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BARRIERS TO EXCLUSIVE BREASTFEEDING PRACTICE AMONG HIV POSITIVE MOTHERS ATTENDING PREVENTION OF MOTHER TO CHILD TRANSMISSION CLINIC, SAGAMU, OGUN STATE, NIGERIA

CHAPTER ONE

INTRODUCTION

1.1       Background to the Study

 There are 36.7 million (34.0 million – 39.8 million) people estimated to be living with Human Immunodeficiency Virus (HIV) Worldwide in 2015, with 15.7 million and 2 million of these being women and children younger than 15 years of Age respectively, with a global HIV prevalence of 0.8% (WHO, 2015). It has also been established as the leading cause of mortality among women of reproductive age worldwide, a major contributor to maternal, infant and child Morbidity and mortality (UNAIDS 2009; UNICEF, 2009). In 2015, it was estimated that 1.8 million pregnant women living with HIV in low- and middle-income countries, most especially in sub-Saharan Africa, gave birth but without treatment the infants are at risk as one third of children living with HIV die before the age of one year and over 50% die by the second year of life (UNAIDS, 2009).

Of all people living with HIV globally, 9% of them live in Nigeria, with the size of the population of Nigeria, this means 3.5 million people were living with HIV in 2015.  (UNAIDS, 2014). Since the beginning of the epidemic in the mid-1980s, a total of 2,200,000 new HIV infections have been reported in 2014 (WHO, 2015). Most cases were adults over the age of 15 years. Nigeria is now the second largest HIV disease burden in the world with 3.2 million after South Africa which has 6.8 million burden of the disease though prevalence is stable at 3.4% (Federal Ministry of Health, 2013; Nigeria National Agency for the Control of AIDS, 2012). Ogun State has been rated as the state with the second highest prevalence rate of Human Immunodeficiency Virus (HIV) in the South-West zone of the country with the prevalence of the disease in the state, it was gathered, increased from 1.5 percent in 2003 to 3.1 percent in 2010 (UNAIDS, 2010).

Mother-to-child HIV transmission occurs intrauterine (during pregnancy), intra-partum (at birth) and during breastfeeding and it is the leading cause of infant mortality in Africa where 1700 children are infected each day principally by mother to child transmission (WHO & UNICEF 2013), without antiretroviral treatment, the risk of an infected woman transmitting the virus to her child is between 16 and 40% with breastfeeding contributing at least 10% risk of transmission (De Cock, Fowler, Mercier , de Vincenzi, Saba, Hoff,  et al, 2000). An effective Prevention of Mother to Child Transmissions (PMTCT) programme requires mothers and their babies to receive antenatal services and HIV testing during pregnancy, have access to antiretroviral treatment (ART), and practice safe childbirth practices and appropriate infant feeding.

In developing countries where replacement feeding is generally not feasible or safe, hundreds of thousands of infants acquire HIV infection during breastfeeding (Bhandari, Bahl & Mazumadar, 2000). While breastfeeding improves child survival especially in resource settings, breastfeeding by HIV infected women however increases the incidence of HIV infection among breastfed infants (Pilay & Kam Kuhn, 2001; Coutsouchis, Goga, Rollins & Coovadia, 2002;Chopra, Piwoz & Sengwai, 2002; WHO, 2006). Mixed feeding has also been established to be more risky for HIV transmission than exclusive breastfeeding, this is partially due to damage to the epithelial integrity of the infant intestine that facilitates entry of the virus and because of breast engorgement that increases the viral load in breast milk between 3 to 6 months (Goga, Rollins & Coovadia, 2002; WHO, 2009).

Breastfeeding remains a common practice in parts of the world where the burden of HIV is highest. The difficult dilemma faced by HIV positive mothers is whether to breastfeed their infants in keeping with cultural norms, knowing the risk of transmitting the virus through breastfeeding, or to pursue formula feeding, which also comes with its own set of risks including a higher rate of infant mortality from diarrheal illnesses, while reducing transmission of HIV (Kruger & Gericke, 2001; Iliff, Piwoz, Tavengwa & Clare, 2005; WHO & UNICEF, 2013).

Breast milk transmission of HIV can occur at any time during the entire duration of breastfeeding and the risk of late postnatal transmission which occurs after 2.5 months of age into breastfeeding is revealed to be 3.2 per 100 child (Bulterys, Ellington & Kourtis, 2010). Breast milk contains immunoactive cells, antiinfectious substances, immune globulins, cytokines, and complement factors, however, HIV has been found in breast milk from HIV-infected mothers as both cell-associated and cell-free particle. Increased maternal ribonucleic acid (RNA) viral load in plasma and breast milk is strongly associated with increased risk of transmission through breast-feeding, and it has been suggested that exclusive breast-feeding could be associated with lower rates of breast-feeding transmission than mixed feeding of both breast- and other milk or feeds, (WHO, UNFPA & UNAIDS, 2010). Transmission through breast-feeding can take place at any point during lactation, and the cumulative probability of acquisition of infection increases with duration of breast-feeding WHO (2009).

World Health Organization (2009) released the “rapid advice” guideline where the use of ART prophylaxis during the breastfeeding period until one week after all exposure to breast milk has stopped is recommended. It was also recommended that HIV-infected mothers intending to breastfeed should do so exclusively for the first six months, and should introduce appropriate complementary food thereafter, and continue breastfeeding until the infant is 12 months of age. In a study by Onubogu, Ugochukwu, Egnuonu & Onyeaka (2015) where it was determined that HIV positive mothers who practiced Exclusive Breastfeeding declined within the first six months of stipulated period owing to the fear of transmitting the infection to their child where as it has been established to be the best feeding option for Prevention of Mother To Child Transmission (PMTCT) of HIV (Lunnney, Lliff, Mutasa, Ntozini, Magder, Moulton et al,2010; Nwaozuzu & Dozie, 2014; Saloojee & Cooper, 2010).

Several strategies have been initiated by UNICEF and WHO in order to promote optimal breastfeeding practices that is, start breastfeeding within one hour thirty minutes after birth, Exclusive Breast Feeding (EBF) for first 6 months of infant life and after 6 months introduction of appropriate weaning foods while continuing to breastfeed for 2 years (WHO & UNICEF, 2003; Black, Victoria, Walker & Bhutta, 2013; WHO & UNICEF, 2013). Nigerian government has endorsed these global commitments to improve EBF practices. These strategies are Baby Friendly Hospital initiative (BFHI), Infant Young Child Feeding policy (IYCF) and breastfeeding recommendation in Prevention of Mother to Child Transmission of HIV (PMTCT) (WHO & UNICEF, 2003; MOHSW 2014). The investment should be targeted to effectively prevent infants from becoming infected with HIV through breastfeeding, improve HIV free-survival of infants and achieve international developments goals, such as Millennium Development Goals (MDGs) (WHO, 2010).

As key gatekeepers in influencing mothers’ decisions on infant feeding, health workers can help to reduce rates of postnatal  transmission  of  HIV  by  providing  HIV infected  mothers  with  accurate  information  on  infant feeding  that  captures  the  risks  and  benefits  of  different feeding options.  Studying what health workers  currently believe  and  practice  regarding  infant  feeding  for  HIV infected  women  is  an  important  concern  because attitudes  and  cultural  beliefs may  affect  their  counselling behaviour (Setegn, Belachew, Gerbaba, Deribe, Deribew & Biadgilign, 2012). Transmission of HIV by breastfeeding has to be taken into account in designing interventions to reduce/prevent mother-to-child transmission in developing countries especially Nigeria (Townsend, Byrne & Cortina-Borja, 2011). Interventions that offer alternatives to prolonged breastfeeding and are both socially acceptable and safe for infant can effectively reduce the risk of postnatal HIV transmission. But operational implementation of these postnatal interventions remains complex.

1.2       Statement of the Problem   

The risk of HIV transmission increases between 25% and 45% with the age of infant and maternal practice of mixed feeding before 6 months of life (Federal Ministry of Health, 2010). Supporting optimal infant feeding practices was a challenge for health systems especially in Nigeria where it was influenced by limited number of health facilities, health workers, competing demands on time, inadequate capacity, illiteracy among mothers and poor information sharing. There are limited comprehensive intervention package available to postpartum mothers in most health facilities in Ogun State. Interventions on PMTCT were offered in some facilities in Ogun State through the AIDS Prevention Initiative in Nigeria (APIN) project funded by President’s Emergency Plan for AIDS Relief (PEPFAR). Feeding of the HIV-exposed infant in settings where a high premium is placed on breastfeeding is therefore a major challenge. Few researches have highlighted factors influencing infant feeding choice of HIV positive mothers in Nigeria, including resumption of work and family support (Agbo, Envuladu, Adams, Inalegwu, Okoh, Agba et al, 2013) however, Uchendu, Ikefuna and Emodi (2009) revealed that a good perception of EBF lead to better practice of EBF among mothers.

Despite all efforts made in recent years to increase the awareness of HIV mothers on the great importance of exclusive breastfeeding to their infants regardless of their viral load and CD4 count, none have been able to completely ascertain that all HIV mothers now breastfeed their infants exclusively (Brown, Oladokun & Osinusi, 2009; Olatona, Ginigeme, Roberts & Amu, 2014). This has continued to pose a serious public health problem with devastating outcome.

1.3       Objective of the Study       

The main objective of this study is to examine the barriers to exclusive breastfeeding practice among HIV positive mothers in PMTCT Clinic, Olabisi Onabanjo University Teaching Hospital in Sagamu, Ogun state. The specific objectives are to:

1.       determine the level of knowledge of HIV positive mothers in OOUTH on mother-to-child transmission of HIV;

2.         ascertain the perceived barriers to exclusive breastfeeding practice;

3.         determine the roles individual beliefs play in exclusive breastfeeding practice among         HIV positive mothers in OOUTH and

4.         assess the practice level of EBF adoption among HIV positive mothers in OOUTH, Ogun State.

1.4       Research Questions

1.         What is the level of knowledge of HIV positive mothers accessing care in Olabisi Onabanjo University Teaching Hospital on mother-to- child transmission of HIV?

2.         What are the perceived barriers to exclusive breastfeeding practice among HIV positive    mothers in OOUTH?

3.         What roles do individual beliefs play in exclusive breastfeeding practice among HIV         positive mothers in OOUTH and;

4.         What is the level of practice of EBF among HIV positive mothers in OOUTH?

1.5       Justification for the Study

Although some progress has been reported in scaling up of access to prevention of mother to child transmission of HIV (PMTCT) services in Nigeria, with annual HIV positive births of 56,681, much work remains to be done (NACA Fact Sheet, 2011). The highest pediatric HIV burden, and the second highest burden of HIV infection in women of childbearing age, globally, is accounted for in Nigeria preceding the enlisting of Nigeria as one of 22 priority countries targeted for the elimination of the MTCT of HIV by 2015 (IATT, 2015; UNICEF, 2015). However, this target was not achieved, and Nigeria was recently reported to account for approximately one third of all new pediatric HIV infections in priority countries with a Mother to Child Transmission (MTCT) of HIV rate of 28% (The Joint United Nations Programme on HIV/AIDS, 2013).

It is of great importance that studies unveiling the factors delimiting the adoption of exclusive breastfeeding which have been proven to reduce mother to child transmission of HIV be carried out which is the aim of this study, this will help in reduction of burden of pediatric HIV infection.

1.6       Hypotheses

H1:       There will be a significant difference in the level of knowledge of HIV positive mothers on mother to child transmission of HIV and the educational status of these mothers.

H2:       There will be a significant difference between perceived barriers on exclusive                     breastfeeding and the practice of EBF among the respondents.

H3:       There will be a significant difference between individual beliefs of respondents                 on EBF and the practice of EBF among the respondents.

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