HIV Transmission Through Breastfeeding: A Review of Available Evidence

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When multiple counselling sessions were provided, many mothers received mixed messages that negatively affected their understanding. This occurred, in particular, when counselling was received from two or more HCPs in the PMTCT treatment cascade; this lead to confusion and potential distrust around infant feeding counselling messages [ 13 , 28 , 29 , 30 , 37 , 39 , 42 ]. Another tells you that you must not give breast milk, as it will make the baby positive. Delivery of mixed messages by HCPs was also seen through the provision of free infant formula to mothers, even in regions where only a minority of mothers could ensure safe formula feeding, and the recommended policy was to exclusively breastfeed [ 18 , 27 , 36 , 37 , 39 ].

Those who received the commercial materials…had notably lower rates of EBF and overall duration [ 39 ], p. The provision of formula is problematic, as free infant formula in clinics is often only provided for a limited amount of time, leaving HIV-positive mothers in a position where they are vulnerable to mix feeding [ 37 ].

Conflicting messages and confusion for HCPs around which feeding mode to recommend can be attributed to frequently changing infant feeding guidelines and poor training of HCPs. The challenge of having to explain an ever-changing message and maintain the trust of mothers has proved to be difficult [ 1 , 13 , 14 , 16 , 19 , 21 , 27 , 28 , 29 , 30 , 33 , 35 , 37 , 39 ]. How can we tell these mothers? In addition to the mixed messages provided, the outcomes of infant feeding counselling have also been affected by a lack of quality and modes of practical counselling for HIV-positive mothers.

In understaffed centers, as well as in larger facilities, group counselling was commonly used for infant feeding counselling. In these circumstances, the education provided was often superficial. Participants raised concerns about these environments as they felt less involved in the counselling and were less likely to voice their concerns.

Individualized counselling was preferred, as it allowed for more in-depth counselling [ 1 , 21 ]. An outcome of low quality counselling is mixed feeding due to a poor understanding of the definition of exclusivity in breastfeeding, as seen in the example below:. She does not like the tin [infant formula] [. Another belief well represented in the literature that led to mixed feeding was the concern that breastmilk was insufficient for infant feeding [ 17 , 18 , 19 , 31 , 34 , 37 , 38 , 41 , 42 ].

Though some women can experience low milk supply, perceived insufficient breastmilk results in mixed feeding [ 31 ]. The beliefs regarding poor milk supply in some cases were reinforced by a lack of practical education by HCPs about correct infant positioning and stimulation of milk production [ 19 , 37 , 42 ]. From this we see that for a woman to exclusively breastfeed, she firstly needs to have the capacity for EBF and in addition receive high quality practical counselling, which can equip mothers to troubleshoot some of the causes of low milk supply, and also increase their belief in their capacity to EBF [ 19 ].

The issue of stigma relating to infant feeding in the context of HIV is well documented in the studies reviewed [ 14 , 18 , 19 , 32 , 33 , 39 ], however, this mechanism also works in a manner not considered in the initial program theory to produce different outcomes. It was expected that there would be stigma associated with formula feeding, that as a protective mechanism, would lead to the uptake of EBF; this was documented in the literature [ 30 , 40 ]. However; because mix feeding is so deeply engrained into many cultures [ 1 , 8 , 14 , 19 , 27 , 30 , 31 , 33 , 37 , 41 ], stigma was also present towards EBF because it goes against cultural norms [ 14 , 33 , 41 ].

Furthermore, those women who were experiencing weight loss due to exclusive breastfeeding were exposed to increased stigma, as this physical change was misinterpreted as an effect of AIDS. This additional risk of stigma, from the effects of breastfeeding resulted in demotivation of the mothers and reduced EBF [ 14 , 33 , 41 ]. Infant feeding counselling for EBF, whilst a universal recommendation for all mothers, has been so heavily targeted at HIV-positive women, that it is a likely reason why EBF is seen as an activity done by HIV-positive women [ 33 ]. A minority stated EBF was recommended for all women.

In this context, the imbalance in the delivery of health information to women based on HIV status led to an increased risk of stigma, which had the potential to decrease EBF. There have been multiple instances noted in the review process where, despite the provision of counselling and infant feeding support, a significant percentage of mothers still made the decision to practice mixed feeding [ 9 , 18 ].

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HIV transmission through breastfeeding: a review of available evidence

A gap has been identified in the theorized mechanisms, in that even when counselling had increased EBF knowledge, deeply engrained cultural norms led to mixed feeding [ 38 ]; highlighting that the mechanism of learning and understanding does not fire consistently. For this reason, an additional CMO configuration was created to explore the mechanism of prioritisation of counselling advice over cultural feeding norms. The mechanism of prioritisation is well represented in the literature, with some examples of the intended CMO configuration seen.

Another example highlights how a woman was able to adhere to EBF and prioritize counselling advice received over the cultural ideas opposing EBF:. The significant finding here is that even when cultural misconceptions were still present, such as when the woman felt she was underfeeding her child by not providing mixed-feeding with water, she was still able to adhere to PMTCT recommendations and EBF [ 30 ]. In other cases, prioritisation of infant feeding advice, that was opposed to cultural norms proved to be more difficult. Fear and insecurity at the thought of opposing cultural norms and being exposed to the potentially adverse effects of EBF were identified as barriers to EBF adherence.


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These cultural beliefs were highly valued and had been passed down for generations, and the prioritisation of them, over counselling advice led to mixed feeding [ 1 ]. Another barrier to the prioritisation of infant feeding advice was seen in the level of trust mothers had in HCPs, particularly when counselling information was contradictory to cultural norms [ 18 ].

Giving the baby two kinds is not allowed [ I gave him food when he was still just 1 month old, I gave him porridge and I saw that he eats it. Then I decided to give him porridge frequently and not be hesitant. These cultural ideas relating to the insufficiency of breastfeeding alone were often reinforced by the idea mixed feeding soothed babies and breastfeeding alone was the reason infants cried so much [ 17 , 18 , 41 ].

There was strong evidence to support the role of support and empowerment in encouraging EBF.

HIV Transmission through Breastfeeding A Review of Available Evidence

Male partners of HIV-positive women play a highly influential role in the determination of infant feeding choice, whether that be individually or jointly with the mother [ 9 , 14 , 31 , 39 ]. They are also one of the greatest supports in maintaining infant feeding choice [ 40 ]. EBF was found to be associated with marital status; this was certainly true of stable marital relationships where there was disclosure of HIV status [ 9 ]. Partners were found to defend the mixed feeding pressure from extended family, many who were not be aware of infant feeding guidelines for EBF [ 16 , 33 ].

This support also mitigated stigma that came from EBF choices [ 16 , 33 ]. She used to drink that porridge and breastfeed the child. Partner support was important in defending against the pressure to mix feed that often came from mothers-in-law and extended family [ 9 ]. This was more evident when the mothers-in-law lived in the same house as the HIV-positive woman.

Grandmothers in particular had a lot of power when it came to make infant feeding decisions, especially in contexts where women were young, inexperienced, unmarried or with no partner support. Particularly in situations of non-disclosure to family members, or when partner disclosure had produced negative outcomes.

They provided strength and support to women, reinforcing the infant decision they had made [ 32 ]. The objective of this realist review was to evaluate key mechanisms theorised to be involved in resulting in EBF adherence in HIV positive women from sub Saharan-Africa. The findings of this review highlight how EBF best occurs when an HIV-positive woman has a desire for motherhood, understands EBF and feels equipped to do it, is not affected by stigma, prioritizes infant feeding counselling advice over cultural feeding norms, and finally, when she feels supported in her infant feeding decision to EBF.

These theories have been tested to better understand for whom and in what circumstances EBF adherence occurs. This realist review identified the role of a desire for motherhood and motivation for child survival in EBF adherence. This mechanism had a lesser effect on EBF adherence when mothers were young and transferred the parenting role to their own mothers.

This highlights the need for expansion of PMTCT services, which are currently targeted at mothers, to target grandmothers as well who are often a crucial support in infant feeding. Furthermore, healthcare providers who counselled mothers based on their own personal beliefs, discouraging EBF, often led mothers to make feeding decisions based on fear of HIV transmission, instead of the promotion of child survival.

Frequently changing guidelines, and the provision of free infant formula have led to mixed messages in counselling [ 13 , 28 , 29 , 30 , 37 , 39 , 42 ]. The subsequent maternal confusion and distrust of counselling advice has resulted in a decrease in EBF. Furthermore, little emphasis has been placed on high quality, in-depth counselling with practical tools to equip mothers for EBF. The evidence shows that EBF can best occur when a mother learns and understands the role of EBF through regular, in-depth and practical counselling, and where there is clarity around feeding expectations and trust of HCPs.

This increased clarity was seen in regions that did not provide free government funded formula. In these regions, there was less mixed feeding and participants were better able to maintain exclusive feeding [ 16 , 42 ]. From initial scoping of the literature, it was expected that stigma around formula feeding would be protective for EBF, which it was.

However, other mechanisms were also at play due to EBF being seen as a deviation away from cultural norms of mixed feeding, and consequently being identified as an activity for HIV positive women. For instance, when women perceived the physical effects of breastfeeding to mimic those seen in AIDS, they were less likely to adhere to EBF due to the increased stigma. During the process of testing our hypothesized mechanisms, a theory gap was found when trying to explain the mechanism that led to EBF in the context of strongly held cultural beliefs.

Evidence was found that some women were able to EBF, even in times when cultural beliefs were still strongly held. It was theorized that for women to EBF when faced with cultural feeding norms of mixed feeding, they would need to be able to prioritize the information received during feeding counselling over any cultural ideas. There were contexts where prioritisation of EBF over cultural norms was difficult.

In these cases, it was suggested that fear and insecurity around going against cultural norms was the mechanism inhibiting EBF prioritisation. EBF adherence could be improved if HCPs regularly challenged the mixed feeding cultural beliefs held by women through infant feeding counselling; however, it was noted that even HCPs had little confidence that overcoming cultural barriers to EBF would be possible for mothers [ 13 ].

References

This mechanism was well documented in the literature, with both males and HCPs playing key supportive roles for women. Male involvement, for women in stable marriages who had disclosed their HIV status, facilitated EBF through the support provided in making and adhering to feeding choices, in the face of feeding pressure from extended family. HCPs provided support by empowering women to be assertive about their feeding choices, particularly in cases of non-disclosure to other family members. These situations highlight the supportive role that extended family could play in encouraging EBF adherence, as strong influencers of feeding habits.

This re-iterates the role for increased family involvement in PMTCT, targeting not only mothers but also fathers and grandmothers [ 16 ]. The strengths of this review of infant feeding counselling for EBF lie in the chosen review methodology. Taking a realist approach meant this review considered that interventions work in different ways to produce different outcomes in different contexts [ 23 ]. This allowed for a more in-depth analysis of various successes and failures of the interventions. There are however limitations to this review, some of which are inherent to the realist approach and others which due to the research topic itself.

It is important to note that mechanisms are all interconnected, with multiple mechanisms operating in contexts. As such CMO configurations do not act independently and two mechanisms can work concurrently to produce an outcome [ 43 ]. There were occasions when the methodology of the review, similarly to Rycroft-Malone et al.

This was not done due to the time constraints of the review. An important limitation to the review was that it focussed on women in sub-Saharan Africa engaged with PMTCT services and received infant feeding counselling. The reality is that many women do not have access to these interventions. Further research on this topic could look into mechanisms that result in a woman attending and engaging with PMTCT services.

This review has identified the basis for future research studies that use an intervention approach to encourage mothers to exclusively breastfeed their infant. Another study of value would be to follow these infants prospectively to evaluate how many become and remain HIV positive and develop disease over time. Such research would take immense commitment and support but would be of great value to understanding the role of breastfeeding in HIV prevention and management.

The aim of this review was to create a model showing how and in what contexts infant feeding counselling best worked to fire mechanisms in HIV positive women to result in EBF. It was found that EBF occurred when a woman desired or had motivation for motherhood, correct learning and understanding about infant feeding practices obtained through good quality and practical counselling, the resolve to prioritize EBF advice over cultural beliefs and stigma, no fear of breastfeeding or the impact of opposing feeding related cultural beliefs, and the support from partners and HCPs to be assertive about the feeding choices when faced with pressure to mix-feed.

The primary audience for this review are researchers and health care workers in PMTCT in low and middle-income countries, particularly sub-Saharan Africa, who may benefit from the work that has been done to identify contexts for the success and failures of EBF. Socio-cultural determinants of exclusive breastfeeding: lessons learnt from experiences of HIV-positive mothers in Lusaka, Zambia.

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Preservar la lactancia maternal a pesar de la pandemia de VIH

BMC Infect Dis. PLoS One. A protocol for a cluster randomized trial on the effect of a "feeding buddy" program on adherence to the prevention of mother-to-child-transmission guidelines in a rural area of KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr. Challenges faced by health-care providers offering infant-feeding counseling to HIV-positive women in sub-Saharan Africa: a review of current research.

AIDS Care. Pan African Medical Journal. How acceptable are the prevention of mother to child transmission Pmtct of Hiv services among pregnant women in a secondary health Facility in Ibadan, Nigeria? Ann Ib Postgrad Med. Social circumstances that drive early introduction of formula milk: an exploratory qualitative study in a peri-urban south African community.

Matern Child Nutr. Factors affecting exclusive breastfeeding among women in Muheza District Tanga northeastern Tanzania: a mixed method community based study. Matern Child Health J. Mother's perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa. Ostergaard LR, Bula A. Afr J Reprod Health. BMC Med.

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HIV Transmission through Breastfeeding A Review of Available Evidence

London: Sage Publishing; Realist synthesis: illustrating the method for implementation research. Implement Sci. A time-responsive tool for informing policy making: rapid realist review. Critical Appraisal Tools. Poisonous milk and sinful mothers: the changing meaning of breastfeeding in the wake of the HIV epidemic in Addis Ababa. Citation World Health Organization. World Health Organization. Description This publication is an update of the review of current knowledge on HIV transmission through breastfeeding, with a focus on information made available between and It reviews scientific evidence on the risk of HIV transmission through breastfeeding, the impact of different feeding options on child health outcomes, and conceivable strategies to reduce HIV transmission through breastfeeding with an emphasis on the developing world.

The publication provides the evidence base and rationale for two additional documents in the revised HIV and infant feeding series; HIV and Infant Feeding. Collections Publications. Metadata Show full item record. Related items Showing items related by title and subject.

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