Infant Feeding and HIV Prevention: A Needs Assessment: Mbarara, Uganda.

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Infant Feeding and HIV Prevention A Needs
Assessment Mbarara, Uganda.

• Sarah K. Nabukera, MD, MPH.1,2
• Juliet A. Mwanga, MBchB, MMED.3
• Jude Senkungu, MBchB, MMED.3
• 1Department of Maternal Child Health
• UAB, School of Public Health
• 2 Department Community Health
• 3 Department of Pediatrics
• Mbarara University of Science Technology
• 12th Annual CDC MCH Epidemiology Conference
• Atlanta, Georgia
• December, 2006

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Presentation Outline

• Background
• Study Objectives
• Methodology
• Findings
• Comments
• Implications for future research

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Background

• In 1999, the first research findings on how ARVS
  could prevent mother-to-child transmission of HIV
  where published.
• Over the last 5 years, several perinatal HIV
  prevention programs have been implemented in
  several developing countries.

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Background

• Programs have had varying degrees of success in
  different countries.
• One issue that has raised great concern and
  debate in the health sector regards
  breastfeeding.

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Background

• Different recommendations have been proposed by
  WHO to deal with the issue, include
• Artificial feeding exclusively.
• Exclusive breast feeding with early weaning.
• Normal breastfeeding and weaning.
• Countries have been encouraged to adapt
  recommendations that best meet the needs of the
  population.

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Problem Statement

• Given that background, there is limited
  information as to how PMTCT programs have
  addressed infant feeding issues from providers
  and clients perspectives.

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Study Objectives

• To investigate feeding practices used by HIV
  positive mothers enrolled in perinatal HIV
  prevention program.
• To identify the challenges faced by caregivers in
  meeting the nutritional needs of their infants.

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Study Objectives (cont.)

• To identify health workers challenges in
  providing services to HIV positive mothers and
  their infants.
• To identify potential solutions for future
  intervention to address the problems.

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Methodology
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Methods

• Study Design
• Cross sectional needs assessment study.
• Study Population
• HIV positive mothers attending an infant
  follow-up clinic.
• Health care workers.

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Methods (cont)

• Study Setting
• Mbarara Regional hospital
• Main referral hospital in Southwest
• Teaching hospital
• In 2002 hospital implemented first pilot PMTCT
  program.
• Included, VCT, and use of Nevirapine for HIV
  positive mothers

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Methods (cont)

• Data collection
• Interviewer-administered questionnaire survey
  (mothers).
• Key informant interviews (health workers).
• IRB approval was obtained for this study.
• Informed consent was obtained from all study
  participants.

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Data Analysis

• Content analysis was done for key informant
  interviews.
• Survey data were analyzed using SPSS Statistical
  package (version 12)
• Focused mainly on descriptive statistics.

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Study Findings
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Key Informant Interviews

• Eighteen health workers participated in the key
  informant interviews.

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Services Provided
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Key Informant Interviews

• 72 of providers received training regarding
  prenatal HIV counseling
• 61 reported receiving training on infant
  nutritional issues for HIV positive mothers
• Only 20 of interns received any training

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Key Informant Interviews

• 61 of providers indicated that they provide
  counseling on infant nutrition.
• 60 of health workers felt that mothers were not
  receiving adequate information on infant
  nutritional issues.

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Barriers/Challenges

• Health workers barriers included
• Inadequate training
• Time constraints
• Other challenges faced
• Socio-cultural barriers
• Stigma
• Lack of spousal support
• Cultural beliefs regarding breastfeeding

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Barriers/Challenges

• Economic barriers
• Poverty, families unable to provide alternative
  feeding methods
• Health system barriers
• Poor staffing
• Insufficient training
• Uncoordinated follow up system

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Proposed Solutions

• Better coordinated follow up system with home
  visits.
• Training for health workers and general
  community.
• Increased staffing for the health sector.
• Provision of supplemental feeds.

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Survey

• 42 mothers were interviewed for the survey,
• Mean age 27.9 (SD. 8.5).
• 64 married (monogamous).
• At least 50 had primary school education.

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Survey

• Approximately 90 attended prenatal care
• 70 participated in PMTCT program.
• 55 received Nevirapine treatment.
• Over 80 received information on infant feeding,
  and prevention of re-infection.

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Infant Feeding Options

• 51 of mothers opted to exclusively breast feed
  for 3 months, with accelerated weaning.
• 29 opted for modified cows milk.
• 3 opted for formula feeding.
• 12 opted for exclusive breast feeding with
  normal weaning.

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Feeding Practices

• 72 of mothers ever breastfed.
• 61 exclusively breastfed for the first 3 months.
• For infants older than 3 months, 56 of mothers
  had discontinued breastfeeding.

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Alternative Feeding Practices

• For 33 of infants, artificial feeds were
  introduced with in first 3 months.
• 37 of infants are fed 4-7 times a day.
• Cows milk is the main alternative food, (60).

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Adherence to Selected Feeding Option

• Adherence to selected feeding choice was poor.
• STIGMA main factor cited by all mothers for poor
  adherence to selected feeding method.

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Comments

• There are gaps in the delivery services for the
  PMTCT program.
• Providers are poorly trained to counsel on infant
  nutritional issues.
• Breastfeeding is an important cultural function
  for many mothers.
• While mothers opted for the best feeding option,
  adherence is poor.

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Strength Limitations

• The study gives an idea as to what challenges
  perinatal HIV programs face in resource
  constrained countries.
• Study is limited as it was conducted in only one
  program, and had a limited sample size.

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Take Home Message

• There is a need to ensure balance between HIV
  prevention and the social-cultural need for
  breastfeeding.
• STIGMA needs to be addressed if programs are to
  succeed.

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Take home message (cont.)

• Health workers need continuing education
  especially regarding strategies for HIV
  prevention as there are constant changes going on.

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Implication for future research

• Further research needed to identify best
  strategies for addressing social stigma.
• How best to encourage male partners to get
  involved in reproductive health issues as a whole.

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Acknowledgments

• Dr John Ehiri, PhD. (UAB).
• Advisor
• Dr JoAna Stallworth, PhD (CDC).
• Technical assistance
• The Sparkman Center for Global Health (UAB).
• Provided funding for this project
• Staff and patients, Mbarara Regional Hospital.

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