Kiersten Israel-Ballard

Current knowledge and future research on infant feeding in the context of HIV: Basic, clinical, behavioral, and programmatic perspectives

In 2008, between 129,000 and 194,000 of the 430,000 pediatric HIV infections worldwide were attributable to breastfeeding. Yet in many settings, the health, economic, and social consequences of not breastfeeding would have dire consequences for many more children. In the first part of this review we provide an overview of current knowledge about infant feeding in the context of HIV. Namely, we describe the benefits and risks of breastmilk, the evolution of recommended infant feeding modalities in high-income and low-income countries in the last two decades, and contextualize the recently revised guidelines for infant feeding in the context of HIV current knowledge. In the second section, we suggest areas for future research on the postnatal prevention of mother-to-child transmission of HIV (PMTCT) in developing and industrialized countries. We suggest two shifts in perspective. The first is to evaluate PMTCT interventions more holistically, to include the psychosocial and economic consequences as well as the biomedical ones. The second shift in perspective should be one that contextualizes postnatal PMTCT efforts in the cascade of maternal health services. We conclude by discussing basic, clinical, behavioral, and programmatic research questions pertaining to a number of PMTCT efforts, including extended postnatal ARV prophylaxis, exclusive breastfeeding promotion, counseling, breast milk pasteurization, breast milk banking, novel techniques for making breast milk safer, and optimal breastfeeding practices. We believe the research efforts outlined here will maximize the number of healthy, thriving, HIV-free children around the world.

Infant feeding practices among HIV-positive women in Dar es Salaam, Tanzania, indicate a need for more intensive infant feeding counselling

OBJECTIVE To assess feeding practices of infants born to HIV-positive women in Dar es Salaam, Tanzania. These data then served as a proxy to evaluate the adequacy of current infant feeding counselling. DESIGN A cross-sectional survey of infant feeding behaviours. SETTING Four clinics in greater Dar es Salaam in early 2008. SUBJECTS A total of 196 HIV-positive mothers of children aged 6-10 months recruited from HIV clinics. RESULTS Initiation of breast-feeding was reported by 95·4 % of survey participants. In the entire sample, 80·1 %, 34·2 % and 13·3 % of women reported exclusive breast-feeding (EBF) up to 2, 4 and 6 months, respectively. Median duration of EBF among women who ever breast-fed was 3 (interquartile range (IQR): 2·1, 4·0) months. Most non-breast-milk foods fed to infants were low in nutrient density. Complete cessation of breast-feeding occurred within 14 d of the introduction of non-breast-milk foods among 138 of the 187 children (73·8 %) who had ever received any breast milk. Of the 187 infants in the study who ever received breast milk, 19·4 % received neither human milk nor any replacement milks for 1 week or more (median duration of no milk was 14 (IQR: 7, 152) d). CONCLUSIONS Infant feeding practices among these HIV-positive mothers resulted in infants receiving far less breast milk and more mixed complementary feeds than recommended, thus placing them at greater risk of both malnutrition and HIV infection. An environment that better enables mothers to follow national guidelines is urgently needed. More intensive infant feeding counselling programmes would very likely increase rates of optimal infant feeding.

Projecting health: community-led video education for maternal health

We present a qualitative study of Projecting Health, a public health project we deployed in rural Uttar Pradesh (India) to address persistently high maternal and infant mortality rates. This project is based on our model of Community-led Video Education (CVE), which leverages community resources for the generation, dissemination, and assimilation of visual media. We use the lens of information flows to examine how our instantiation of CVE enables the translation of globally approved health care norms to local household practices. We also demonstrate how CVE allows for integration with current community practices, existing state-supported health care infrastructure, social and patriarchal structures, and power dynamics within our target populations to drive community participation.

Mobile video for patient education: the midwives' perspective

The study presented in this paper demonstrates how nurse midwives used video on mobile phones to support patient education in a maternal and child health project in rural India. The main goals of the study were to understand how the technology impacted the workflow of the nurses and to assess the acceptability of the use of video during patient encounters. The study was based on interviews of the midwives, observation of patient visits, and an analysis of logs from the mobile devices. The overall results were positive; the midwives accepted use of mobile video as part of the workflow for postnatal care examinations. Using video changed the process of patient education, in some cases making it a more focused activity. The use of video also led to midwife multitasking, which was enabled by the technology. The study suggests that the midwives felt that their authority was enhanced by the use of video.

Establishing an integrated human milk banking approach to strengthen newborn care

The provision of donor human milk can significantly reduce morbidity and mortality among vulnerable infants and is recommended by the World Health Organization as the next best option when a mother’s own milk is unavailable. Regulated human milk banks can meet this need, however, scale-up has been hindered by the absence of an appropriate model for resource-limited settings and a lack of policy support for human milk banks and for the operational procedures supporting them. To reduce infant mortality, human milk banking systems need to be scaled up and integrated with other components of newborn care. This article draws on current guidelines and best practices from human milk banks to offer a compilation of universal requirements that provide a foundation for an integrated model of newborn care that is appropriate for low- and high-resource settings alike.

Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 months of age in urban Tanzania.

Objective:Heat-treating expressed breastmilk is recommended as an interim feeding strategy for HIV-exposed infants in resource-poor countries, but data on its feasibility are minimal. Flash-heating (FH) is a simple in-home technique for heating breastmilk that inactivates HIV although preserving its nutritional and anti-infective properties. Our primary objective was to determine, among HIV-infected mothers, the feasibility and protocol adherence of FH expressed breastmilk after 6 months of exclusive breastfeeding. Design:Prospective longitudinal. Participants:One hundred one HIV-infected breastfeeding mothers Setting:Dar es Salaam, Tanzania Intervention:Peer counselors provided in-home counseling and support on infant feeding from 2 to 9 months postpartum. Mothers were encouraged to exclusively breastfeed for 6 months followed by FH expressed breastmilk if her infant was HIV negative. Clinic-based staff measured infant growth and morbidity monthly, and mothers kept daily logs of infant morbidity. FH behavior was tracked until 9 months postpartum using daily logs, in-home observations, and clinic-based and home-based surveys. Bacterial cultures of unheated and heated milk samples were performed. Results:Thirty-seven of 72 eligible mothers (51.4%) chose to flash-heat. Median (range) frequency of milk expression was 3 (1–6) times daily and duration of method use on-study was 9.7 (0.1–15.6) weeks. Mean (SD) daily milk volume was 322 (201) mL (range 25–1120). No heated and 32 (30.5%) unheated samples contained bacterial pathogens. Conclusions:FH is a simple technology that many HIV-positive women can successfully use after exclusive breastfeeding to continue to provide the benefits of breastmilk while avoiding maternal-to-child transmission associated with nonexclusive breastfeeding. Based on these feasibility data, a clinical trial of the effects of FH breastmilk on infant health outcomes is warranted.

Infant feeding buddies: a strategy to support safe infant feeding for HIV-positive mothers.

Background: Prior to 2010, the World Health Organization recommended that HIV-positive mothers exclusively breastfeed for the first 6 months of life unless replacement feeding was acceptable, feasible, affordable, sustainable, and safe. Community pressure to practice mixed feeding, lack of knowledge on safe feeding, and shame regarding HIV status discourage mothers from breastfeeding exclusively and contribute to South Africa’s low exclusive breastfeeding prevalence of 7% for infants under 6 months. Objective: This pilot study explored the feasibility of implementing a feeding buddy system to provide a mother with support to achieve her infant feeding goal. Methods: A convenience sample of 14 HIV-positive mothers and their buddies was recruited from the Butterworth Gateway Clinic in South Africa. HIV-positive mothers selected a buddy who accompanied them on clinic visits and counseling sessions on safe infant feeding. The research team conducted in-depth interviews to gather qualitative information on participants’ experiences at 3 points in time. Results: Buddy selection was influenced by the mother’s relationship to the buddy, trust, and previous disclosure of HIV status. The 3 most cited forms of support were the buddy’s accountability, teaching, and help in feeding the infant correctly. Conclusions: Buddies were successfully integrated into routine Prevention of Maternal-to-Child Transmission visits. Study participants confirmed that having a buddy was a helpful support for HIV-positive mothers.

Informed choice in infant feeding decisions can be supported for HIV-infected women even in industrialized countries.

Following the first report of HIV transmission through breast milk in 1985 [1], the US Centers for Disease Control issued a recommendation against breastfeeding by HIV-infected mothers [2]. In the last 25 years, prevention strategies in industrialized countries have evolved to reduce the risk of mot

Acceptability of a Nipple Shield Delivery System Administering Antiviral Agents to Prevent Mother-to-Child Transmission of HIV through Breastfeeding

Background: Breastfeeding is a route of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV). The World Health Organization recommends antiretroviral (ARV) prophylaxis as the best method to prevent mother-to-child transmission of HIV (PMTCT) during breastfeeding. The nipple shield delivery system (NSDS) is being developed as an accessible method to deliver ARVs to infants and PMTCT during breastfeeding. The NSDS can potentially circumvent hygiene and storage issues in delivering drugs to infants in low-resource settings. Objectives: The primary objective was to determine acceptability of the NSDS for PMTCT in Kenya. Secondary objectives included assessing mothers’ understanding of MTCT and identifying cultural and implementation issues that might affect NSDS acceptability. Methods: Eleven focus group discussions were conducted, each group consisting of 7 to 12 participants. Seven focus group discussions consisted of HIV-positive mothers, 2 included grandmothers/mothers-in-law, and 2 included fathers/husbands. Ten in-depth interviews were also conducted with individual maternal/child health care providers. Topics included infant feeding and HIV stigma, as well as safety, effectiveness, and feasibility of the NSDS. Device prototypes were used in discussions. Results: Participants felt that the NSDS could be trusted if validated scientifically and promoted by health care professionals. HIV-related stigma, access, efficacy, and hygiene were identified as important considerations for acceptance. Conclusion: The NSDS is a potentially acceptable method of PMTCT during breastfeeding. Further studies are needed to confirm acceptability, safety, and efficacy. For NSDS adoption to PMTCT, strategies will need to be developed to minimize HIV-related stigma and to ensure that continuous hygiene of the device is maintained.

Demonstrating the efficacy of the FoneAstra pasteurization monitor for human milk pasteurization in resource-limited settings.

UNLABELLED Human milk provides crucial nutrition and immunologic protection for infants. When a mothers own milk is unavailable, donated human milk, pasteurized to destroy bacteria and viruses, is a lifesaving replacement. Flash-heat pasteurization is a simple, low-cost, and commonly used method to make milk safe, but currently there is no system to monitor milk temperature, which challenges quality control. FoneAstra, a smartphone-based mobile pasteurization monitor, removes this barrier by guiding users through pasteurization and documenting consistent and safe practice. This study evaluated FoneAstras efficacy as a quality control system, particularly in resource-limited settings, by comparing bacterial growth in donor milk flash-heated with and without the device at a neonatal intensive care unit in Durban, South Africa. MATERIALS AND METHODS For 100 samples of donor milk, one aliquot each of prepasteurized milk, milk flash-heated without FoneAstra, and milk pasteurized with FoneAstra was cultured on routine agar for bacterial growth. Isolated bacteria were identified and enumerated. RESULTS In total, 300 samples (three from each donor sample) were analyzed. Bacterial growth was found in 86 of the 100 samples before any pasteurization and one of the 100 postpasteurized samples without FoneAstra. None of the samples pasteurized using FoneAstra showed bacterial growth. CONCLUSIONS Both pasteurization methods were safe and effective. FoneAstra, however, provides the additional benefits of user-guided temperature monitoring and data tracking. By improving quality assurance and standardizing the pasteurization process, FoneAstra can support wide-scale implementation of human milk banks in resource-limited settings, increasing access and saving lives.