the postnatal period because of the high emphasis placed on the use of ARV during pregnancy, labour and delivery with less emphasis on ARV use during breastfeeding.24 In developing countries, ARV has been used to reduce the risk of prenatal and peri partum transmission for more than a decade(Chopra M., Doherty T., Jackson D., and Ashworth A. (2005)).

Consequently, testing, counselling, and ARV provided by PMTCT programmes have been largely responsible for the steady decrease in the incidence of paediatric (less than 15 years old) HIV. Therefore, there is a need to investigate the attitudes and alternatives to breast feeding recommendations with a view to improve breastfeeding practices.
In Sub-Sahara African countries where majority of mothers with HIV infection live, complete avoidance of alternatives to breast feeding is often not feasible due to lack of resources and/or affordable replacement feeding. However, extended regimens, such as those recommended during breastfeeding, will be difficult to make universally accessible without exploring issues of attitude and adherence to breastfeeding.

Furthermore, most of the studies on postnatal Prevention of Mother to Child Transmission programmes (PMTCT) have focused on the biomedical consequences of alternatives to breast feedingmodalities, primarily disease transmission and survival. Thus, the range of strategies for reducing MTCT has frequently come with unintended and unmeasured psychosocial ramifications, examples; physical abuse, rejection by partners, families, and abandonment of infants.

PMTCT in Africa, including Nigeria, has provided infant-feeding one-on-one counseling to HIV positive mothers. However, this approach has given the women the chance to freely decide the most appropriate alternative on their own with little attention to other important influences which are beyond the mothers‟ control, but which may be essential for adherence to the chosen options. Thus, ensuring safe Breast feeding practices will entail finding a strategy that takes into account discrepancies between the counselling provided to the women and attitude that is socially and culturally acceptable to the mothers.

Consequently, PMTCT interventions, postnatal and otherwise, will be more effective if they are evaluated in terms of their psychosocial effects as well as their biological ones. HIV positive mothers are likely to exclusively breastfeed with extended ARV given to either mother or infant pair if they have the right attitude and adhered to the recommendation. Therefore, this study, aimed to describe the adherence of HIV-infected mothers, to recommended breastfeeding in postnatal period, as well as identify factors influencing adherence in HIV positive mothers in Kaduna. Knowing these will not only influence their willingness and ability to participate in the programme but also to adhere to programme recommendations. Without support to maintain good adherence to breastfeeding with extended ARV in the postnatal period, substantial number of children will be infected.

1.7 Scope of the Study

This study focused on the alternative Breast feeding option among HIV positive Mothers attending post-natal services in health facilities in Kaduna, in the North Western Zone of Nigeria.

1.8 Limitations of the Study

Recommendations were acquired based on recall of alternatives to breast feeding practice. To minimize bias 24-hour recall was used. However, several misclassifications might have occurred since a mother who has been exclusively breastfeeding her infant but for some reasons gave her infant water or some other liquids the previous day is considered not exclusively breastfeeding.

1.9 Definition of Terms

Alternatives to Breast Feeding:

These are not breastfeeding food offered to children

HIV Positive:

A person infected with HIV

1.10 Organization of the Study

The first chapter contains the study’s introductory section, which includes the study background, the research problem statement, the objective study, and the scope of the study. The second chapter is a critical review of other literatures pertinent to the study and its objectives, as well as the theoretical framework of the study. The third chapter goes over the study’s data collection, sampling, and data analysis methods. The fourth chapter examines the research findings, including how they relate to previous findings. The fifth chapter includes a summary of the findings, a conclusion, and recommendations based on the objectives of the study.

Chapter Five

Conclusion and Recommendations

5.1 Conclusion

Majority (93%) of the respondents have good knowledge, their attitude was fair (42%) with low adherence (17%) to the recommended feeding option. Predictors of adherence were good knowledge, type of health facility attended and employment status.

5.2 Recommendations

  1. Reinforced alternative Breast feeding recommendation during postnatal period or after delivery and this should be complimented with support in the community to be provided by peer groups (example mother to mother support group). Knowledge is high but uptake of ARV during postnatal period is low , this is an area for further research
  2. Provide treatment to HIV positive mothers irrespective of the time of initiation of antenatal care throughout pregnancy, delivery and breastfeeding.
  3. Where possible HIV positive mothers should be encouraged and supported to attend antenatal care and deliver at secondary facilities.
  4. While effort should be made by government at different level of care to operationalize and strengthen the provision of one PHC per ward with trained nurse/midwifes and community health workers to support service delivering at this level.
  5. The federal government should approve a compulsory one-year attachment of Nurses/midwifes at PHC /MCH as part of their in service training including engagement of retired Nurses or midwives among others.

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Frequently Asked Questions

Can a HIV positive mother breastfeed?

Breastfeeding for HIV-Positive Mothers. Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first six months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival.

What is the best approach to HIV and infant feeding?

Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first six months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival.

How to prevent HIV transmission through breast milk?

The best way to prevent transmission of HIV to an infant through breast milk is to not breastfeed. External recommend that HIV-infected mothers completely avoid breastfeeding their infants, regardless of ART and maternal viral load.

Can HIV-infected mothers breastfeed?

In the United States, where mothers have access to clean water and affordable replacement feeding (infant formula), CDC and the American Academy of Pediatrics recommend that HIV-infected mothers completely avoid breastfeeding their infants, regardless of ART and maternal viral load.

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