MPH Project

1. PROJECT PROPOSAL
TOPIC:
INFANT FEEDING OPTIONS AMONG HIV POSITIVE
NURSING MOTHERS ATTENDING ANTENATAL CLINIC IN
MURTALA MOHAMMED SPECIALIST HOSPITAL KANO
By
DR Habibu, Ahmed Tijjani
MPH/MED/15115/2007-2008
SUPERVISOR

2. DR C L Ejembi
INTRODUCTION
As the Acquired Immune Deficiency syndrome enters its 3rd
Decade,
the number of people living with Human Immune Deficiency Virus (HIV)
infection continues to increase (1)
. The estimated number of persons living
with HIV world wide in 2009 was 33.4 million including 2.1 million
children and every day over 6800 person infected with HIV and over 5,700
person die from AIDS. Sub-Saharan Africa is the region most affected
accounting for 22.4 million and is home to 67% of all people living with
HIV worldwide and 91% of all new infections among children.
(UNAIDS/WHO 2009) (2)
. It was estimated that 1,000-1,600 children world
wide are infected daily, mostly by their mothers. (3)
.
In 2009 2.5 million children under 15 years are living with HIV
globally, with 420.000 children newly infected and 330.000 children dead as
a result of AID in the same year (2)
90% were infected as a result of mother
to child transmission and of these, 90% were from sub-Saharan Africa.
Mother to child transmission HIV can occur during pregnancy, labour,
delivery and breast-feeding. Without intervention 5-20% of infant breastfed
by mothers who are HIV infected may acquire HIV through breast feeding
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3. (9)
. Breast-feeding is the best form of nutrition for infant, 97% of women
breast feeds their infants in Nigeria. However, only (17%) of women
breast feed exclusively for the first 6 months. This implies that mixed
feeding rate is high. The promotion of exclusive breastfeeding has a great
importance in reducing morbidity and mortality in infants particularly in
resources constrained countries like Nigeria. It is important to note that
breast-feeding accounts for about one third of the transmission of HIV
infection from mother to child. Avoidance of breast feeding by HIV infected
mothers certainly blocks transmission through breast milk, but introduce the
problems to use of Breast Milk Substitutes (BMS) especially diarrhea
disease and malnutrition. Thus, a clear understanding of the determinants of
transmission through breast-feeding helps individualizing feeding options
for HIV exposed infants.
Some HIV infected mothers even when aware of the fact that they can
transmit the infection through breast feeding went ahead to breast feed their
infants due to fear of stigma, and discrimination. Even those mothers that
opted to use Breast milk substitute may end up doing mixed feeding due to
economic situation of the country. Therefore HIV positive mothers should
be enable by trained health or nutrition workers to make an informed
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4. decision about the best infant feeding option in their situation based on what
is acceptable, feasible, affordable sustainable and safe (AFASS).
They should be advice on avoidance of mixed feeding. If those
mother do not fulfill the (AFASS) criteria. They should be advice on
exclusive breastfeeding for at least 4-6 months with Abrupt weaning to
avoid mixed feeding. This prevents diarrhea disease and infection associated
with breast milk substitute.
Infant feeding practice correctly implemented can reduce the
likelihood of mother to child transmission of HIV through breast feeding
and reduce the risk of infant death from diarrhea and other childhood
infection.
Pediatric HIV transmission occurs during pregnancy, with
transmission rate of (5-10%), labour and delivery (10-15%) and
breastfeeding accounting for (5-20%). HIV/AIDS in children remains
contracted in sub Saharan Africa where more than 2 million women with
HIV infection give birth each year. Women in this region represent 60% of
those infected and 77% of newly infected persons 15 to 24 years of age (4)
Breast feeding by HIV –positive women is a major means of HIV
transmission, but not breast feeding carries significant health risks infant and
young children. Breast-feeding is vital to the health of children, reducing the
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5. impact of many infectious diseases and preventing some chronic diseases. In
view of this dilemma, the objective of health services should be to protect,
promote and support breast feeding as the best infant feeding choice for all
women in general, while giving special advice and support to HIV positive
women and their families so that they can make decision about how best to
feed infants in relation to HIV Infections. Lack of breast feeding compared
with any breast feeding substitute has been shown to expose children to
increase risk of malnutrition and life threatening infectious disease other
than HIV especially in the first year of life, and exclusive breastfeeding
appears to offer greater protection against disease, than any breastfeeding
substitute. This is especially the case in developing countries, where over
one- half of all under five year deaths are associated with malnutrition (4)
.
Malnutrition has been responsible, directly of indirectly for 60% of
the 10.9 million deaths annually among children under five years. Well over
two third of these deaths are often associated with inappropriate infant
feeding practice, occurring during the first year of life (5)
. In Nigeria about
97% of women breast-feed their children, but only 17% practice exclusive
breastfeeding during the first six months of the life. Not breast-feeding
during the first two month of life is also associated in poor countries. With a
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6. six fold increase in mortality from infectious diseases. This risk drops to les
than three fold by six month and continues to decrease with time.
Sub Saharan African has continued to bear the greatest burden of
HIV/AIDS epidemics more than two out of three (68%) adult and nearly
90% of children infected with HIV live in this region and more than three in
four (76%) AIDS deaths in 2007 occurred there. (2)
Majority of these
infections are due to mother to child transmission. The high prevalence of
HIV in women of reproductive age group and the high fertility rates of
African women are factors that contribute to the high prevalence of
transmission of HIV to infants. In the Absence of preventive intervention,
the probability of an HIV positive woman’s baby becoming infected ranges
from 15-25% in industrialized countries to 25-45% in developing countries,
Nigeria inclusive (6)
. In 2005 alone there were an estimated 20, 000 new
infection and 570,000 HIV/AIDS among children under 15 years of age (7)
.
Offering HIV testing and counseling as part of routine antenatal care
(ANC), in combination of Anti-retroviral treatment and prophylaxis
provided during pregnancy, labour, delivery and elective caesarean section
and advising complete avoidance of breast feeding have reduced mother to
child transmission of HIV to below 2% among women in developed
countries of the world (8,9)
. However, in the developing nation where the vast
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7. majority of HIV infected women of child bearing age reside, mother to child
transmission rate remains high due to lack of access to feasible, affordable
preventive intervention and are worsen by the nearly universal practice of
breast feeding for prolonged period of time. The burden of MTCT of HIV is
HIV is higher in sub Saharan Africa. Than the rest of the world, because of
the higher levels of heterosexual transmission, high female to male rates,
high total fertility rate (TFR) and high rate of breast-feeding. The rate of
MTCT of HIV is affected by many factors including high maternal viral
load, mode of delivery, prolonged ruptured of membrane, prematurity, and
prolonged or mixed breast feeding.
One of the goals of the June 2001 Declaration of commitment of the
United Nation General Assembly special session on HIV/AIDS (UNGASS).
Is to reduce the proportion of infants infected with HIV by 20% by 2005
and 50% by 2010. Reducing HIV transmission to pregnant women, mothers
and their children. Including transmission by breast-feeding should be part
of a comprehensive approach both to HIV prevention, care and support and
to antenatal prenatal and post natal care and support. In line with these goals,
the 2003 AIDS policy set national goal for PMTCT of HIV to reduce the
transmission of the HIV through MTCT by 50% by the year 2010 and to
increase access to quality voluntary confidential counseling and testing
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8. services by 50% by the same year(9)
. Infant feeding option counseling is vital
in reducing MTCT of HIV during breast-feeding.
.JUSTIFICATION OF THE STUDY
This study is justified on the following basis.
The Federal Ministry of Health in line with WHO initiative have
promoted breast-feeding as the best method of feeding a child in his or her
first year and beyond. This emphasized exclusive breast-feeding for the first
6 months of live before any substitute feeding should be introduced. Breast
milk is generally considerer to be the best nutritional source for children.
Breast feeding provides both physical and psychological benefits for the
mother and child, nutrients and antibodies are passed to the baby, while
hormones are released into the mothers system. This strengthened the bond
between mother and child. However, there is evidence that HIV can be
transmitted from infected mother to babies through breast milk. Therefore,
avoidance of breast-feeding lowers the risk of HIV transmission from an
infected mother. On the other hand, non-breastfed infant are at increased risk
of acute respiratory infection, diarrhea disease and severe dehydration.
Evidence has shown that exclusive breast feeding for up to six months was
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9. associated with a three to four fold decreased risk of transmission of HIV
compared to non exclusive breast feeding(1)
.
HIV can be transmitted through breast milk at any point during
lactation and thus the rate infection in breast fed infants increases with
duration of breast feeding. When replacement feeding is acceptable, feasible
affordable, sustainable and safe (AFASS) avoidance of all breasts feeding by
HIV infected mothers is recommended. Otherwise, exclusive breast feeding
is recommended during the first month of life and then discontinued as soon
as it is feasible to do so. (11)
To help HIV positive mothers make the best choice, they should
receive counseling that includes information about both the risks and
benefits of various infants feeding options based on local assessment, and
guidance in selecting the option that best suits their circumstances. They
should seek to balance the nutritional and other benefits of breast feeding,
with the risk of transmitting HIV to their infants and choose between
exclusive breastfeeding and replacement feeding (commercial infant formula
or home modified animal milk) or other breast milk options (heat treated
expressed breast milk, wet –nursing, or donor’s milk from a milk bank).
Recent research in sub Saharan Africa indicates that mortality in the first 12-
18 months is similar in HIV infected breastfed and non-breastfed infants. (12)
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10. Stigmatization of non-breast feeding was making it almost impossible
for many women to practice exclusive replacement feeding of young infants.
Despite the fact that post natal HIV transmission remains responsible for at
least 40% of pediatric HIV infections in setting where prolonged breast
feeding is widely practiced. (13)
However, mixed feeding is mostly done in
areas where prolonged breast feeding is widely practiced. Thus, increasing
chances of HIV transmission.
This study therefore will attempt to evaluate the option of infant
feeding methods adopted by HIV infected mothers and the socio-cultural
and demographic characteristics associated with the various options of
feeding chosen. Information regarding the breast feeding options the HIV
infected mothers chooses and the reasons for their choice is scanty, this
study will therefore be carried out to find out infant feeding options adopted
and reasons for such adoptions, socio-economic implication of such a
adoptions and experience after adoption among HIV infected nursing
mothers.
AIMS AND OBJECTIVES
General Objectives
The aim of the study is to:
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11. - Assess the infant feeding options practices adopted by HIV
positive nursing mothers seen in Antenatal clinic at Murtala
Mohammed Specialist Hospital Kano .
Specific Objectives
- To determine the knowledge of HIV positive ANC attendees at
MMSH on infant feeding options.
- To determine factors influencing their choice of infant feeding
options.
- To assess the method of infant feeding choices made at the
antenatal clinic.
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