Infant Feeding Alternatives for HIV Positive Mothers in Kenya
By Tom Oguta, Abiud Omwega and Jaswant Sehmi
Tom Oguta is currently a PhD student of Nutrition at the University of Nairobi. He has worked as a Research Officer at KIRDI (Kenya Industrial Research & Development Institute) in several research programmes, including HIV/AIDS & Infant Feeding studies, food security evaluations and micronutrient-fortified food efficacy studies in Kenyan children.
Dr. Abiud Omwega is a Senior Lecturer in the Applied Nutrition Programme, Department of Food Technology and Nutrition, University of Nairobi. He has worked with many NGOs and CBOs to develop community based nutrition programmes, including those for the care and support of people affected with HIV/AIDS.
Dr. Jaswant Sehmi is a Lecturer in the Department of Food Technology & Nutrition at the University of Nairobi. She has wide experience in food analysis, nutrition surveys, epidemiological studies (including HIV/AIDS) and monitoring of clinical & malnutrition cases.
The co-authors would like to express sincere thanks to UNICEFEastern & Southern Africa Regional Office (ESARO) for financing this study, and to Homa Bay District Hospital Management for the logistical support they provided during the study.
A mother engaged in pottery as an economic activity in Obera Village
The HIV pandemic sweeping southern Africa and other parts of sub- Saharan Africa is increasingly being perceived and described as a chronic emergency. Innovative and relatively new types of nutrition/food security/ HIV programming are emerging to address the growing HIV crisis. These include PMTCT, MTCT plus, OVC and NCP programming and home based care. Many of these programmes are being rolled out under Protracted Relief and Recovery Operation (PRRO) arrangements in regions recovering from recent emergencies, i.e. southern Africa. However, as these programmes are relatively new, there is enormous headway to be made in defining optimal design and practice.The article below describes a study undertaken to help inform PMTCT programming practice. It highlights the dilemma for HIV positive mothers between using home prepared formula (in this case using cow's milk) which is extremely poor in micronutrient content, and infant formula which is nutritionally better but may be impractical for many contexts in terms of cost, supply and sustainability (ed).
Mother-to-child Transmission (MTCT) rates for HIV are estimated at 25- 45% in the primarily breastfed population of Sub-Saharan Africa. In Kenya, an estimated 300,000 newborn babies are at risk if HIV infection every year, with between 75,000 and 135,000 infants actually infected. Over 75% of these do not even celebrate their fifth birthday. If a mother is infected with HIV, it may thus be preferable to replace breastmilk to reduce the risk of HIV transmission to her infant.
Based on Reliefweb Map centre
For infected mothers living in poor conditions in developing countries, however, it is important to consider very carefully the risks related to not breastfeeding and whether there are alternative feeding methods. In a rural community, where access to clean water and sanitation is inadequate, where families are too poor to afford enough fuel to prepare food and to sterilise feeding bottles or to buy sufficient infant formula, deaths from diarrhoea and respiratory infections could far outnumber those from HIV. The problem is further aggravated by cultural or social stigmas that a community may attach to substitute feeding and to HIV/AIDS in general. Hitherto, there has not been good data available on the relative risks and benefits of different feeding options.
As part of a concerted effort within Kenya to prevent MTCT of HIV, a collaborative programme was initiated in three pilot sites where HIV positive pregnant women were identified and provided with free anti-retroviral (ARV) drug and infant formula feed regimens. In order to inform this study, the Applied Nutrition Programme at the University of Nairobi was asked to conduct a study on alternative feeding practices in one of the project sites (Homa-Bay District)1,2.
The purpose of this study was to assess the feeding alternatives for infants born to HIVpositive mothers in the context of vertical transmission of HIV. The specific objectives of the study were:
- To explore the prevailing alternative feeding practices in the community and among the HIV- positive mothers.
- To explore the factors affecting mother's decision and choice of the various feeding options.
List of abbreviations
ARV - Anti-retroviral
MTCT - Mother To Child Transmission
NCP - Neighbourhood Care Programmes
OVC - Orphans and Vulnerable Children
PMTCT - Prevention of Mother to Child Transmission
Profile of study group
The study population consisted of an observation group of HIV positive mothers with children aged 0-2 years old in Homa-Bay District Hospital, and selected respondents from the rural population as case studies, key informants or focus discussion members. Homa-Bay district (with a population of about 350,000) is inhabited by the Luo ethnic group and is one of the Kenyan districts with the highest HIV prevalence (24%). A number of socio-economic factors are thought to have contributed to the rapid spread of HIV/AIDS in this community:
- Widow inheritance/remarriage
As the majority of the population do not know their sero-status, the cultural practice of remarriage is likely to favour the spread of HIV/AIDS. - Fishing industry and migrant fishermen
Most people involved in the fishing industry in the district either stay away from their families or are single. Others are widowed having lost their spouses, probably from AIDS, and gone to seek a source of livelihood at the beaches. - Concept/ belief of Chira
Belief in the concept of chira (death or curse arising from failure to abide by traditions) is rampant and even when death occurs as a result of AIDS, some people still believe that it was as a result of chira and therefore no special precautions are taken against possible transmission of HIV by prospective sexual partners. - Polygamy
The cultural ideal that a man should have many wives is still widely held by many people in the district and more than 50% of married women live in polygamous unions. Having multiple partners is one of the recognised risk factors for spread of HIV/AIDS.
Information gathering
Using qualitative research tools, four focus group discussion (FGD) sessions were conducted, with eight members in each session (16 women and 16 men). The women participants were aged 18-45 years while their male counterparts were between 20-54 years old. Five experienced and/or elderly women, aged 45-75 years, participated in key-informant interviews on areas related to traditional and contemporary alternative feeding practices.
Eleven HIV-positive mothers were observed and monitored. An additional four women participated as case studies who, for various reasons, were using different feeding methods - see table 1 for infant feeding options considered3. Two of the four women were HIV positive, of whom one opted for infant formula and one continued breastfeeding. The remaining two were not tested for HIV- the first used cow's milk to feed her infant, while the second woman was a wetnurse.
| Table 1 Alternatives to maternal breastfeeding considered for feeding infants of HIV positive mothers in Homa-Bay District | |||
| Option | Characteristics | Indications/ Contra-indications | |
| Commercial infant formula/ formula milk | Based on modified cow's milk or soy protein. Closest in nutrition composition to breastmilk | The family has reliable access to sufficient formula, clean water, fuel, utensils, skills and time to prepare it accurately and hygienically. | |
| Home prepared formula | Made with fresh animal milks, dried milk powder or with evaporated milk. Additional micronutrients, like iron, zinc and vitamins A, C and folic acid are required |
Care is needed to avoid over-concentration or over-dilution. | |
| Unmodified cow's milk | Unmodified cow's milk is not recommended for infants under six months of age | Unmodified cow's milk could be considered as an exceptional option by the HIV positive mother when the supply of cow's milk is reliable and affordable for the six months; the family lacks resources, time and fuel to modify cow's milk to make home prepared formula; the family will be able to offer extra water and monitor dehydration; and commercial infant formula is not available/affordable for the family. | |
| Early cessation of breastfeeding and heattreatment of expressed breastmilk | Early cessation of breastfeeding and heat-treatment of expressed breastmilk reduces the risk of MTCT. Early cessation reduces the length of time for which an infant is exposed to HIV through breast milk. The optimum time for early cessation of breastfeeding is not known. | It is advisable for an HIV positive mother to stop breastfeeding as soon as she is able to prepare and give her infant adequate and hygienic alternative feed (WHO, 1998)*. It could be a good option for those who find it difficult for social and cultural reasons to avoid breastfeeding completely. | |
| Pasteurised breastmilk | Pasteurisation of expressed breastmilk involves heating to about 65oC for 30 minutes, or boiling and then cooling in a refrigerator or cold water. Heat-treated expressed breast milk is still nutritionally superior to other milks, though heat-treatment reduces the level of the antibodies. | May be a good option especially for sick and low birth weight (LBW) babies in a hospital setting | |
| Wet nursing | Wet-nursing is practicable in some traditional settings where a relative breastfeeds the infant | UNICEF/UNAIDS/WHO recommends that wet-nursing be considered only when a potential nurse is informed of her risk of acquiring HIV from the infant in question; she has been offered HIV counselling & testing; she voluntarily takes a test and is found to be HIV negative; and when wet-nursing takes place in a family context with no payment involved.7 | |
| Breastmilk banks | May be an option in some settings, for example as a source of breastmilk for a short time especially for the sick and LBW newborn. | It should be certain that donors are screened for HIV and that donated milk is correctly pasteurised. | |
* HIV and Infant Feeding. UNAIDS/WHO/UNICEF. Guidelines for Decision Makers. WHO, Geneva, 1998. Recently updated 2003. Full text available at http://www.who.int
| Table 2 Comparisons and Contrast between AIDS and Chira | |||
| AIDS | Chira | ||
| 1. | Is recent, never heard of or hardly known 20 years ago. | Is traditional and is as old as the Luo tradition itself. | |
| 2. | Mostly caused by sexual contact with an infected person irrespective of the social approval of the relationship between the persons. | Results from a divergence/deviance from the social norms, even though this can be, but not necessarily related to, sexual contact. | |
| 3. | Has no known cure. It is a final clearance to death (fatal). Treatment cannot prevent the resulting death. | Is curable, by administration of manyasi - a herbal preparation to cleanse against social/cultural evil done by an individual. | |
| 4. | Has multiple rather than single opportunistic infections (associated illnesses) including diarrhoea, TB, skin infections, loss of hair, etc. | Mono-symptomatic, the commonest being gradual weight loss by a seemingly healthy individual, but if many, then comes sequentially with diarrhoea only coming in advanced stages. | |
| 5. | Can be diagnosed in the hospital. | Cannot be scientifically diagnosed in medical laboratory, but the victim's health continues deteriorating. | |
| 6. | Is prevalent among the sexually active youth and reproductive age. | Knows no age. Even children can suffer because of their parents' misdeeds. | |
| 7. | There is severe weight loss (wasting). | There is severe weight loss (wasting). | |
Culture and knowledge of HIV/AIDS and MTCT
The respondents were asked a number of questions about HIV/AIDS, e.g. whether it is preventable and curable, and possibility of transmission from mother to child. The key-informants and members of the FGD were also asked for differences, or similarities, between AIDS and chira (see Table 2)
The FGDs found that women do not have authority over their sexual lives. The Luo cultural norms demand that a woman must have particular sexual contact with her husband to mark certain events like planting, harvesting, marriage and death rituals. One woman complained loudly:
"How can you stop the spread of HIV/AIDS when some of our men move all over the villages inheriting widows even where it was strongly suspected the husbands died of AIDS? To make it worse, they do it secretly and the wife only discovers later when the damage has been caused!"
| Table 3 Summary of case studies | ||||
| Characteristics | Cases | |||
| Case I | Case II | Case III | Case IV | |
| Socio-economic profile |
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| Feeding choice |
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| Health/ environmental conditions |
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| MTCT Knowledge |
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Alternative infant feeding practices amongst case studies
The four case studies are summarised in Table 3, and illustrate alternative feeding methods as practiced in the study area. They show examples of cow's milk feeding, wet-nursing, formula feeding and breastfeeding among those with unknown sero-status and confirmed sero-status cases of HIV.
The four case studies looked at socio-economic profile, feeding choice, health and environment conditions, and knowledge of MTCT. Education varied from no formal education to secondary level. Number of births ranged from 1 - 11. Feeding choices were influenced by practicalities (e.g. mother died and so was wet nursed, or infant formula was provided free and so was used) and social influences (e.g. HIV positive mother feared stigmatisation if she did not breastfeed). The household conditions varied from poor, to acceptable. The health and nutritional status of the infants also varied, from wasted to well nourished. Three of the four women had good knowledge of how HIV may be transmitted in breastmilk and how feeding choice can influence transmission. All accepted cow's milk and milk powder based feeds, and infant formula as feeding alternatives. Three of the four accepted wet nursing, while only one accepted expressed breast milk/heat treated milk as an option.
Infant feeding practice and beliefs amongst the HIV-positive mothers (Homa-Bay District Hospital)
Cow's milk feeding was practiced by the majority of the HIV-positive mothers as an alternative to breastfeeding. Knowledge regarding dilution was very poor, with some mothers over-diluting and others over-concentrating rendering the practice inappropriate.
Attitudes to surrogate breastfeeding are governed by rigid cultural norms. It is believed that a wet-nurse should not have sexual intercourse until the baby is old enough (about 3 years), otherwise the baby, if touched ('soiled') by such a person, would die. Consequently, elderly women who have reached menopause are preferred as carers, in the belief that they are more likely to abstain from sexual intercourse.However, the increase in numbers of orphans due to HIV/AIDS has led to more younger women wet-nursing. This is accepted, provided the surrogate mother bathes before she touches the baby every time she is involved in any sexual intercourse or the wet-nurse and the baby take some manyasi (herbal concoctions for cleansing purposes) to guard/protect against chira affecting the baby. In certain cases, mothers argue that wet-nursing is safe without these practices provided the baby is closely related (by blood) to the husband of the surrogate mother, e.g. wet-nursed by a co-wife. It is accepted that wet-nursed babies are more likely to survive than the ones fed on other alternative foods.
The idea of expressing and/or heating breastmilk was alien and unacceptable to mothers. Ideas about this included, it is not normal to milk a human, breastmilk cannot be expressed to produce enough to satisfy the baby, milking would make the breasts painful, and that breastmilk is so volatile that on heating all of it would evaporate.
The infant formula milks were believed to be good, in that they are hygienic and prepared to suit the baby's nutritional needs. However, they are expensive and are not available in the local markets.
All of the 11 HIV positive subjects reported that if they were to choose, given their serostatus, cow's milk would be the most viable breast milk alternative due to its availability and accessibility. However, eight of the eleven also believed that infant formula would be the best option if it could be provided cheaply and made available.
Conclusions and recommendations
The choice of a breastmilk alternative is influenced by many factors, among them knowledge of MTCT, wealth, cultural attitudes (stigmatisation) and information attained from health facilities. Whilst wet-nursing may be a practicable infant feeding alternative at family level among the non-tested mothers, it was not for these HIV positive mothers. The use of infant formula as a breastmilk alternative by HIV positive mothers is limited by its cost, but would be the most suitable if it were provided freely or at a subsidised price. Cow's milk was the most practicable breastmilk alternative in the study area. It is culturally acceptable, common/familiar and relatively accessible (produced or purchased) to many. However, micronutrient supplements were not available locally, at the district headquarters or through the PMTCT.
Based on our findings, we recommend that mothers attending antenatal care should be sensitised regarding vertical transmission of HIV.
Counselling of HIV positive mothers on cow's milk feeding would be appropriate for those who produce the milk or have sufficient money to buy it, and PMTCT programmes should endeavour to improve the supply of cow's milk in the area. The women should also be guided on how to prepare and modify cow's milk and micronutrient supplements should be made available for them.
The UNICEF/UNAIDS/WHO recommendation that any potential wet-nurse should be confirmed HIV-negative and well informed of her risk of getting HIV from the infant is supported.
For further information, contact Tom Joseph Oguta, P.O. Box 30650- 00100, Nairobi, Kenya.
Tel: 254-020-535966/ 630149 or 0722392499.
Fax: 254-020-555738
E-mail: ogutajoseph@yahoo.com or tjoguta@anp-uon.ac.ke
1Other parts of the study, not including this article, have been accepted for publication in the East African Medical Journal.
2Case Study: Infant Feeding Alternatives for HIV positive mothers in Homa Bay District, South Western Kenya. OGUTA Tom J, OMWEGA Abiud M and Sehmi Jaswant K.
3The PMTCT programme provided free infant formula and ARV only to mothers who were registered into the programme and counselled at the district hospital. However, the case studies included other women who did not have access to free infant formula supplies.
Imported from FEX website