IMPACT OF HIV INFECTION ON INFANT FEEDING PRACTICES AMONG HIV-POSITIVE MOTHERS, AND NUTRITIONAL ASSESSMENT OF THEIR CHILDREN (0-6 MONTHS) IN AHMADU BELLO UNIVERSITY TEACHING HOSPITAL ZARIA, NIGERIA

ABSTRACT
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 exclusive 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 exclusive breast feeding.


CHAPTER ONE
1.0                                                         INTRODUCTION
1.1 Research Background
The Global Strategy for Infant and Young Child Feeding (IYCF), adopted by the World Health Organization (WHO) and United Nations Children Fund (UNICEF), states that the optimal feeding pattern for overall child survival is exclusive breastfeeding for the first six months, and continued breastfeeding for up to two years and beyond, with complementary feeding from age six months, together with related maternal nutrition and support (WHO, 2010). The Global Strategy contains specific recommendations for children in exceptionally difficult circumstances, including those born to HIV-positive women. Action to reduce child morbidity and mortality and to promote family health has greatly improved child health (Walker et al., 2002, Black et al., 2003).

Promotion of breast-feeding has contributed significantly in that it provides optimum nutrition, protects against common child-hood infections, reduces mortality significantly, and has child-spacing effects (Nicollet al., 2000; WHO Collaborative Study Team, 2000). Nearly all infants in developing countries are initially breastfed, and most continue until at least six months of age but often into the second year (Nicollet al., 2000, WHO Collaborative Study Team, 2000). Continued breastfeeding (beyond six months) is common in sub-Saharan Africa and Asia, but much less so elsewhere. Up to 94% of infants in the world are estimated to be ever breastfed, 79% to continue at one year, and 52% at two years, with an estimated median duration of breast feeding of 21 months (WHO, 2010). Overall, an estimated 41% of infants less than four months of age and 25% under six months are exclusively breastfed; in sub-Saharan Africa 23%of infants less than six months of age are exclusively breastfed (WHO, Global Databank on Breastfeeding and Complementary Feeding, 2003a).In 2001 the World Health Assembly endorsed the recommendation that infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. After six months, they should receive nutritionally adequate and safe complementary foods while breastfeeding continues up to 24 months or beyond. This recommendation takes into account the considerable benefits of breast-feeding, as well as the adverse effects of artificial feeding at an early age. Exclusive breastfeeding is the best form of feeding for the infant during the first six months of life (WHO, 2001a). Also, it helps the mother space her pregnancies. A woman who exclusively breastfeeds during the first six months and who has not resumed menstruation has a less than 2% risk of becoming pregnant (WHO, 2000b). Exclusive breastfeeding on a population basis has been shown to be feasible with adequate support and training of health-care professionals (Kramer et al., 2001; Bhandari et al., 2003).

Infant and young child feeding in the context of Human Immunodeficiency Virus (HIV) poses significant challenges due to the risk of transmission of the virus via breastfeeding. Prior to the 2010 guidelines on HIV and infant feeding, avoidance or early cessation of breastfeeding seemed logical or appropriate (United Nations, 2014). However, the repercussions for the health and survival of the infants were serious, with studies howling much higher mortality rates due to diarrhoea, malnutrition and other diseases in non-breastfed children. The 2010 recommendations were based on evidence of positive outcomes for HIV-free survival through provision of ARVs to breastfed HIV-exposed infants. Thus the focus is now firmly on ensuring HIV-free survival, not just on preventing transmission. The WHO, (2010) guidelines provide a much clearer pathway towards this goal. Breastfeeding carries significant health benefits for infants and young children and is an essential child survival intervention. Without intervention, about 35% of HIV-positive pregnant women will pass on the infection to their babies during pregnancy, delivery and post-natally through breastfeeding. Without preventive interventions, about 10-20 per cent of infants born to infected mothers will contract the virus through breast milk if breastfed for two years. The risk of postnatal HIV transmission after 6 weeks of age is estimated at around 1% per month of breastfeeding (WHO, 2006).Several other factors affect the risk of transmission, including the ―viral load‖ or amount of virus in the mother‘s body (highest risk after infection and when AIDS develops; a very sick mother is eight times more likely to transmit HIV to her infant than a healthy mother), the duration of breastfeeding (the longer the period, the greater the risk, as transmission is cumulative), and the condition of the breasts (whether there are sores around the nipples e t c.) (WHO, 2010).

Method of infant feeding is clearly associated with the risk of transmission through breast milk. Exclusive breastfeeding for the first six months is associated with a 3-4 fold lower risk of HIV transmission as compared to mixed feeding (mixed feeding means the infant receives both breastmilk and any other food or liquid including water, non-human milk and formula before 6 months of age)(WHO, 2010). One study found that only about 4% of exclusively breastfed infants became infected with HIV between 6 weeks and 6 months, even in the absence of ARVs (WHO, 2007). It is believed that mixed feeding in the first six months carries a greater risk of transmission because the other liquids and foods given to the baby alongside the breastmilk can damage the already delicate and permeable gut wall of the small infant and allow the virus to be transmitted more easily. Mixed feeding also pose the same risks of contamination and diarrhea as artificial feeding; diminishing the chances of survival (WHO, 2010).Unfortunately mixed feeding is still the norm for many infants less than six months old in many countries with high HIV prevalence.

Exclusive breastfeeding rates among children less than six months of age in two-thirds of developing countries with trend data have increased between 1998 and 2008, but are still quite low at 33% in sub-Saharan Africa (WHO, 2010). Thus HIV transmission through breastfeeding can be reduced if HIV-positive women breastfeed exclusively for six months rather than practising mixed feeding. Public health programs for protection, promotion and support of breastfeeding can have major benefits for HIV-positive women and their children, as well as for the population in general. With the new recommendations, it is postulated that an HIV-infected woman who takes ARVs and mix-feeds may still have a higher rate of transmission than a mother who exclusively breastfeeds and takes ARVs: the transmission risk is shifted downwards for all breastfeeding mothers but the pattern of higher risk remains for the mixed-fed infants (WHO, 2010). Therefore continued emphasis needs to be placed on discouraging mixed feeding in the first six months. The risk of HIV-infection has to be compared with the risk of morbidity and mortality due to not breastfeeding. In general, babies who do not breastfeed are more than 14 times more likely to die from diarrhoea or respiratory infections than babies who are exclusively breastfed in the first six months (Bhandari et al., 2003).

The benefits of breastfeeding have been well described in the medical literature (Cesar et al., 1999; WHO, 2000a; Kramer et al., 2001). These benefits – including providing optimal nutrition, preventing common childhood illnesses and improving child spacing – are of particular importance in resource-poor countries such as in sub-Saharan Africa. For this reason, the possibility of HIV transmission through breastmilk poses a dilemma, particularly in conditions where breastfeeding is a strong cultural norm, and where large numbers of women are infected with HIV.

It is estimated that 15% of infants born to HIV-infected women acquire the infection through breast-feeding (De Cock et al., 2000). Risk factors for Mother-To-Child Transmission of HIV (MTCT) through breastfeeding include: the duration of breast-feeding; maternal characteristics such as younger maternal age and higher parity; low CD4+ count; high peripheral blood and maternal milk viral load; mastitis and breast abscess; infant characteristics such as oral candidiasis; and possibly the pattern and duration of breastfeeding (de Martino et al., 1992; Ekpini et al., 1997; Miotti et al., 1999; Semba et al., 1999; Coutsoudis and Rollins, 2003).

Research has provided some evidence about the risk of HIV transmission according to the pattern of breastfeeding, and has provided additional incentive for consistent and strict definitions of infant feeding patterns (Greiner, 2002). The possible association between infant feeding patterns among infants who are breastfed by infected mothers and the risk of MTCT was first evaluated in a prospective study conducted in South Africa (Coutsoudis et al., 2001). In the study, it was found that, by 15 months of age, the cumulative probability of HIV infection was lower among infants who were exclusively breastfed compared with those who were mixed fed (i.e. those who received other foods and liquids in addition to breast milk). These findings were later confirmed in Zimbabwe (Iliff et al., 2005)

HIV can be transmitted through breast milk at any point during lactation, and thus the rate of infection in breastfed infants increases with duration of breastfeeding. The persistence of maternal antibodies and the presence of a ―window period‖ during which infection is undetectable by current technology makes it difficult to determine whether an infant has been infected during delivery (intrapartum) or – through breastfeeding – immediately after birth. There is too little information to estimate the exact association between duration of breastfeeding and risk of transmission. There is strong evidence, however, that the longer the duration of breastfeeding the greater the risk of transmission – in other words, the risk is cumulative (Leroy et al., 1998; Miotti et al., 1999; Leroy et al., 2002; Read, 2003).

It is difficult to draw any conclusions about the relative risk of transmission by colostrum and mature breast milk (Van de Perre et al., 1993; Ruff et al., 1994; Nduati et al., 1995; Lewis et al., 1998). First, colostrum and mature breast milk contain different types of cells and different levels of immune modulating components (e.g., vitamin A, immunoglobulins and lactoferrin). Second, the infant ingests much less colostrum than mature breast milk. Third, the infant‘s immune system is less well developed in the first few days of lactation than later, and younger infants have an increased blood concentration of maternal antibodies. There is no evidence to suggest that avoidance of colostrum would reduce the risk of breastfeeding transmission to the infant ( Lewis et al., 1998).

Statistical modelling, with data from studies in which breastfeeding was of limited duration, has suggested that the highest-risk period for transmission is the first several weeks of life, and that infectivity may vary in populations at different stages of the epidemic (Dunn et al., 1998). The randomized trial in Nairobi, Kenya, comparing breast milk with formula, suggested that 10% of the cumulative difference in infection rates between infants in the breastfed and formula-fed arms had occurred by six weeks of age, compared with the total cumulative difference of 16%. Also, 75% of all breastfeeding transmission had occurred by six months of age (Nduati et al., 2000).

Given the risk of HIV transmission associated with breastfeeding, it would appear that the simplest and most straightforward approach to prevention is to avoid breastfeeding when mothers are infected. This is the recommendation in many parts of the developed world (American Academy of Paediatrics, Committee on Paediatric AIDS, 1995). However, a similar recommendation would be difficult for sub-Saharan Africa. First, most women in sub-Saharan Africa breastfeed their infants from birth, and for well over two years. Second, in most parts of Africa, replacement feeding is often associated with an increased risk of morbidity and mortality, in part because poverty constrains the provision of appropriate and safe replacement feeds for children (WHO, 2000b).

WHO guidelines for infant feeding in the context of HIV recommend the avoidance of all breasts feeding in conditions where foods that can replace breastmilk are ‗Acceptable, Feasible, Affordable, Sustainable and Safe‘. These conditions are often referred to as the AFASS conditions for replacement feeding. Otherwise, the WHO recommends exclusive breast-feeding up to 6 months of age. Thereafter, because the risk of HIV transmission may outweigh the protective benefits of breast milk, mothers should quicken transition from breastfeeding to exclusive replacement feeding (ERF) (Ross and Labbok, 2004). In the HIV and infant feeding literature, this is commonly referred to as ‗rapid weaning‘. Rapid weaning poses an additional problem for HIV-infected mothers. Even before the advent of the HIV pandemic, the risk of transition from breast milk to replacement feeds had been widely recognized. Up to 6 months of age, breastfeeding provides considerable benefits for infant health; however, thereafter, breastmilk is an inadequate source of nutrition, and it needs to be supplemented with other foods and liquids (Ross and Labbok, 2004).

With the introduction of weaning foods, infants experience an increased risk of morbidity, particularly when the transition is not well managed, putting them at a high risk of malnutrition and/or infection. This is commonly referred to as the ‗weanling dilemma‘. Diarrhoea rates have been shown to be highest between the ages of 6 and 12 months, coinciding with the introduction 24 of weaning foods (Pelto et al., 2003). There have been relatively few studies investigating the issue of rapid weaning for HIV-infected mothers. Anecdotal reports suggest that rapid weaning is associated with increased mortality, particularly for mothers who do not have adequate weaning foods. However, to the best of my knowledge, there have been no published studies investigating the problem of rapid weaning for HIV-infected mothers.

1.2 Statement of Research Problem
Paediatric AIDS is poised to become a major public health problem in Nigeria. Nutritional status of mother is an important indicator which determines the fetal malnutrition, newborn morbidity and mortality in HIV infection.

Forty two countries in the developing world carry 90% of child global deaths, and 25% of those deaths could be reduced through simple and preventive nutritional interventions, such as, exclusive breastfeeding, appropriate complementary feedings, and vitamin A and zinc supplementation. (Bhandari et al., 2003).

Various ongoing or planned trials and studies concern either mode of infant feeding (exclusive or mixed) or antiretroviral therapy to either the mother or the infant over the breastfeeding period; but the main problem is, whether breastfeeding by HIV-infected mothers can be made safer as to transmission risk, given the possible adverse effects of refraining from breastfeeding (Ross and Labbok, 2004).

Nutritional impairment is a big problem in our society today, with all the Government has initiated, i .e. different nutritional strategies at both community and health facility levels. At the community level, an outreach program of vitamin A supplementation for 6 to 9 months-old children was implemented. Further, IYCF strategies and policies were adjusted to guide health 25 workers and nutritionists practicing at central and local levels in counseling HIV-positive mothers [WHO, 2009]; but still there are no positive results.

Little is known about infant feeding practices and their relationship to the nutritional status among HIV exposed infants. Still less knowledge on this topic has been generated from longitudinal data.

1.3 Justification for Research
i.        Although some data exist about the deleterious effect of HIV infection on the growth of infected children, no data exists about the importance of nutritional assessment of newborn of HIV infected mothers.

ii.      Prevention of HIV transmission during breast-feeding should be considered in a broad context that takes into account the need to promote breastfeeding of infants and young children in the general population.

In view of the above statements, there is a need to understand and come up with effective strategies of infant feeding among HIV positive mothers.

1.4 Aim and Objectives

1.4.1 Aim
The aim of this study is to assess the Impact of HIV on infant feeding practices and nutritional status of HIV-exposed infants (0-6 months) of HIV positive mothers.

1.4.2 Specific Objectives
i.            To assess the impact of the HIV infection on infant feeding practice among HIV infected mothers.

ii.             To assess the effect of feeding practices on the nutritional status of the infants of HIV infected mothers using anthropometry parameters.

iii.             To assess the impact of education, on the infant feeding practiced, among HIV positive mothers.

1.4.3 Research Hypothesis
 Null Hypothesis (Ho): There is no association between educational status and breast feeding pattern.

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