ABSTRACT

Poor breastfeeding and infant feeding practices have adverse effects on the health and

nutritional status of children, HIV being one of the major confounding circumstances in

infant feeding. Against the backdrop of this realization, efforts are therefore required to

protect, promote and support appropriate infant feeding practices.

The study was designed to assess the infant feeding practices and feeding alternatives

available for children of the untested mothers and those born to HIV positive mothers,

and the factors determining choice of infant feeding alternatives. The Mother-to- child

transmission (MCTC) knowledge level of mothers and the general nutrition status of the

children were also assessed.*

The study was cross sectional and explanatory. It was carried out in Kisii District hospital

on a sample of 186 children aged 0-24 months with their respective mothers or caretakers

as respondents. A previously pre-tested and structured questionnaire was used to collect

data on: infant feeding practices; breast milk alternatives; MTCT knowledge of the

mothers; anthropometry of the children; socio-economic and demographic characteristics

of the households; morbidity; and nutritional status. In addition focus group discussions,

key informant interviews and observations were used as supplementary methods of data

collection.*

Simple descriptive statistics, bivariate analysis (chi-square test) and multivariate logistic

regression analysis were performed on the data using SPSS (version 12.01) and Epi Info

(version 6) software.*

In general there were significant differences in the infant feeding practices by the non

tested mothers from those of the HIV positive mothers. The main complementary foods

given were cow milk, uji, meat, pulses and eggs. The HIV positive mothers gave

significantly more meat, legumes and eggs than the non-tested mothers.*

On 19.5% of the children below the age of 2 months were exclusively breastfed. The

practice of giving pre-lacteal (cow milk and herbal concoctions was common.

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Complementary foods mainly cow’s milk and uji were introduced early at a mean age of

2-3 months due to perceived milk insufficiency. Up to 85.4% of the children had been

breast fed. Slightly more than half of the mothers introduce breast milk within the first 24

hours of delivery. Breast feeding was mainly on demand and continued to the second

year (median 23 months) of life of the infant.*

There were significant differences p<0.05 between the level of use of the infant feeding

alternatives by the HIV positive mothers and by the non- tested mothers. The main

alternatives were wet nursing, breast milk, cow milk. Cow milk was the most popular

alternative and wet nursing was significantly more acceptable to the HIV positive

mothers than the non tested mothers. The HIV positive mothers had a higher MTCT

knowledge level than the non-tested mothers. The maternal MTCT knowledge was poor

at 19.6 among the non tested mothers and a bit higher among the HIV positive mothers at

39.4%. The choice of infant feeding alternative was influenced by a number of factors

including: cultural attitudes, health and nutrition education and knowledge on MTCT.*

Exclusive breastfeeding was significantly associated with nutritional status of the child in

regards to the underweight status of the child. Children who were not exclusively

breastfed had a higher likelihood of being underweight. Immunization status of the child

also had significant association with the nutritional status of the child.* Marital status of

the mother has significant association with wasting and underweight status. Age of the

index child also has a significant association with wasting and underweight status.*

The nutritional status of the children born to the non tested mothers indicated that: 9.9%

were severely stunted, 0.8% was severely wasted and 6% were severely underweight.

However the nutritional status of children born to the HIV positive mothers indicated that

46.4% were severely stunted, 28.6% were severely wasted, and 35.7% were severely

underweight.*

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There were significant differences (P=<0.05) in the morbidity patterns of the children

born to HIV Positive mothers in comparison to the non-tested mothers. Anaemia and

pneumonia were significantly more prevalent among children born to HIV positive

mothers than among those born to the non tested mothers.*

The two main predictors of the nutritional status were age of the child, and exclusive

breastfeeding. The nutritional status of children born to HIV positive mothers was

significantly poorer than that of the children born to untested mothers.

The level of use of alternatives was significantly higher among the HIV positive mothers

than among the non tested ones.

1

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Globally about 30-40 million men, women and children are infected with HIV, 28.5

million of them from Sub-Saharan Africa (UNAIDS, 2002). Each day more than 6000

young people aged 15-24 years are newly infected with HIV. It is estimated that there are

10-15 million Aid’s orphans worldwide, 83 percent of them from Sub-Saharan Africa.

Women take up more than half the number of people living with HIV/AIDS (PLWHA).

In Kenya since the first AIDS case was reported in early 1980s, the epidemic has

expanded in alarming proportions. The current female to male ratios in Kenya is 1:9 one

of the highest Africa, while 10 percent of all PLWHA are children (NASCOP 2002).

Increasing numbers of children who have HIV infection, especially in the countries

hardest hit by the pandemic. In 2002 an estimated 3.2 million children less than 15 years

of age were living with HIV/AIDS, a total of 80,000 were newly infected and 610,000

died.

About 70-80 percent of HIV transmission is through sexual contact. Besides HIV can be

transmitted through parenteral contamination, and perinatal (mother to child) modes . In

children 90 percent of HIV transmissions are as a result of mother to child transmission

during pregnancy, delivery and breastfeeding (Preble and Piwoz, 2000). The remaining

10 per cent is from blood contamination or sexual abuse. According to a sentinel survey

done 30% of women attending antenatal care were diagnosed HIV positive. (NASCOP

2004). In Kenya 1 million children are born every year. Therefore this parallel puts about

300,000 newborn infants at risk of HIV every year.

Since in developing countries total of transmission varies between 25-45 percent, hence

between 75000 – 135,000 are actually infected with HIV. However, not all mothers’

access health care hence more undiagnosed cases go unattended. By far the main source

of HIV infection in young children is Maternal to Child Transmission (MTCT). The

virus may be transmitted during pregnancy labour and delivery, or by breastfeeding.

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HIV/AIDS however transmitted has been estimated to account for about 8% of deaths in

children below 5 years of age in Sub –Saharan Africa. In areas where the prevalence of

HIV in pregnant women exceeded 35% the contribution of HIV/AIDS to childhood

mortality was as high as 42%. (Lancet, 2002). Rates of MTCT range from 14-25% in

developed countries and 13-42% in developing countries, where breastfeeding is more

common.

If a mother is infected with HIV, it may thus be preferable to replace breast milk to reduce

the risk of HIV transmission to her infant. The risk of replacement or alternative feeding

should be less than the potential risk of HIV transmission through infected breastmilk, so

that infant morbidity and mortality from other causes do not increase. The risk of HIV

infection through breastfeeding needs to be weighed against the great dangers posed by

artificial feeding. If the only consideration were to prevent HIV from infecting the child

through breast milk, the recommendation would be for the infected mothers not to

breastfeed, and usually to use infant formula. This is what is widely recommended to HIV

Infected mothers in industrialized countries and affluent mothers in non- industrialized

countries. For infected mothers living in poor conditions in developing countries

however, it is important to consider very carefully the risks related to not breastfeeding

and whether there are alternative feeding methods (Latham, 1999; WHO/UNICEF, 1992).

In a rural community where access to clean water and sanitation is inadequate, where

families are too poor to afford enough fuel to prepare food and to sterilize feeding bottles or

to buy sufficient infant formula, deaths from diarrhea and respiratory infections could far

out-number those from HIV. The problem is further aggravated by cultural or social

stigmas that a community may attach to substitute feeding and to HIV/AIDS in general.

There is need for intensified research to guide formulation of and/or influence policy and

intervention programs on this matter. Hitherto there has not been good data available on

the relative risks and benefits of different feeding options (Morrision, 1999). We do not

know which options would save the most lives, be of least cost to society, and have the

fewest negative effects. Health workers and policy makers in are not sure or well

informed to decide on what appropriate actions or advice to give to a mother who is HIV

positive on how to feed her infant (Latham, 1998).

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Despite the huge amount of work done on HIV/AIDS including on MCTC, there still

remain some important gaps in knowledge in areas related to appropriate feeding for

infants of mothers infected with HIV-1. Such gaps result into a good deal of confusion in

the minds of health workers, and policy makers are often uncertain about policy

recommendations.

Some feeding options that are appropriate for mothers living in advantaged positions may

be totally. The fourth millennium development goal MDG calls for a two-thirds reduction

between 1990 and 2015 in deaths of children aged less than 5 years. Less than 10% of

HIV infected pregnant women have access to appropriate health care. (UNAIDS 2006)

It is this fraction of infants that have become a major challenge to health professionals

and policy makers alike. It gives a glummer of hope to role that HIV transmission can be

reduced from 25-45 percent to near zero. This endeavor requires a complete package of

health care including maternity and family planning; increased antenatal care; VCT

services for HIV possible use of ART drugs; and safe alternatives to HIV infected

mothers breast milk.

Multidisciplinary efforts are required to curb the rapid spread of HIV. This study is to

explore the prevailing feeding practices, while acknowledging that reduction of postnatal

HIV transmission through breast milk is particularly problematic in resource poor

settings as there are completing risks which are individual and context specific.

1.2 STATEMENT OF THE PROBLEM

Some feeding options that are appropriate for mothers living in advantaged positions may

be totally inappropriate for mothers whose families are less privileged. Some suggested

infant feeding methods in theory have merit, but little investigation has been done to

determine their feasibility, in practical terms, and in different settings.

All evidence suggests that mixed breast and formula feeding is the most dangerous -

feeding option for the young infant because it results in greater risks both of HIV and

other infections. It has been noted that the regimens supporting formula feeding to

reduce MTCT of HIV need especially to consider risks of non- compliance in

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different settings. Even in an elaborate urban clinical trial in Kenya, in which

women were assigned either to breastfeed or formula feed, it was reported that there was

poor compliance in the formula group (Nduati et al., 2000). It was difficult to assure

exclusive formula feeding even by mothers who had agreed to participate in the trial,

where infant formula was provided free, punctuated with occasional free counselling. The

question that arises is what then, is the likelihood of compliance elsewhere where

expensive formula needs to be purchased, piped water is lacking and very limited

counselling is given.

A major concern is that formula feeding from the day of birth will result in great increases

in child morbidity, malnutrition and mortality. There are no reliable data from poor families

in Sub-Saharan Africa because almost all babies are breastfed. But, data from other

developing countries (Brazil, Pakistan and Philippines) show that infants who are not

breastfed are likely to have mortality rates from diarrhea, acute respiratory infections, and

other infectious diseases 5-6 times higher than breastfed babies in the first two months of

life (Victoria et al., 1999).

Of more concern still, is what impact not breastfeeding will make on the infected mother's

social standing, health, fertility and vertical transmission to subsequent children. If large

numbers of women do not breastfeed because of fears of HIV transmission, there may be a

spill over effect and gains made over the years through efforts to protect, support and

promote breastfeeding could be reversed. Where significant number of mothers opts not

to breastfeed, it is imperative that studies are undertaken to evaluate the consequences.

Studies on possible stigmatization of women who may opt not to breastfeed need careful If

consideration.

For individual women who opt not to breastfeed, studies need to be done on the fertility

implications, because they are much more likely than those who do to have an early

pregnancy, which may place the next infant at risk of both HIV, and of becoming an

orphan (Stecklov, 2000).

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1.3 JUSTIFICATION FOR THE STUDY

HIV is currently a global pandemic which has a multifaceted effect in the way in which it

has affected humanity. No single approach has been successful hence multidisciplinary

and multi-sectorial efforts are required to deal with it to be able to have effective

interventions. This study is one of such kinds of efforts aimed in the prevention of

vertical transmission of HIV. In the study area Kisii District (Central); a report released

by the medical officer of Health indicated that 14 % of the pregnant mothers at the

District hospital are HIV positive. Hence there is need to limit MTCT by using

appropriate locally prepared and also appropriate commercial infant feeding options.

1.4 OBJECTIVES

1.4.1 Main Objective:

The main objective of this study was to assess the infant feeding practices of children

aged 0-24 months and feeding alternatives available, for infants born to HIV Positive

mothers in Kisii district, Kenya.

1.4.2 Specific objectives

1. To determine the socio-economic and demographic characteristics of the families

of non-tested mothers and HIV positive mothers.

2. To determine the feeding practices of the children aged 0-24 months.

3. To determine the infant feeding alternatives for the infants born to the HIV

positive mothers.

4. To determine the nutritional status of the infants aged 0-24 months.

5. To determine maternal knowledge on Maternal To Child Transmission of HIV

6. To determine the factors determining the HIV Positive mothers choice of the

feeding options.

7. To determine the prevailing morbidity/disease patterns of the children.

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1.5 HYPOTHESES

Based on the objectives this study tested 3 null hypotheses

1. There exists no difference between the feeding practices and alternatives for

children from non-tested mothers and those from HIV Positive mothers.

2. The relationship between infant feeding practices and nutritional status of

children aged 0-24 months is not significant.

3. There is no difference between the morbidity patterns of children born to the

non-tested mothers and those born to the HIV Positive mothers.

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