South African guidelines for prevention-of-mother-to-child-transmission (PMTCT) of HIV emphasize exclusive breastfeeding (EBF). This study examined the impact of a PMTCT intervention and male involvement on EBF. In a two-phase cluster-randomized trial, rural South African community health centers were randomized to offer HIV-infected pregnant women PMTCT standard of care plus either: a behavioral PMTCT intervention, or a time-equivalent attention-control condition. Phase 1 women had non-participating male partners; Phase 2 women had participating partners. Pregnant women (n = 1398) were assessed on HIV stigma, disclosure of HIV status to partner, male involvement, and family planning knowledge. Feeding practices were assessed 6 weeks postpartum (56% retained). Reduced depressive symptomatology predicted EBF 6 weeks postpartum, adjusting for attrition (AOR = 0.954, p = 0.001). Neither male involvement in antenatal care, phase, HIV stigma, disclosure, nor family planning knowledge predicted EBF. Future studies and perinatal care should address depression, which has important implications for infant health.
Prevention of mother-to-child transmission HIV Prevention Infant feeding Women South Africa
Las recomendaciones para la prevención de la transmisión maternoinfantil (PTMI) del VIH en Sudafrica enfatizan la lactancia materna exclusiva (LME). Este estudio examinó el impacto de una intervención de PTMI y la participación de parejas masculinas en la LME. En un ensayo aleatorizado por grupos de dos fases, centros de salud comunitarios rurales sudafricanos se asignaron al azar para ofrecer a las mujeres embarazadas infectadas por el VIH a un estándar de atención de PTMI más: 1) una intervención conductual de PTMI o 2) una condición de control equivalente al mismo tiempo. Las mujeres de la Fase 1 tenían parejas masculinas que no participaron en el estudio; las parejas de las mujeres en la Fase 2 participaron en el estudio. Las mujeres embarazadas (n = 1398) fueron evaluadas sobre el estigma del VIH, la revelación de su estado del VIH, el nivel participación de su pareja, y el conocimiento de planificación familiar. Las prácticas de alimentación se evaluaron 6 semanas (56%) después del parto. Menos depresión basal predijo LME 6 semanas posparto, ajustando por pérdidas durante el seguimiento (AOR = 0,954, p = 0,001). Ni la participacion masculina (AOR = 0,984, p = 0,614), la fase (AOR = 0,894, p = 0,514) ni otros factores predijeron la presencia de LME. Los estudios futuros y la atención perinatal deben tratar la depresión, ya que esto puede tener implicaciones importantes para la salud infantil.
This is a preview of subscription content, log in to check access.
This study was funded by a Grant from NIH, R01HD078187 and with the support of the University of Miami Miller School of Medicine Center for AIDS Research, funded by an NIH Grant, P30AI073961.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Prior to study onset, ethical approval was obtained from the Mpumalanga Department of Health, the Human Sciences Research Council (HSRC) and the University of Miami (UM) Institutional Review Board. Ethical approval for the study was procured from the Human Sciences Research Council (HSRC) Research Ethics Committee (REC) (Number: REC4/21/08/13), the Department of Health and Welfare, Mpumalanga Provincial Government, and the University of Miami Miller School of Medicine Institutional Review Board (IRB ID: 20130238). The study was registered as a clinical trial on clinicaltrials.gov, Number NCT02085356.
Human and Animal Participants
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
Statistics South Africa. Mid-year population estimates. 2017.Google Scholar
South African Medical Research Council. Early mother-to-child transmission of HIV stats plunge. 2017.Google Scholar
Goga AE, Dinh TH, Jackson DJ, Lombard C, Delaney KP, Puren A, et al. First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa. J Epidemiol Community Health. 2015;69(3):240–8.CrossRefPubMedGoogle Scholar
Peltzer K, Mosala T, Shisana O, Nqueko A, Mngqundaniso N. Barriers to prevention of HIV transmission from mother to child (PMTCT) in a resource poor setting in the Eastern Cape, South Africa. Afr J Reprod Health. 2007;11(1):57–66.CrossRefPubMedGoogle Scholar
Peltzer K, Mlambo G, Phaweni K. Factors determining prenatal HIV testing for prevention of mother to child transmission of HIV in Mpumalanga, South Africa. AIDS Behav. 2010;14(5):1115–23.CrossRefPubMedGoogle Scholar
Rodriguez VJ, LaCabe LP, Privette CK, Douglass KM, Peltzer K, Matseke G, et al. The Achilles’ heel of prevention to mother-to-child transmission of HIV: protocol implementation, uptake, and sustainability. SAHARA J. 2017;14(1):38–52.CrossRefPubMedPubMedCentralGoogle Scholar
Ukpe IS, Blitz J, Hugo J, Theledi M. The infant-feeding practices of mothers enrolled in the prevention of mother-to-child transmission of HIV programme at a primary health care clinic in the Mpumalanga province, South Africa. S Afr Fam Pract. 2009;51(4):337–9.Google Scholar
WHO. Guidelines Approved by the Guidelines Review Committee. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization Copyright (c) World Health Organization. 2016.Google Scholar
National Department of Health. - Republic of South Africa. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents, and adults. 2015.Google Scholar
World Health Organization. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva; 2016.Google Scholar
Tuthill E, Pellowski JA, Young SL, Butler LM. Perinatal depression among HIV-infected women in KwaZulu-Natal South Africa: prenatal depression predicts lower rates of exclusive breastfeeding. AIDS Behav. 2017;21(6):1691–8.CrossRefPubMedPubMedCentralGoogle Scholar
Cyimana A, Andrews B, Ahmed Y, Vwalika B. HIV/AIDS and postnatal depression at the University Teaching Hospital, Lusaka, Zambia. Med J Zambia. 2010;37(2):78–83.PubMedPubMedCentralGoogle Scholar
Madiba S, Letsoalo R. HIV disclosure to partners and family among women enrolled in prevention of mother to child transmission of HIV program: implications for infant feeding in poor resourced communities in South Africa. Glob J Health Sci. 2013;5(4):1–13.CrossRefPubMedPubMedCentralGoogle Scholar
Maman S, Cathcart R, Burkhardt G, Omba S, Thompson D, Behets F. The infant feeding choices and experiences of women living with HIV in Kinshasa, Democratic Republic of Congo. AIDS Care. 2012;24(2):259–65.CrossRefPubMedGoogle Scholar
Maonga AR, Mahande MJ, Damian DJ, Msuya SE. Factors affecting exclusive breastfeeding among women in Muheza District Tanga Northeastern Tanzania: a mixed method community based study. Matern Child Health J. 2016;20(1):77–87.CrossRefPubMedGoogle Scholar
Matovu A, Kirunda B, Rugamba-Kabagambe G, Tumwesigye NM, Nuwaha F. Factors influencing adherence to exclusive breast feeding among HIV positive mothers in Kabarole district, Uganda. East Afr Med J. 2008;85(4):162–70.CrossRefPubMedGoogle Scholar
Hampanda K. Intimate partner violence against HIV-positive women is associated with sub-optimal infant feeding practices in Lusaka, Zambia. Matern Child Health J. 2016;20(12):2599–606.CrossRefPubMedPubMedCentralGoogle Scholar
Surkan PJ, Kennedy CE, Hurley KM, Black MM. Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis. Bull World Health Organ. 2011;89(8):608–15.CrossRefPubMedGoogle Scholar
Onono MA, Cohen CR, Jerop M, Bukusi EA, Turan JM. HIV serostatus and disclosure: implications for infant feeding practice in rural south Nyanza, Kenya. BMC Public Health. 2014;14:390.CrossRefPubMedPubMedCentralGoogle Scholar
Iwelunmor J, Ezeanolue EE, Airhihenbuwa CO, Obiefune MC, Ezeanolue CO, Ogedegbe GG. Socio-cultural factors influencing the prevention of mother-to-child transmission of HIV in Nigeria: a synthesis of the literature. BMC Public Health. 2014;14:771.CrossRefPubMedPubMedCentralGoogle Scholar
Lawani LO, Onyebuchi AK, Iyoke CA, Onoh RC, Nkwo PO. The challenges of adherence to infant feeding choices in prevention of mother-to-child transmission of HIV infections in South East Nigeria. Patient Preference Adherence. 2014;8:377–81.CrossRefPubMedGoogle Scholar
Lazarus R, Struthers H, Violari A. Promoting safe infant feeding practices - the importance of structural, social and contextual factors in Southern Africa. J Int AIDS Soc. 2013;16:18037.CrossRefPubMedGoogle Scholar
Maman S, Moodley D, Groves AK. Defining male support during and after pregnancy from the perspective of HIV-positive and HIV-negative women in Durban, South Africa. J Midwifery Womens Health. 2011;56(4):325–31.CrossRefPubMedPubMedCentralGoogle Scholar
Bergman M, Nygren-Brunell O, Vilakati D, Malqvist M. Prolonged exclusive breastfeeding through peer support: a cohort study from a community outreach project in Swaziland. J Community Health. 2016;41(5):932–8.CrossRefPubMedGoogle Scholar
Andreson J, Dana N, Hepfer B, King’ori E, Oketch J, Wojnar D, et al. Infant feeding buddies: a strategy to support safe infant feeding for HIV-positive mothers. J Hum Lact. 2013;29(1):90–3.CrossRefPubMedGoogle Scholar
Nor B, Ahlberg BM, Doherty T, Zembe Y, Jackson D, Ekstrom EC. Mother’s perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa. Matern Child Nutr. 2012;8(4):448–58.CrossRefPubMedGoogle Scholar
Laar AS, Govender V. Individual and community perspectives, attitudes, and practices to mother-to-child-transmission and infant feeding among HIV-positive mothers in Sub-Saharan Africa: a systematic literature review. Int J MCH AIDS. 2013;2(1):153–62.CrossRefPubMedPubMedCentralGoogle Scholar
Odeny BM, Pfeiffer J, Farquhar C, Igonya EK, Gatuguta A, Kagwaini F, et al. The stigma of exclusive breastfeeding among both HIV-positive and HIV-negative women in Nairobi, Kenya. Breastfeed Med. 2016;11:252–8.CrossRefPubMedPubMedCentralGoogle Scholar
Koye DN, Zeleke BM. Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at a PMTCT clinic in northwest Ethiopia. BMC Public Health. 2013;13:398.CrossRefPubMedPubMedCentralGoogle Scholar
Berhan Z, Abebe F, Gedefaw M, Tesfa M, Assefa M, Tafere Y. Risk of HIV and associated factors among infants born to HIV positive women in Amhara region, Ethiopia: a facility based retrospective study. BMC Res Notes. 2014;7:876.CrossRefPubMedPubMedCentralGoogle Scholar
Wudineh F, Damtew B. Mother-to-child transmission of HIV infection and its determinants among exposed infants on care and follow-up in Dire Dawa City, Eastern Ethiopia. AIDS Res Treat. 2016;2016:3262746.PubMedPubMedCentralGoogle Scholar
Ngwende S, Gombe NT, Midzi S, Tshimanga M, Shambira G, Chadambuka A. Factors associated with HIV infection among children born to mothers on the prevention of mother to child transmission programme at Chitungwiza Hospital, Zimbabwe, 2008. BMC Public Health. 2013;13:1181.CrossRefPubMedPubMedCentralGoogle Scholar
Ladzani R, Peltzer K, Mlambo MG, Phaweni K. Infant-feeding practices and associated factors of HIV-positive mothers at Gert Sibande, South Africa. Acta Paediatr. 2011;100(4):538–42.CrossRefPubMedGoogle Scholar
Straus MA. Measuring intrafamily conflict and violence: the conflict tactics (CT) scales. J Marriage Family. 1979;41(1):75–88.CrossRefGoogle Scholar
World Health Organization. Breastfeeding and replacement feeding practices in the context of mother-to-child transmission of HIV: an assessment tool for research. Geneva; 2001.Google Scholar
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6.CrossRefPubMedGoogle Scholar
Lawrie TA, Hofmeyr GJ, de Jager M, Berk M. Validation of the Edinburgh Postnatal Depression Scale on a cohort of South African women. S Afr Med J. 1998;88(10):1340–4.PubMedGoogle Scholar
Visser MJ, Neufeld S, de Villiers A, Makin JD, Forsyth BW. To tell or not to tell: South African women’s disclosure of HIV status during pregnancy. AIDS Care. 2008;20(9):1138–45.CrossRefPubMedPubMedCentralGoogle Scholar
Byamugisha R, Tumwine JK, Semiyaga N, Tylleskar T. Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey. Reprod Health. 2010;7:12.CrossRefPubMedPubMedCentralGoogle Scholar
Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):87–93.CrossRefPubMedGoogle Scholar
Kalichman SC, Simbayi LC, Jooste S, Toefy Y, Cain D, Cherry C, et al. Development of a brief scale to measure AIDS-related stigma in South Africa. AIDS Behav. 2005;9(2):135–43.CrossRefPubMedGoogle Scholar
Idonije B, Oluba O, Otamere H. A study on knowledge, attitude and practice of contraception among secondary school students in Ekpoma, Nigeria. JPCS. 2011;2:22–7.Google Scholar
Allen J, Le H. An additional measure of overall effect size for logistic regression models. J Educ Behav Stat. 2008;33(4):416–41.CrossRefGoogle Scholar
Asparouhov T, Muthén B. Multiple imputation with Mplus. MPlus Web Notes. 2010.Google Scholar
Muthén L, Muthén B. Mplus (Version 7.4). Los Angeles, CA. 2014.Google Scholar
Avan B, Richter LM, Ramchandani PG, Norris SA, Stein A. Maternal postnatal depression and children’s growth and behaviour during the early years of life: exploring the interaction between physical and mental health. Arch Dis Child. 2010;95(9):690–5.CrossRefPubMedGoogle Scholar
Kaaya S, Garcia ME, Li N, Lienert J, Twayigize W, Spiegelman D, et al. Association of maternal depression and infant nutritional status among women living with HIV in Tanzania. Matern Child Nutr. 2016;12(3):603–13.CrossRefPubMedGoogle Scholar
Lusskin SI, Pundiak TM, Habib SM. Perinatal depression: hiding in plain sight. Can J Psychiatry. 2007;52(8):479–88.CrossRefPubMedGoogle Scholar
Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90.CrossRefPubMedGoogle Scholar
Henrick BM, Yao XD, Nasser L, Roozrogousheh A, Rosenthal KL. Breastfeeding behaviors and the innate immune system of human milk: working together to protect infants against inflammation, HIV-1, and other infections. Front Immunol. 2017;8:1631.CrossRefPubMedPubMedCentralGoogle Scholar
Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis. Curr HIV/AIDS Rep. 2014;11(3):291–307.CrossRefPubMedPubMedCentralGoogle Scholar