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Review of SAfAIDS discussion forum on safer breast feeding
June 23, 2004

Audio files are associated with this document. View details

Read more about ZVITAMBO's PMTCT work

Presenter: Dr. 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) .

Zvitambo’s research 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 at all.

The study broke the mothers into three categories which were slightly adapted from WHO standards.

  • 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 milk; and
  • 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 significant amount.

The Zvitambo 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 less efficient.

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.

Another factor was the social pressure on mothers to supplement their babies diets with other foods which would also result in a dangerous mixed breast-feeding practice.

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.
  • Exclusive Breast-feeding for up to six months.
  • Avoid now or re-infection, ie barrier contraception during pregnancy and lactation.
  • Early treatment of breast and nipple problems (mastitis increases the risk of transmission.)
  • Early treatment of oral problems in the babies.
  • Consideration of rapid weaning in six months.

The gathering of qualitative, social information involved several different approaches.

Focus Discussion 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
  • Individual interventions, specifically counseling and infant feeding information was integrated into any form of counseling prior to or after HIV testing.

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."

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Audio Files

  • What 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 feeding.

    This is a
    transcript from an interview with an HIV+ mother.

    Language: English
    Duration: 43sec
    Date: June 23, 2004
    File Type: MP3
    Size: 169KB

  • Reflections 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.

Language: English
Duration: 2min 27sec
Date: June 23, 2004
File Type: MP3
Size: 576KB

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