Background: Although the risk of HIV transmission through breastfeeding is reduced considerably with the use of antiretroviral therapy, infant feeding by HIV positive mothers remains controversial. Weighing risks against benefits generates intense debate among policymakers, program managers and service providers in sub-Saharan Africa, considering that the major causes of infant death of malnutrition and infectious diseases, could be prevented if mothers breastfeed their babies. Whereas breastfeeding involves some risk of HIV transmission, not breastfeeding poses considerable risk to infant survival. This study investigated perceptions and practice of breastfeeding of HIV-exposed infants among HIV positive mothers. Methods: A cross-sectional descriptive study was conducted in Enugu metropolis among HIV positive mothers receiving care for prevention of mother-to-child transmission of HIV from two public and two private hospitals. Interviewer-administered questionnaire survey was done with 550 participants as they exited the final point of service delivery. Descriptive statistics of perception and practice variables and cross tabulation of selected variables was performed. Results: Most mothers knew that HIV could be transmitted through breast milk. The majority perceived any type of breastfeeding as beneficial to the infant: 230 (83.6%) in private facilities, and 188 (68.4%) public facilities. Over three-quarters of the mothers breastfed their infants and their reasons for breastfeeding included personal choice, cultural norms, fear of HIV status being disclosed and pressure from family members. A statistical significant association was found between; (i) practice of breastfeeding and marital status, (p<0.01), and (ii) practice of breastfeeding and household income provider (p=0.02). However, neither marital status (AOR 1.4; 95% CI 0.3, 6.8) nor being the household income provider (AOR 4.9; 95% CI 0.6, 12.9) is a significant predictor of breastfeeding of HIV-exposed infants. Conclusions: Breastfeeding remains a common trend among HIV positive women and it is associated with economic independence of women and social support. Fear of stigma negatively affects practice of breastfeeding. Hence, HIV positive mothers need economic independence and the support of family members to practice recommended infant feeding options.
The study was conducted in 2015 in the metropolis of Enugu city, capital of Enugu state. Enugu is located in the Southeast geopolitical zone of Nigeria [16]. Women and children constitute about 62% of the population [16]. The prevalence of HIV among pregnant women attending antenatal clinic in Nigeria was estimated as 3% [17]. According to the UNAIDS 2017 report, 32% of HIV positive pregnant women had access to ART in 2016, and there were 37,000 new infections among children [9]. It has been reported that MTCT rate is about 32% in Nigeria [18]. A range of public, private and faith-based health facilities serve as key sources of maternal and child health care delivery (Uzochukwu BSC, Onwujekwe OE, Soludo E, Nkoli E, Uguru NP, The District Health System in Enugu State, Nigeria: An analysis of policy development and implementation, unpublished). PMTCT services are offered in some of these facilities in the State. However, only two public and two private facilities were offering comprehensive PMTCT services at the time of the study. All four facilities were included in this study and they are, for public facilities, University of Nigeria Teaching Hospital (UNTH) and Enugu state University Teaching Hospital (ESUTH); and for private facilities, Annunciation specialist Hospital and Mother of Christ specialist Hospital. PMTCT services are offered daily by skilled health workers (doctors and nurses). Comprehensive PMTCT services consisting of HIV testing for mothers, antiretroviral treatment for mothers, post-exposure prophylaxis for infants, Polymerase chain reaction (PCR) testing for infants and infant feeding counselling are offered to pregnant women and mothers living with HIV in Nigeria. These services are offered in line with the Nigerian National PMTCT guideline [19] and the 2010 WHO guideline for HIV and infant feeding, which also provide for women living with HIV to choose to breastfeed with maternal or infant antiretroviral cover [13]. The aim of the study was to examine the perception and practice of breastfeeding of HIV-exposed infants among HIV positive mothers receiving comprehensive care for PMTCT in public and private hospitals in Enugu metropolis. The study used a cross-sectional descriptive design and HIV positive mothers were interviewed as they exited the final point of service delivery for the day. The study population consisted of HIV positive women receiving care for PMTCT during pregnancy, childbirth and postnatal care. Additionally, women who had babies in the 12 months preceding the study and were still receiving care for PMTCT were included in the study. This is because PMTCT services are provided to mothers until 12 months after delivery, when they are either transferred to adult ART clinic, if they do not become pregnant in the period, or remain in the PMTCT clinic, if they become pregnant. In order to achieve a power of at least 80% with 95% confidence using a prevalence value of 11% as utilization of PMTCT services, a minimum sample size of 500 was calculated and increased to 550 to account for possible incomplete or non-response of 10%. Proportionate method was used to allocate women to be sampled from each facility and participants were selected consecutively as they exited the PMTCT clinic. Table 1 shows the number of women on PMTCT in each facility and the samples selected. The formula used to calculate sample size per facility is as follows: Proportionate allocation of sample selected per facility Pre-tested interviewer administered questionnaires were used to collect information on demographic characteristics of respondents, perception and practice of any type of breastfeeding disaggregated by type of facility (public vs private). Information was also obtained on their individual perception of positive HIV status, as well as their family and community members’ perceptions and support for HIV positive people. The questionnaire was translated to the local language, and validated through pre-testing and expert review. Data was collected between February and July 2015 by trained field workers and health workers (nurses) working in the PMTCT centers. Descriptive statistics was performed using Statistical Package for Social Sciences (SPSS) software version 20. Frequencies and proportions were calculated for categorical variables while means were calculated for numeric variables. Demographic characteristics and perception of HIV status were cross-tabulated with clients’ practice of infant breastfeeding. Chi square test was used to examine the association between, (1) practice of infant breastfeeding and respondents’ demographic characteristics, and (2) practice of infant breastfeeding and perception of HIV positive status. Statistical significance was reported if p value was less than 0.05. Logistic regression analysis was done to identify the determinants of breastfeeding among HIV positive mothers. The independent variables that had statistically significant association with practice of breastfeeding at p value of less than 0.05 were included in the model.
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