Breastfeeding Disparities Among Mothers Living with HIV in Sub-Saharan Africa: Implications and Recommendations

A recent article by Glaubius, et al., (2024) titled “Differences in breastfeeding duration by maternal HIV status: a pooled analysis of nationally representative surveys in Sub-Saharan Africa” published in JAIDS Journal of Acquired Immune Deficiency Syndromes, shows that mothers living with HIV (MLHIV) in sub-Saharan Africa are less likely to breastfeed initially and stop breastfeeding sooner than HIV-negative mothers.

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Mothers living with HIV in sub-Saharan Africa breastfeed less and for a shorter duration, impacting child health and HIV transmission risks. – Glaubius, et al., 2023

Breastfeeding practices play a critical role in infant health and nutrition, particularly in sub-Saharan Africa where optimal breastfeeding can significantly impact child survival rates. However, maternal HIV status adds a layer of complexity to breastfeeding recommendations and practices. A recent pooled analysis of nationally representative surveys in sub-Saharan Africa sheds light on the differences in breastfeeding duration among mothers living with HIV (MLHIV) compared to HIV-negative mothers, and its implications. One of the key findings of the analysis is that MLHIV were less likely to initiate breastfeeding and ceased breastfeeding sooner compared to HIV-negative mothers, irrespective of the region and time period studied. This discrepancy underscores the need for targeted interventions and support systems to ensure that MLHIV and their infants receive adequate nutrition and care during the critical early stages of life. Moreover, the analysis revealed regional variations in the magnitude of differences in breastfeeding practices by maternal HIV status. Southern Africa exhibited the largest gap between MLHIV and HIV-negative mothers in terms of breastfeeding duration, while Western Africa showed the smallest difference. These regional disparities emphasize the importance of context-specific strategies and policies to address the unique challenges faced by MLHIV and their infants across different geographic areas. Furthermore, the study observed a concerning trend of decreasing median breastfeeding duration over time in all regions, regardless of maternal HIV status. This decline in breastfeeding duration raises questions about the underlying factors contributing to the shift away from optimal breastfeeding practices. It is essential to explore these trends further and implement targeted interventions to promote and support breastfeeding among all mothers, including MLHIV. The implications of shorter breastfeeding duration among MLHIV are far-reaching. Not only does it impact infant nutrition and health outcomes, but it also has implications for estimating new HIV infections in children. Breastfeeding serves as a potential route for HIV transmission from mother to child, and shorter breastfeeding duration may influence the risk of transmission. Therefore, comprehensive strategies that balance the benefits of breastfeeding with the need to prevent mother-to-child transmission of HIV are essential. In addition, supporting optimal breastfeeding practices and ensuring adherence to antiretroviral therapy among MLHIV are crucial components of comprehensive HIV care and treatment programs. By providing access to timely and appropriate support services, healthcare providers can help MLHIV make informed decisions about breastfeeding while minimizing the risk of HIV transmission to their infants.

How the Study was Conducted

The study utilized national cross-sectional household surveys conducted in sub-Saharan Africa between 2003 and 2019, focusing on women aged 15–49 years. These surveys, sourced from the Demographic and Health Surveys (DHS) Program, the Population-Based HIV Impact Assessment (PHIA) project, and the National Bureau of Statistics of Kenya, provided comprehensive data on HIV testing and current breastfeeding practices among women in the region. To analyze breastfeeding duration, the study developed a model comprising a proportion of mothers initiating breastfeeding and a log-logistic distribution for the duration of breastfeeding among those who did breastfeed. The model parameters, including country, year, and maternal HIV status, were estimated using linear models tailored for each sub-Saharan African region (Eastern, Central, Southern, and Western). Parameter estimation was employed through Bayesian methods using Stan in R. Models were fitted to aggregated counts of mothers from each survey, stratified by country, survey year, maternal HIV status, months since last birth, and current breastfeeding status. Non-informative flat prior distributions were assumed for all model parameters, and the NUTS sampler was employed to obtain samples from the posterior distribution. Sensitivity analyses were performed to assess the impact of including or excluding the 2016 DHS of South Africa on estimates of breastfeeding duration in Southern Africa. This survey, conducted later, displayed a shorter breastfeeding duration compared to others in the region, prompting the need for careful consideration in the analysis. Additionally, the study utilized Spectrum to estimate incident and prevalent HIV infections in children based on different breastfeeding duration inputs: those derived from mothers living with HIV and from all mothers regardless of HIV status. By comparing pediatric HIV estimates between the two breastfeeding assumptions in each region of sub-Saharan Africa, the study illuminated the potential impact of breastfeeding practices on pediatric HIV transmission dynamics.

What the Authors Found

The authors found that mothers living with HIV (MLHIV) in sub-Saharan Africa are less likely to breastfeed initially and stop breastfeeding sooner than HIV-negative mothers. The magnitude of these differences varies by region and is largest in Southern Africa and smallest in Western Africa. The authors also found that the median duration of breastfeeding and the proportion of mothers who breastfeed initially decreased over time in all regions regardless of maternal HIV status. No region showed an increase in breastfeeding practices over time. In addition, the study posits that using breastfeeding durations among MLHIV instead of all mothers in the Spectrum model lowers the estimates of new HIV infections and children living with HIV in sub-Saharan Africa. The proportionate differences are larger in Eastern and Southern Africa than in Western and Central Africa.

Why is this Important

HIV Prevention and Treatment: Understanding the differences in breastfeeding practices between mothers living with HIV (MLHIV) and HIV-negative mothers is essential for designing effective prevention and treatment strategies. MLHIV are less likely to initiate breastfeeding and stop breastfeeding sooner, which impacts the risk of mother-to-child HIV transmission. Identifying these disparities allows for targeted interventions to improve breastfeeding practices among MLHIV.

Child Health and Survival: Breastfeeding provides essential nutrients and immune protection to infants. The shorter breastfeeding duration among MLHIV may affect child health and survival. Addressing this gap can contribute to better child health outcomes and reduce mortality rates.

Public Health Programs: Public health programs need accurate data on breastfeeding practices to plan and implement effective interventions. The study’s findings highlight the need for tailored programs that support MLHIV in breastfeeding while minimizing HIV transmission risk.

What the Authors Recommend

• The authors highlight that mothers living with HIV should be supported in recommended breastfeeding practices and to adhere to antiretroviral drugs for HIV treatment and prevention of postnatal mother-to-child transmission.
• The authors emphasize that healthcare providers should be supported to provide clear guidance about recommended infant and young child feeding practices, especially for mothers living with HIV who may face confusion or stigma.
• The authors suggest that using breastfeeding patterns among mothers living with HIV for estimating new HIV infections among children and children living with HIV results in lower estimates than previous assumptions that did not account for maternal HIV status. The authors state that these methods have been used to prepare UNAIDS estimates since 2020.

In conclusion, the findings underscore the critical importance of addressing disparities in breastfeeding practices among mothers living with HIV in sub-Saharan Africa. By understanding the complex interplay between maternal HIV status, regional variations, and temporal trends, tailored interventions and policies can be developed to support optimal breastfeeding while minimizing the risk of HIV transmission to infants. These efforts not only improve child health outcomes but also contribute to the broader goals of maternal and child health equity in the region. Moving forward, continued research, collaboration, and advocacy are essential to ensure that all mothers, regardless of HIV status, receive the necessary support to make informed decisions about infant feeding practices, ultimately leading to better health outcomes for both mothers and their children.

AR Managing Editor (2024). Breastfeeding Disparities Among Mothers Living with HIV in Sub-Saharan Africa: Implications and Recommendations. Retrieved from https://www.africanresearchers.org/breastfeeding-disparities-among-mothers-living-with-hiv-in-sub-saharan-africa-implications-and-recommendations/