June 2003, Vol. 9, No. 2

HIV Prevention
Education Improves Breastfeeding Practices in Zambia

Last year, 800,000 children became infected with HIV, most of them during their mother’s pregnancy, childbirth, or through breastfeeding. The Population Council’s Horizons program has tested the introduction of infant feeding counseling to inform women about ways to reduce the risk of HIV transmission during breastfeeding and to support them in their infant feeding choices. The program is being tested at antenatal care clinics in Ndola, Zambia, a low-income setting where antiretroviral drugs are unavailable. The intervention is a collaboration with three nongovernmental organizations, Hope Humana, the LINKAGES project, and the Zambia Integrated Health Project, and two government agencies, the Zambian National Food and Nutrition Commission and the Ndola District Health Management Team. 

The research shows that women receiving infant feeding counseling maintain healthier breastfeeding practices in the first six months of their infants’ lives. But more work is needed to increase community use of voluntary HIV counseling and testing services and to promote behavior change for preventing HIV transmission and seeking care and support for HIV infection. 

The Horizons program of operations research is implemented by the Population Council with the International Center for Research on Women, the International HIV/AIDS Alliance, the Program for Appropriate Technology in Health, Tulane University, Family Health International, and Johns Hopkins University. 

Horizons is funded by the U.S. Agency for International Development; its findings allow the agency and its cooperating partners to allocate limited funds most effectively on the basis of empirical information. 

Breastfeeding conundrum 
In richer countries, mothers with HIV are advised to feed their babies exclusively with formula to avoid transmitting the infection. In poorer countries, however, this strategy can be problematic. In addition to the high cost of formula, a stigma is often attached to formula feeding babies because it suggests the mother may have HIV. Thus, formula feeding may lead to discrimination against the mother. Moreover, if clean water is unavailable, as it often is in poor countries, formula can do more harm than good by exposing babies to waterborne microorganisms that cause diarrhea and respiratory infections. These conditions, combined with malnutrition, are the leading causes of death among children under five years of age worldwide. 

Feeding babies with a combination of formula or other feeds and breast milk can result in a higher rate of HIV transmission than breastfeeding alone. UNAIDS, UNICEF, and the World Health Organization advise that health-care managers conduct a thorough investigation into local infant feeding options and that health workers help individual HIV-positive mothers weigh the relative risks specific to each locality. Such an assessment conducted in Zambia’s Ndola district found that for most mothers breastfeeding is the safest option, even when the mother knows she is HIV-positive. 

Working with the study partners, six maternal and child health clinics in Ndola added services aimed at preventing the transmission of HIV from mother to child. The services included counseling on infant feeding and voluntary HIV counseling and testing. The Sisters of the Sacred Heart, part of the Catholic Diocese in Ndola, participated by referring pregnant women to voluntary HIV counseling and testing services at the Ndola clinics. For social support the clinics referred HIV-positive mothers and their families to the Sisters of the Sacred Heart Home Based Care program and Hope Humana, a nongovernmental organization focused on HIV/AIDS. 

Researchers assessed knowledge, attitudes, and practices regarding these added services and HIV in general through questionnaires administered to community members and mothers attending clinics. Baseline interviews among 1,430 people were conducted in 2000. An additional 1,300 respondents were interviewed in 2001, one year following the introduction of the intervention. Results from a third and final round of questionnaires are forthcoming. 

In the study, all mothers were given information about feeding choices and offered the opportunity to learn their HIV status through confidential on-site counseling and testing services. A trained counselor guided each mother through the feeding choices and encouraged each to weigh the relative risks and benefits of infant-feeding options. Counselors advised HIV-negative women and women who did not know their HIV status to breastfeed their infants exclusively for the first six months, and to continue breastfeeding while introducing supplementary foods until the infant reached two years of age. 

HIV-positive mothers were counseled about the option of exclusive formula feeding, including receiving instructions on how to boil water for this purpose, and warned of the negative effects of mixed feeding. The Ndola guidelines recommend that HIV-positive mothers stop breastfeeding at six months. At this age an infant can digest locally available alternative foods, such as maize porridge enriched with mashed fish, which would reduce the duration of potential virus exposure. 

Findings 
During the baseline interviews, researchers found that mothers were already well aware of the possibility of HIV transmission from mother to child. However, most believed nothing could be done to prevent transmission. Twelve months into the intervention, though, more mothers were able to name some of the steps that could be taken to reduce mother-to-child transmission, including, in addition to early weaning, the use of antiretroviral drugs during labor and delivery. 

Exclusive formula feeding and avoidance of breastfeeding remained unpopular. According to the researchers, this may be due to the expense of infant formula supplies, the enormous effort involved in obtaining fuel to boil water for formula preparation, or the stigma of suspected HIV-positive status associated with artificial feeding. 

At the clinics, researchers observed that logistical obstacles, such as a lack of test kits and other supplies, hampered achievement of some of the intervention’s goals. Moreover, the survey revealed that voluntary HIV counseling and testing is widely perceived not as a source of important information about one’s health and available services, but rather as a source of stress. There are few treatment options in Ndola for people who learn they are HIV-positive. Thus, “reported use of this service remained low, rising only to 14 percent from 5 percent among the clinic attendees in the first year of the study,” says Naomi Rutenberg, Population Council senior program associate in the Horizons program. The researchers recommended that facilities further improve routine services while adding enhanced services to prevent the transmission of HIV from mother to child. 

Communication between partners about HIV appears to be improving. Among female respondents from the clinic and the community who were tested for HIV infection, 93 percent told their spouse the result of the test, up from 63 percent at the start of the intervention. 

Most importantly, following the intervention and enhanced counseling, the percentage of mothers in the community reporting they were exclusively breastfeeding rose from 56 percent to 76 percent, with fewer mothers reporting using the riskier practice of mixed feeding. “This trend suggests that with appropriate counseling, women will continue to adopt good breastfeeding practices, even as they become increasingly aware that HIV can be passed from a mother to her child through breast milk," says Sam Kalibala, a Population Council program associate based in Kenya. 

A report on these findings can be downloaded in PDF form at http://www.popcouncil.org/pdfs/horizons/ndolamdtrm.pdf.

Sources
Hope Humana, LINKAGES, National Food and Nutrition Commission, Ndola District Health Management Team, Horizons Program, and Zambia Integrated Health Programme. "Ndola demonstration project: A midterm analysis of lessons learned," Horizons Midterm Report. Washington, DC: Population Council. (PDF)

Schenk, Katie. 2003. "Breastfeeding education helps PMTCT," AIDSLink, Issue Number 78, Global Health Council.

Outside funding
United States Agency for International Development

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See Also

• "Breastfeeding and HIV: No easy answers," Momentum, October 2003 (full text)

• "Infant feeding counseling within Kenyan and Zambian PMTCT services: How well does it promote good feeding practices," Horizons Research Summary, December 2003 (full text)

• "Protecting newborns from HIV infection," Momentum, October 2003 (full text)

• "Family planning and PMTCT services: Examining interrelationships, strengthening linkages," Horizons Research Summary, December 2003 (full text)