Chapter 1


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Chapter 1

  2. 2. DR C L EjembiINTRODUCTIONAs the Acquired Immune Deficiency syndrome enters its 3rdDecade,the number of people living with Human Immune Deficiency Virus (HIV)infection continues to increase (1). The estimated number of persons livingwith HIV world wide in 2009 was 33.4 million including 2.1 millionchildren and every day over 6800 person infected with HIV and over 5,700person die from AIDS. Sub-Saharan Africa is the region most affectedaccounting for 22.4 million and is home to 67% of all people living withHIV worldwide and 91% of all new infections among children.(UNAIDS/WHO 2009) (2). It was estimated that 1,000-1,600 children worldwide are infected daily, mostly by their mothers. (3).In 2009 2.5 million children under 15 years are living with HIVglobally, with 420.000 children newly infected and 330.000 children dead asa result of AID in the same year (2)90% were infected as a result of motherto 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 breastfedby mothers who are HIV infected may acquire HIV through breast feeding2
  3. 3. (9). Breast-feeding is the best form of nutrition for infant, 97% of womenbreast feeds their infants in Nigeria. However, only (17%) of womenbreast feed exclusively for the first 6 months. This implies that mixedfeeding rate is high. The promotion of exclusive breastfeeding has a greatimportance in reducing morbidity and mortality in infants particularly inresources constrained countries like Nigeria. It is important to note thatbreast-feeding accounts for about one third of the transmission of HIVinfection from mother to child. Avoidance of breast feeding by HIV infectedmothers certainly blocks transmission through breast milk, but introduce theproblems to use of Breast Milk Substitutes (BMS) especially diarrheadisease and malnutrition. Thus, a clear understanding of the determinants oftransmission through breast-feeding helps individualizing feeding optionsfor HIV exposed infants.Some HIV infected mothers even when aware of the fact that they cantransmit the infection through breast feeding went ahead to breast feed theirinfants due to fear of stigma, and discrimination. Even those mothers thatopted to use Breast milk substitute may end up doing mixed feeding due toeconomic situation of the country. Therefore HIV positive mothers shouldbe enable by trained health or nutrition workers to make an informed3
  4. 4. decision about the best infant feeding option in their situation based on whatis acceptable, feasible, affordable sustainable and safe (AFASS).They should be advice on avoidance of mixed feeding. If thosemother do not fulfill the (AFASS) criteria. They should be advice onexclusive breastfeeding for at least 4-6 months with Abrupt weaning toavoid mixed feeding. This prevents diarrhea disease and infection associatedwith breast milk substitute.Infant feeding practice correctly implemented can reduce thelikelihood of mother to child transmission of HIV through breast feedingand reduce the risk of infant death from diarrhea and other childhoodinfection.Pediatric HIV transmission occurs during pregnancy, withtransmission rate of (5-10%), labour and delivery (10-15%) andbreastfeeding accounting for (5-20%). HIV/AIDS in children remainscontracted in sub Saharan Africa where more than 2 million women withHIV infection give birth each year. Women in this region represent 60% ofthose 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 HIVtransmission, but not breast feeding carries significant health risks infant andyoung children. Breast-feeding is vital to the health of children, reducing the4
  5. 5. impact of many infectious diseases and preventing some chronic diseases. Inview of this dilemma, the objective of health services should be to protect,promote and support breast feeding as the best infant feeding choice for allwomen in general, while giving special advice and support to HIV positivewomen and their families so that they can make decision about how best tofeed infants in relation to HIV Infections. Lack of breast feeding comparedwith any breast feeding substitute has been shown to expose children toincrease risk of malnutrition and life threatening infectious disease otherthan HIV especially in the first year of life, and exclusive breastfeedingappears to offer greater protection against disease, than any breastfeedingsubstitute. This is especially the case in developing countries, where overone- half of all under five year deaths are associated with malnutrition (4).Malnutrition has been responsible, directly of indirectly for 60% ofthe 10.9 million deaths annually among children under five years. Well overtwo third of these deaths are often associated with inappropriate infantfeeding practice, occurring during the first year of life (5). In Nigeria about97% of women breast-feed their children, but only 17% practice exclusivebreastfeeding during the first six months of the life. Not breast-feedingduring the first two month of life is also associated in poor countries. With a5
  6. 6. six fold increase in mortality from infectious diseases. This risk drops to lesthan three fold by six month and continues to decrease with time.Sub Saharan African has continued to bear the greatest burden ofHIV/AIDS epidemics more than two out of three (68%) adult and nearly90% of children infected with HIV live in this region and more than three infour (76%) AIDS deaths in 2007 occurred there. (2)Majority of theseinfections are due to mother to child transmission. The high prevalence ofHIV in women of reproductive age group and the high fertility rates ofAfrican women are factors that contribute to the high prevalence oftransmission of HIV to infants. In the Absence of preventive intervention,the probability of an HIV positive woman’s baby becoming infected rangesfrom 15-25% in industrialized countries to 25-45% in developing countries,Nigeria inclusive (6). In 2005 alone there were an estimated 20, 000 newinfection 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 prophylaxisprovided during pregnancy, labour, delivery and elective caesarean sectionand advising complete avoidance of breast feeding have reduced mother tochild transmission of HIV to below 2% among women in developedcountries of the world (8,9). However, in the developing nation where the vast6
  7. 7. majority of HIV infected women of child bearing age reside, mother to childtransmission rate remains high due to lack of access to feasible, affordablepreventive intervention and are worsen by the nearly universal practice ofbreast feeding for prolonged period of time. The burden of MTCT of HIV isHIV is higher in sub Saharan Africa. Than the rest of the world, because ofthe higher levels of heterosexual transmission, high female to male rates,high total fertility rate (TFR) and high rate of breast-feeding. The rate ofMTCT of HIV is affected by many factors including high maternal viralload, mode of delivery, prolonged ruptured of membrane, prematurity, andprolonged or mixed breast feeding.One of the goals of the June 2001 Declaration of commitment of theUnited Nation General Assembly special session on HIV/AIDS (UNGASS).Is to reduce the proportion of infants infected with HIV by 20% by 2005and 50% by 2010. Reducing HIV transmission to pregnant women, mothersand their children. Including transmission by breast-feeding should be partof a comprehensive approach both to HIV prevention, care and support andto 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 thetransmission of the HIV through MTCT by 50% by the year 2010 and toincrease access to quality voluntary confidential counseling and testing7
  8. 8. services by 50% by the same year(9). Infant feeding option counseling is vitalin reducing MTCT of HIV during breast-feeding..JUSTIFICATION OF THE STUDYThis study is justified on the following basis.The Federal Ministry of Health in line with WHO initiative havepromoted breast-feeding as the best method of feeding a child in his or herfirst year and beyond. This emphasized exclusive breast-feeding for the first6 months of live before any substitute feeding should be introduced. Breastmilk is generally considerer to be the best nutritional source for children.Breast feeding provides both physical and psychological benefits for themother and child, nutrients and antibodies are passed to the baby, whilehormones are released into the mothers system. This strengthened the bondbetween mother and child. However, there is evidence that HIV can betransmitted from infected mother to babies through breast milk. Therefore,avoidance of breast-feeding lowers the risk of HIV transmission from aninfected mother. On the other hand, non-breastfed infant are at increased riskof acute respiratory infection, diarrhea disease and severe dehydration.Evidence has shown that exclusive breast feeding for up to six months was8
  9. 9. associated with a three to four fold decreased risk of transmission of HIVcompared to non exclusive breast feeding(1).HIV can be transmitted through breast milk at any point duringlactation and thus the rate infection in breast fed infants increases withduration of breast feeding. When replacement feeding is acceptable, feasibleaffordable, sustainable and safe (AFASS) avoidance of all breasts feeding byHIV infected mothers is recommended. Otherwise, exclusive breast feedingis recommended during the first month of life and then discontinued as soonas it is feasible to do so. (11)To help HIV positive mothers make the best choice, they shouldreceive counseling that includes information about both the risks andbenefits of various infants feeding options based on local assessment, andguidance in selecting the option that best suits their circumstances. Theyshould seek to balance the nutritional and other benefits of breast feeding,with the risk of transmitting HIV to their infants and choose betweenexclusive breastfeeding and replacement feeding (commercial infant formulaor home modified animal milk) or other breast milk options (heat treatedexpressed 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)9
  10. 10. Stigmatization of non-breast feeding was making it almost impossiblefor many women to practice exclusive replacement feeding of young infants.Despite the fact that post natal HIV transmission remains responsible for atleast 40% of pediatric HIV infections in setting where prolonged breastfeeding is widely practiced. (13)However, mixed feeding is mostly done inareas where prolonged breast feeding is widely practiced. Thus, increasingchances of HIV transmission.This study therefore will attempt to evaluate the option of infantfeeding methods adopted by HIV infected mothers and the socio-culturaland demographic characteristics associated with the various options offeeding chosen. Information regarding the breast feeding options the HIVinfected mothers chooses and the reasons for their choice is scanty, thisstudy will therefore be carried out to find out infant feeding options adoptedand reasons for such adoptions, socio-economic implication of such aadoptions and experience after adoption among HIV infected nursingmothers.AIMS AND OBJECTIVESGeneral ObjectivesThe aim of the study is to:10
  11. 11. - Assess the infant feeding options practices adopted by HIVpositive nursing mothers seen in Antenatal clinic at MurtalaMohammed Specialist Hospital Kano .Specific Objectives- To determine the knowledge of HIV positive ANC attendees atMMSH on infant feeding options.- To determine factors influencing their choice of infant feedingoptions.- To assess the method of infant feeding choices made at theantenatal clinic.11
  12. 12. 12