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of SAfAIDS discussion forum on safer breast feeding
June 23, 2004
Audio files are associated with this document. View
more about ZVITAMBO's PMTCT work
Peter Iliff of the Zvitambo Project
After a brief
welcome and a reminder to switch off all cellular telephones, Dr.
Peter Iliff of the Zvitambo Project was introduced by the discussion
chair who told the group that the session was intended to be a discussion
involving all present. The primary thesis of Dr. Iliff’s presentation
concerned the impact of breast-feeding methods on mother to child
transmission of the HIV virus.
The field research
trial from which Dr Iliff drew his conclusions was conducted between
1997 and 2002 He warned that the research started not as an investigation
of PMTCT through breast-feeding technique, but as a study of the
benefits of randomised vitamin A supplementation in preventing post
natal mother to child transmission of HIV (PMTCT) .
was conducted in Harare, Chitungwiza and Epworth on 14 000 mother/baby
pairs. Of these approximately 4 500 mothers were knowingly HIV positive.
The remainder were HIV negative, or chose not to know their HIV
status. The process of data collection was conducted at the same
time as a qualitative social intervention programme, but due to
the conditions in which the study was carried out, not all mother/baby
pairs were exposed to the full social intervention, some had only
partial exposure, and others had no exposure to the intervention
The study broke
the mothers into three categories which were slightly adapted from
- Those who
were practicing Exclusive Breast-feeding, only breast milk from
birth to six months of age.
- Those who
practiced Predominant Breast-feeding, mostly breast milk but including
other non-milk liquids, usually water, fruit juice or tea without
- Those who
practiced Mixed Breast-feeding, breast milk in addition to other
foods and other milk products.
It was found
that the incidence of transmission of HIV from mothers to their
babies was lower among pairs who practiced exclusive breast-feeding
for the first three months. Dr Iliff explained that ideally the
controlled research would have continued to six months of age which
is a more appropriate time for the babies diet to change, but under
the circumstances this was not possible.
Of the 14 000
Zvitambo mothers, only those who were HIV+ and whose babies were
found to be HIV- at six weeks of age were involved in the final
testing. Of these nearly 3000 babies, Dr Iliff reported that there
was an "overall transmission rate of nearly 13%, and mixed
breast feeders transmitted nearly twice as often as those who only
exclusively breast-fed, and that distance is statistically significant."
PMTCT also appeared to be higher among mother/baby paris who practiced
Predominant breast-feeding, but this was not by a statistically
project concluded that, up to three months, "mixed breast-feeding
doubles the risk of postnatal transmission or death, compared to
exclusive breast-feeding." For this reason, exclusive breast-feeding
is recommended. However, in mother child pairs who continued breast-feeding
after six months, the incidence of PMTCT increased by 68%.
When asked to
further explain the cause of the above findings, Dr. Iliff admitted
that further research needed to be conducted but that there are
currently two popular theories. First, is that the gut of infants
is generally vulnerable and so complicated foods, such as animal
milk, might cause slight damage, which becomes problematic when
discussing HIV transmission. The second reason is that the relationship
between baby and breast is a very efficient system which works well
to meet both the needs of the mother and the baby, but when that
system is interrupted by the introduction of other foods, it becomes
As part of their
program the Zvitambo project engaged in qualitative information
gathering, as well as information dissemination programmes aimed
at both mothers and fathers. They found certain social barriers
to be problematic.
Dr. Iliff explained
that much of Zvitambos laboratory work continues, but that most
of their attention "is in programme support work, doing prevention
of parent to child transmission work with mission hospitals in the
country." He later said that Zimbabwe is, beneficially, a breast-feeding
society. Generally the use of formula or other food supplements
(which he discourages because they can be unhealthy) are frowned
upon by society. For this reason, some HIV positive mothers who
hope to reduce the possibility of transmitting the virus to their
children through breast milk will generally use alternative foods
in private but might breast-feed publicly, i.e. mixed breast-feeding.
was the social pressure on mothers to supplement their babies diets
with other foods which would also result in a dangerous mixed breast-feeding
Dr Iliff said
that most mothers in Zimbabwe will choose breast-feeding, "our
mothers are going to continue to breast-feed, so we have to help
them to do the best that they can under those circumstances. . .
we are happy to live in a breast-feeding tradition. . .So the issue
is how to make breast-feeding safer."
In order to
combat some of the problems that impede healthy infant feeding,
the Zvitombo Programme engaged in a social marketing intervention
strategy that aimed to inform mothers about "Safer Breast-feeding."
The components involved in Safer Breast-feeding are:
- Good breast-feeding
technique, particularly in attachment and positioning.
Breast-feeding for up to six months.
- Avoid now
or re-infection, ie barrier contraception during pregnancy and
- Early treatment
of breast and nipple problems (mastitis increases the risk of
- Early treatment
of oral problems in the babies.
of rapid weaning in six months.
of qualitative, social information involved several different approaches.
Groups dealing with Knowledge attitudes and beliefs in the community
about HIV testing, transmission of HIV from mothers to babies and
infant feeding, were conducted. 148 people participated in these
discussions which took place in 24 smaller groups of pregnant women,
lactating mothers and fathers.
In depth interviews
with mothers from the Zvitambo trial took place. The focus of these
interviews were on receiving test results, disclosing HIV status,
and on infant feeding decisions.
Dr Iliff reported
that some of the key findings of the research were that, "non-breast
feeding mothers face very negative social consequences.," and
that men take interest, "when informed that ceroconversion,
meaning infection during breast-feeding. . . doubles. . .[or] actually
trebles. . .the risk of transmission of HIV to the baby. . . and,
men want to learn about PMTCT directly, not from their wives. .
.Men are often the decision makers even about the intimate issues
of infant feeding."
Based on these
findings, an intervention programme was designed. The intervention
focused on mothers, but did include some male outreach through the
workplace. The intervention programme included components such as:
- Group interventions
both ante-natally and post-natally for mothers. This involved
educational videos, pamphlets and brochures; and
interventions, specifically counseling and infant feeding information
was integrated into any form of counseling prior to or after HIV
There was a
total of 28 possible exposures to the intervention campaign and
it was found that there was a dosed response to the interventions
and impact on infant feeding practice up to three months. "Per
exposure. . . we got a decreasing risk of transmission, of postnatal
HIV infection, and this. . .means that for each exposure there was
a 16% reduction in the likelihood of HIV transmission, which was
. . . statistically significant."
Visit the Zvitambo
will people think of me?
HIV+ mothers are deeply affected by social pressures. A fear of
being stigmatized might result in mothers practising mixed breast
This is a transcript
from an interview with an HIV+ mother.
Date: June 23, 2004
File Type: MP3
of an HIV+ mother
Safe breast feeding requires determination. It is very difficult
for mothers to resist the pressure to give their children other
foods, in addition to breast milk. ZVITAMBO's research shows that
the incidence of transmission of HIV from mothers to their babies
was lower among pairs who practiced exclusive breast-feeding for
the first three months.
This is a
transcript from an interview with an HIV+ mother.
Duration: 2min 27sec
Date: June 23, 2004
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