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Exclusive breastfeeding among HIV exposed

infants from birth to 14 weeks of life in Lira,
Northern Uganda: a prospective cohort study

Agnes Napyo , James K. Tumwine , David Mukunya , Paul Waako , Thorkild

Tylleskär & Grace Ndeezi

To cite this article: Agnes Napyo , James K. Tumwine , David Mukunya , Paul Waako , Thorkild
Tylleskär & Grace Ndeezi (2020) Exclusive breastfeeding among HIV exposed infants from birth to
14 weeks of life in Lira, Northern Uganda: a prospective cohort study, Global Health Action, 13:1,
1833510, DOI: 10.1080/16549716.2020.1833510

To link to this article: https://doi.org/10.1080/16549716.2020.1833510

© 2020 The Author(s). Published by Informa

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Published online: 30 Oct 2020.

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 GLOBAL HEALTH ACTION
2020, VOL. 13, 1833510
https://doi.org/10.1080/16549716.2020.1833510

ORIGINAL ARTICLE

Exclusive breastfeeding among HIV exposed infants from birth to 14 weeks of

life in Lira, Northern Uganda: a prospective cohort study
Agnes Napyo a,b,c, James K. Tumwine c
, David Mukunyab, Paul Waako d
, Thorkild Tylleskär b

and Grace Ndeezi c

a
Department of Public Health, Faculty of Health Sciences, Busitema University, Tororo, Uganda; bCentre for International Health,
University of Bergen, Bergen, Norway; cDepartment of Pediatrics and Child Health, Makerere University, Kampala, Uganda; dDepartment
of Pharmacology, Faculty of Health Sciences, Busitema University, Tororo, Uganda

ABSTRACT ARTICLE HISTORY

Background: Breastfeeding is important for growth, development and survival of HIV Received 2 June 2020
exposed infants. Exclusive breastfeeding reduces the risk of morbidity, mortality and increases Accepted 5 October 2020
HIV free survival of infants. Evidence on risk factors for inappropriate breastfeeding in
RESPONSIBLE EDITOR
Northern Uganda is limited. Stig Wall, Umeå University,
Objective: This study determined the risk factors for non-exclusivity of breastfeeding in the Sweden
first 14 weeks of life.
Methods: This prospective cohort study was conducted among 466 mother-infant pairs KEYWORDS
between August 2018 and February 2020 in Lira district, Northern Uganda. HIV infected Breastfeeding; exclusive
pregnant women were enrolled and followed up at delivery, 6- and 14- weeks postpartum. breastfeeding; HIV exposed
infants; infant feeding;
We used a structured questionnaire to obtain data on socio-demographic, reproductive-
mixed feeding; Women
related, HIV-related characteristics and exclusive breastfeeding. Data were analysed using living with HIV
Stata version 14.0 (StataCorp, College Station, Texas, USA.). We estimated adjusted risk ratios
using modified Poisson regression models.
Results: The proportion of HIV exposed infants that were exclusively breastfed reduced with
increasing age. Risk factors for non-exclusive breastfeeding included infants being born to
HIV infected women who: were in the highest socioeconomic strata (adjusted risk ratio = 1.5,
95%CI: 1.01– 2.1), whose delivery was supervised by a non-health worker (adjusted risk
ratio = 1.6, 95%CI: 1.01– 2.7) and who had not adhered to their ART during pregnancy
(adjusted risk ratio = 1.3, 95%CI: 1.01– 1.7).
Conclusions: HIV infected women: with highest socioeconomic status, whose delivery was
not supervised by a health worker and who did not adhere to ART were less likely to practice
exclusive breastfeeding. We recommend ART adherence and infant feeding counselling to be
emphasised among HIV infected women who are at risk of having a home delivery, those
with poor ART adherence and those of higher socioeconomic status. We also recommend
integration of these services into other settings like homes, community and work places
instead of limiting them to hospital settings.
Abbreviations: HIV: Human Immunodeficiency Virus; ART: Antiretroviral therapy; HEI: HIV
exposed infant; PMTCT: Prevention of mother-to-child transmission of HIV; MTCT: Mother-to-
child transmission of HIV; AFASS: Acceptable, Feasible, Affordable, Sustainable and Safe; LRRH:
Lira regional referral hospital; CI: confidence interval; ARR: Adjusted risk ratio; SD: Standard
deviation; PCA: Principal component analysis

Background
exclusive breastfeeding, increases the risk of morbid­
Breastfeeding is important for growth, development ity and HIV transmission by four fold [6,7] in addi­
and survival in children [1]. In HIV exposed infants tion to reducing HIV free survival among HEI [3].
(HEIs), exclusive breastfeeding is very important Human breast milk contains various immunoglobu­
because they are more prone to diarrhoea, pneumo­ lins, proteins, hormones, growth factors, lipids, car­
nia, malnutrition and even death [2] compared to bohydrates and microbiota that play a very important
unexposed infants. Various studies have demon­ role in the immunomodulation, immune-regulation
strated the positive impact of breastfeeding on child as well as defence against pathogenic bacteria and
survival. A number of studies have shown the benefits viruses for the infant/neonate [8]
of breastfeeding which include: lowered risk of inci­ Guidelines from the World Health Organisation
dence and death from infections like diarrhoea and [1,9] and the Ugandan Ministry of Health [10] recom­
pneumonia [3,4] as well as reduced risk of hospitali­ mend that an HIV infected woman should breast feed
sation [5]. Mixed feeding, when compared with her baby exclusively for the first 6 months and

CONTACT Agnes Napyo [email protected] Department of Public Health, Faculty of Health Sciences, Busitema University, Tororo, Uganda
© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 A. NAPYO ET AL.

continue breastfeeding till the baby is 12–24 months of the week with the exception of weekends. On a daily
age while introducing appropriate complimentary basis, health education is given in group sessions only
foods. In cases where exclusive breastfeeding is not early in the morning to mothers who have come for
possible, exclusive replacement feeding is recom­ antenatal care. Health education topics include infant
mended provided it follows the AFASS criteria mean­ feeding in the context of HIV, adherence to ART, viral
ing it should be Acceptable, Feasible, Affordable, load testing, maternal nutrition and malaria prevention.
Sustainable and Safe. Women living with HIV who
are lactating should take antiretroviral therapy (ART)
Participants and procedures
regardless of their CD4 count and should be adherent
to it [1]. ART helps to prevent HIV transmission This study involved HIV infected women and their
during the phase of exclusive breastfeeding in the infants. At baseline, HIV infected pregnant women who
first 6 months of life and also during mixed feeding were receiving antenatal care at LRRH with a gestational
thereafter [11]. age of 20 weeks or more were consecutively enrolled onto
Barriers to breastfeeding include maternal factors the study and interviewed on socio-demographic and
like breast problems, home delivery [12], lack of safe HIV-related information. A viral load test was done dur­
water, cultural beliefs [13] and lack of counselling or ing any stage of pregnancy. The date of delivery was
support during continuation of infant feeding [6] as estimated using the palpation method, gestational wheel
well as infant factors such as mouth ulcers [11]. and first day of the last normal menstrual period. These
Interventions such as counselling tend to improve women were then followed up with a telephone interview
exclusive breastfeeding rates [3], however, their around the time of delivery. This follow-up visit was
implementation has to be broad based and should estimated at 7 days after the expected date of delivery. If
cover a wide range of settings such as homes, health the woman had not delivered yet, another telephone
facilities, communities and work places so as to yield appointment was scheduled. At this point, women were
a higher impact on breastfeeding. interviewed on circumstances surrounding labour and
Several studies have shown low rates of exclusive delivery such as time of onset of labour, type of delivery,
breastfeeding among HEI [6,11,12,14-16]. Risk factors place of delivery, person who supervised the delivery, if
for these low rates are not well understood and vary the baby received any prelacteal feeds as well as maternal
with in different contexts. The settings for these studies ART adherence. At 6 weeks postpartum, mothers were
have been heterogeneous and tend to vary from country followed up with a face-to-face interview and asked about
to country. Very few studies have been done in Uganda, the infant’s adherence to nevirapine prophylaxis and
particularly Northern Uganda. There is limited informa­ exclusivity of breastfeeding. When the infant was
tion on risk factors for inappropriate breastfeeding by 14 weeks of age, women were also asked about exclusivity
HIV infected women in Lira, Northern Uganda. of breastfeeding through a face-to-face interview. We
Therefore, our study aimed to determine the risk factors used a 7-day recall for and obtained information about
for non-exclusive breastfeeding in the first 14 weeks of life exclusivity of breastfeeding at the different follow up
among HEIs. points from when the infant was born to 14 weeks of
age [19]. All study follow-up visits with the exception of
delivery were done at the PMTCT clinic. The study visits
Methods were conveniently planned to coincide with the mothers’
ART refills and the infants’ immunisation schedule. We
Study design and setting
scheduled the study visits this way so that the mothers did
A prospective cohort study was done in Lira, Northern not have to make extra visits to the clinic just for purposes
Uganda between August 2018 and February 2020 at the of the study and in so doing we saved on extra transpor­
Prevention of Mother-to-Child Transmission (PMTCT) tation costs for the participants.
of HIV clinic in the Lira Regional Referral Hospital
(LRRH). Lira is home to over 400,000 people who are
Sample size estimation
predominantly Langi. It has a diversified economy char­
acterised mainly by farming, brick making, boda boda We calculated a sample size for detecting a difference
(motorcycle) public transportation and pottery [17]. between two independent proportions using STATA ver­
Northern Uganda, particularly Lira, has a very high sion 14.0 (StataCorp; College Station, TX, USA). We
antenatal HIV prevalence of 13.5% [18] which directly assumed 80% power, 95% confidence interval (CI) and
translates into a higher risk of mother-to-child transmis­ a 5% precision. We also assumed that 70% of women [20]
sion (MTCT) of HIV. The PMTCT clinic is an initiative received EBF support and counselling at delivery and that
of the Ugandan Ministry of Health where free HIV care 42.5% of women were not advised or counselled on
and treatment is offered to HIV-infected pregnant and exclusive breastfeeding during pregnancy [21]. We
lactating women. Within this clinic, antenatal care is made these assumptions in order obtain the minimum
offered for HIV infected pregnant women every day of sample size required to detect a difference between
 GLOBAL HEALTH ACTION 3

exclusive breastfeeding and non-exclusive breastfeeding. was summarised into means and standard deviations
The total sample size for this study was 418 HEI. After and if skewed, was summarised into medians with
accounting for 10% non-response the final sample size their corresponding interquartile ranges. Categorical
was 464. We however, included 466 HEI. variables were summarised into frequencies and per­
centages. The incidence of non-exclusivity of breast­
feeding was estimated and its confidence limits
Measurement of variables
calculated using the exact method. Bivariable and
Prelacteal feeding was defined as the baby feeding on multivariable analysis was done using the modified
any liquid other than breast milk immediately after Poisson regression model [23]. All variables that had
birth with the exception of medicines like nevirapine a p value < 0.25 at bivariable level and those with
syrup. The mother was asked, ‘After delivery, did you biological plausibility were entered into the multi­
give the baby anything before giving him/her breast variable model. Variables that were independently
milk?’ This was a ‘yes’ or ‘no’ response. We, however, associated with non-exclusivity of breastfeeding
did not ask which liquids had been given to the baby were determined using the confidence limits.
as pre-lacteal feeds. For both the 6-week and 14-week
visits, the mother was asked, ‘In the past week, have
you given the baby any liquid or solid food other than Results
the breast milk?’ This was also a ‘yes’ or ‘no’ response. A total of 518 HIV infected women were enrolled on
If the mother’s response was ‘yes’, then she was asked, to the study and followed up till delivery at which
‘What food or liquid did you feed to the baby’. The point 505 women had given birth to their infants.
baby was considered to be non-exclusively breastfed These women then were followed up till 6 weeks
if the mother had reported giving prelacteal feeds at postpartum at which point 472 women and their
birth or if the mother had reported giving liquids or infants had the required data on exclusivity of breast­
solid food other than breast milk at the 6-week and feeding. Complete information was obtained for 466
14-week visits with the exception of medicines such mothers by 14 weeks and these were included in our
as nevirapine or supplements like multivitamins. analysis. The reasons for loss to follow up of partici­
We also measured maternal ART adherence during pants at subsequent visits are explained in the study
the follow-up at the time of delivery, we asked the flow chart (Figure 1)
mother, ‘In the past week, did you miss taking any
dose of your medication?’ This was a ‘yes’ or ‘no’
response. If the mother answered ‘yes’ she was con­ Characteristics of HIV infected pregnant women
sidered ‘non-adherent’. We also asked who had at baseline
assisted her during delivery and if she responded that Almost fifty per cent of the women were aged 30 years
it was a nurse, doctor, student nurse, clinical officer, or more with a mean age of 29.5 years (Standard devia­
midwife, all these responses were categorised into one tion (SD) 5.4). Most women were married, unemployed
group and labelled ‘birth supervised by health worker’. and had attained at least 6 years of education (Table 1).
If the response was ‘mother-in-law, traditional birth
attendant, or good samaritan’ all these responses were
categorised together and labelled ‘birth supervised by
non-health worker’
We created a composite index of wealth (socio-
economic status) using principle component analysis
(PCA). We used PCA on house ownership, availability
of electricity in the house, source of drinking water and
fuel used for cooking [22]. Scores were obtained and
categorized into three groups which we refer to as
strata ranging from the poorest to the least poor.

Data analysis and management

Data were collected using pretested, structured ques­
tionnaires, doubly entered into Epi data (www.epi
data.dk, version 4.4.3.1) and exported for analysis to
Stata version 14.0 (StataCorp, College Station, Texas,
USA.). Only mother-infant pairs with data at the
three time points of follow-up were included in the
analysis. Continuous data, if normally distributed, Figure 1. Study flow chart.
4 A. NAPYO ET AL.

Table 1. Antenatal baseline characteristics for HIV infected women in the study in relation to
breastfeeding at 14 weeks postpartum.
Total Exclusive breastfeeding at Not exclusive breastfeeding at
N = 466 14 weeks postpartum N = 266 14 weeks postpartum N = 200
n (%) n (%) n (%) P-value
DURING PREGNANCY
Age 0.5
≤ 20 years 27 (5.8) 13 (4.9) 14 (7)
21– 29 years 202 (43.3) 120 (45.1) 82 (41)
≥ 30 years 237 (50.9) 133 (50) 104 (52)
Education status 0.9
≤ 6 years 229 (49.1) 131 (49.3) 98 (49)
7– 13 years 166 (35.6) 96 (36.1) 70 (35)
≥ 14 years 71 (15.3) 39 (14.6) 32 (16)
Marital status 0.9
Married 435 (93.4) 248 (93.2) 187 (93.5)
Single 31 (6.6) 18 (6.8) 13 (6.5)
Employment status 0.1
Employed 189 (40.6) 100 (37.6) 89 (44.5)
Unemployed 277 (59.4) 166 (62.4) 111 (55.5)
Religion 0.04
Christian 448 (96.1) 260 (97.7) 188 (94)
Moslem 18 (3.9) 6 (2.3) 12 (6)
Ethnic belonging 0.8
Lango 424 (90.9) 243 (91.4) 181 (90.5)
Other 42 (9.1) 23 (8.6) 19 (9.5)
Parity 0.8
1 to 4 329 (70.6) 189 (71.1) 140 (70)
5 to 9 137 (29.4) 77 (28.9) 60 (30)
Gestational age 0.3
20– 27 weeks 243 (52.2) 133 (50) 110 (55)
28– 35 weeks 158 (33.9) 98 (36.8) 60 (30)
≥ 36 weeks 65 (13.9) 35 (13.2) 30 (15)
HIV disclosure 0.8
Disclosed 451 (96.8) 257 (96.6) 194 (97)
Not disclosed 15 (3.2) 9 (3.4) 6 (3)
Socioeconomic strata 0.06
Lowest 164 (35.2) 105 (39.5) 59 (29.5)
Middle 147 (31.5) 82 (30.8) 65 (32.5)
Highest 155 (33.3) 79 (29.7) 76 (38)
Antiretroviral regimen 0.7
Efavirenz-based 420 (90.1) 237 (89.1) 183 (21.5)
Nevirapine-based 38 (8.2) 24 (9.0) 14 (7)
Protease inhibitor- 8 (1.7) 5 (1.9) 3 (1.5)
based
Antiretroviral treatment duration 0.08
≤ 6 months 82 (17.6) 46 (17.3) 36 (18)
7– 30 months 101 (21.7) 50 (18.8) 51 (25.5)
31– 119 months 251 (53.8) 146 (54.9) 105 (52.5)
≥ 120 months 32 (6.9) 24 (9) 8 (40)
Viral load count 0.7
<50 copies/ml 264 (56.8) 150 (56.6) 114 (57)
50– 400 copies/ml 76 (16.3) 43 (16.2) 33 (16.5)
401– 499 copies/ml 12 (2.6) 8 (3) 4 (2.0)
>1000 copies/ml 27 (5.8) 18 (6.8) 9 (4.5)
missing viral load 86 (18.5) 46 (17.4) 40 (20.0)

More than half had been pregnant four times and were women did not adhere to their antiretroviral treat­
20– 27 weeks of gestation at enrolment. Most of the ment in the week preceding delivery. Thirty per cent
women had disclosed their HIV status. A considerable of 6-week old infants missed receiving one or more
proportion of them were taking an efavirenz-based regi­ doses of the nevirapine prophylaxis from their
men and more than half had a viral load less than 50 mother or caregiver.
copies/ml.

Infant feeding practices at delivery, 6 and

Characteristics at birth and 6 weeks postpartum 14 weeks postpartum
Most of the mothers had their labour start during The proportion of infants that were exclusively breastfed
the day time and had a spontaneous vaginal delivery reduced with increasing age of the infant (Figure 2).
(Table 2). Three quarters of them delivered in Incidence of pre-lacteal feeding at birth was 12.7%
a hospital setting with most deliveries being super­ (95%CI: 9.8–16%) (Table 2). The incidence of non-
vised by a health worker. Almost a third of these exclusivity of breastfeeding at 6 weeks and 14 weeks
 GLOBAL HEALTH ACTION 5

Table 2. Characteristics for HIV infected pregnant women and HIV exposed infants at the time
of delivery and 6 weeks postpartum.
Total
N = 466 Exclusive breastfeeding at 14 weeks Mix feeding at 14 weeks
n (%) postpartum N = 266 n (%) postpartum N = 200 n (%) P-value
AT DELIVERY
Time of onset 0.5
of labour
Day time 243 (52.2) 135 (50.8) 108 (54)
Night time 223 (47.8) 131 (49.2) 92 (46)
Type of delivery 0.06
Spontaneous 409 (87.8) 240 (90.2) 169 (84.5)
vaginal
Caesarean 57 (12.2) 26 (9.8) 31 (15.5)
section
Place of 0.3
delivery
Hospital setting 435 (93.4) 251 (94.4) 184 (92)
Non hospital 31 (6.6) 15 (5.6) 16 (8)
setting
Person who supervised 0.05
delivery
Health worker 436 (93.6) 254 (95.5) 182 (91)
Non health 30 (6.4) 12 (4.5) 18 (9)
worker
Infant given 0.000
prelacteal
feeds
Yes 59 (12.7) 0 (0) 59 (29.5)
No 407 (87.3) 266 (100) 141 (70.5)
Maternal adherence to 0.06
antiretroviral treatment
Adhered 325 (69.9) 195 (73.3) 130 (65.3)
Did not adhere 140 (30.1) 71 (26.7) 69 (34.7)
AT 6 WEEKS
POSTPARTUM
Infant adherence to 0.03
nevirapine prophylaxis
Adhered 317 (68.1) 192 (72.2) 125 (62.5)
Did not adhere 149 (30.1) 74 (27.8) 75 (37.5)
Infant exclusive breastfeeds 0.000
at 6 weeks
Exclusively 361 (77.5) 266 (100) 95 (47.5)
breastfed
Mixed feeding 105 (22.5) 0 (0) 105 (52.5)

postpartum were 22.5% (95%CI: 18.8–26.6%) and Risk ratio (ARR) = 1.5, 95%CI: 1.01– 2.1). Women
42.9% (95%CI: 38.3–47.5%) respectively (Table 3). By whose delivery was supervised by a non-health
the time the infants were 14 weeks of age, almost half of worker were 60% more likely to practice mixed feed­
them were not exclusively breastfeeding (Table 3). ing when compared to those whose delivery had been
supervised by a health worker (ARR = 1.6, 95%CI:
1.01– 2.7). Women who had not adhered to their
Risk factors for non-exclusivity of breast feeding ART during pregnancy were also likely to practice
at 14 weeks of age mixed feeding for their infants when compared to
Women who were in the highest socioeconomic their adherent counterparts (ARR = 1.3, 95%CI:
strata were 50% more likely to give their infants 1.01– 1.7) (Table 4).
liquids other than breast milk when compared to
those in the lowest socioeconomic strata (Adjusted Table 3. Feeds given to HIV exposed infants at 6 weeks and
14 weeks postpartum.
Feeds given to infants Feeds given to infants
at 6 weeks at 14 weeks
postpartum (N = 466) postpartum (N = 466)
Type of infant’s feed n % n %
Only breast milk 361 77.5 266 57.1
Honey 55 11.8 44 9.4
Water 23 4.9 36 7.7
Cow’s milk 13 2.8 70 15
Soup 6 1.3 17 3.7
Porridge 5 1.1 21 4.5
Infant formula 3 0.6
Figure 2. Infant feeding practices among HIV exposed infants Juice 11 2.4
by HIV infected lactating women. Solid food 1 0.2
6 A. NAPYO ET AL.

Table 4. Risk factors for non-exclusivity of breastfeeding among HIV exposed infants at
14 weeks postpartum.
Unadjusted RR (95% CI) Adjusted RR (95% CI)
Age
≤ 20 years 1.2 (0.7 – 2.1) 1.1 (0.6 – 2)
21 – 29 years 0.9 (0.7 – 1.2) 0.8 (0.6 – 1.2)
≥ 30 years 1 1
Education status
≤ 6 years 1 1
7 – 13 years 1.0 (0.7 – 1.3) 0.9 (0.7 – 1.3)
≥ 14 years 1.1 (0.7 – 1.6) 1.01 (0.7 – 1.5)
Parity
0 to 4 1 1
5 to 9 1.01 (0.8 – 1.4) 1.0 (0.7 – 1.4)
Socioeconomic status
Lowest 1 1
Middle 1.2 (0.9 – 1.8) 1.3 (0.9 – 1.8)
Top 1.4 (0.9 – 1.9) 1.5 (1.01 – 2.1)
Antiretroviral treatment duration
≤ 6 months 1 1
7 – 30 months 1.2 (0.8 – 1.8) 1.27 (0.8 – 2)
31 – 119 months 0.9 (0.7 – 1.4) 1.0 (0.7 – 1.6)
≥ 120 months 0.6 (0.3 – 1.2) 0.6 (0.3 – 1.3)
Person who supervised delivery
Health worker 1 1
Non health worker 1.4 (0.9 – 2.3) 1.6 (1.01 – 2.7)
Maternal adherence to antiretroviral treatment
Adhered 1 1
Did not adhere 1.2 (0.9 – 1.7) 1.3 (1.01 – 1.7)

Discussion demonstrate that mothers give infants these feeds due

to insufficient breast milk shortly after delivery, because
The proportion of infants that were exclusively
of breast problems or maternal death. One study from
breastfed reduced with increasing age of the infant Northern Uganda, a context similar to our study,
and by 14 weeks of age, almost half of the infants were showed that lactating women discard colostrum shortly
not exclusively breastfeeding. We found a low incidence after delivery because they culturally perceive it to be
of EBF among 14 week-old HEIs probably because their dirty and harmful to the baby [21]. This could possibly
mothers perceive that their breast milk is so insufficient explain why infants in our cohort were given prelacteal
that it will not satisfy the baby and so resort to other feeds. An infant missing out on colostrum misses out on
foods as feeding options for the infant such as cow’s the essential benefits like building up of their immune
milk, water and porridge [21]. Cultural beliefs sur­ system and lining of the infant’s gut to keep pathogens
rounding breastfeeding also influence infant feeding at bay. This is a potential risk for mother-to-child
practices, for example, believing that giving the baby transmission of HIV and development of opportunistic
infections.
honey will protect them against false teeth and colic
In our cohort, women of the highest socioeco­
pain [24]. Giving the baby prelacteal feeds also contrib­
nomic status were more likely not to exclusively
uted to the incidence of non-EBF. Studies from South
breastfeed their infants when compared to those in
Africa [6] and Nigeria [14] report a similar trend in
the lowest socioeconomic strata. One study [26]
exclusive breastfeeding among HIV exposed infants as
demonstrated an association between socioeconomic
they grow older. Some systematic reviews [12,16] and
status and exclusive breast feeding. Most women in
observational studies [11,15] have reported rates similar
the top most socioeconomic strata in our cohort were
to that in our study. However one study from Tanzania
actually employed and probably had to return to
[25] reported a higher prevalence of exclusive breast­
work shortly after delivery because of work-related
feeding than our study. These disparities could be
demands and pressures. Furthermore, because of
explained by the fact that all these studies included
work-related demands these women are more likely
infants of varying ages and were done in different socio-
not to receive adequate antenatal care and infant
cultural contexts.
It was common for mothers to give their infants feeding counselling and this could explain the finding
prelacteal feeds after delivery. Women are most likely in our study. In our study setting, infant feeding
to give their babies prelacteal feeds because of sore counselling has also not been integrated with work-
breasts, perceived insufficient milk flow immediately place environments. Therefore, women with busy
after delivery, social and cultural issues like discarding work schedules are less likely to receive infant feeding
of colostrum [21]. Several studies of HEI infants [11] counselling.
 GLOBAL HEALTH ACTION 7

Women whose delivery was supervised by a non- designing of interventions to promote exclusive breast­
health worker were less likely to exclusively breast­ feeding. We also measured exclusive breastfeeding con­
feed and were likely to have had a home delivery. tinuously from birth and also relied on a 7-day recall
Having a home delivery deprives the mother of inter­ which is likely to avoid exaggeration of the incidence of
facing with the health worker and healthcare there by exclusive breastfeeding in our cohort. To minimize loss
losing out on the benefits of counselling and support to follow-up, we documented the telephone contacts
for exclusive breastfeeding. Some systematic reviews and residential mapping of each participant. Instances
[3,12,16] and observational studies [11,15,21] showed where we could not reach the participant on phone, we
that women who attended antenatal care clinics, made a home visit and this resulted into a high com­
those that delivered in a hospital and those that had pletion rate of 94%.
infant adherence counselling were more likely to Our study had some limitations. This study was
practice exclusive breastfeeding. In a hospital setting, done among HIV infected women attending a public
there is on-going infant feeding training for the health facility therefore our findings may not be gen­
healthcare worker and infant feeding counselling for eralizable to women attending clinics that are private-
the mother. Another study from Northern Uganda for-profit and private-not-for profit. We measured
[24] found that health workers were key decision exclusive breastfeeding at 6 and 14 weeks using
makers when it came to breastfeeding. These findings a 7-day recall of the mother or care giver. This can
from various studies clearly explain why a mother potentially be a source for recall bias.
whose delivery is not supervised by a health worker
is most likely not to exclusively breastfeed her infant.
Conclusion
In light of this, it is important that infant feeding
counselling is introduced in a combination of settings The proportion of exclusively breastfed HEI reduced
and not only at health facilities: such as at the facility, with increase in the infant’s age. HIV infected women
work place, community and home settings. with highest socioeconomic status, those whose deliv­
Our study demonstrated that women who had not ery was not supervised by a health worker and those
adhered to ART during pregnancy were also likely not that who did not adhere to antiretroviral treatment
to exclusively breastfeed their infants. Being non- were likely not to exclusively breastfeed their infants.
adherent to ART is an aftermath of not interfacing We recommend ART adherence and infant feeding
routinely with the healthcare system [27]. Therefore, counselling to be emphasised and integrated in
these women will not achieve the benefits of this rou­ a diverse settings such as homes, work places, com­
tine interaction with the healthcare system like contin­ munities and health facilities.
ued counselling on infant feeding. Women who are
non-adherent to ART will hence most likely not be
adherent to infant feeding guidelines and will not Acknowledgments
exclusively breastfeed their infants. Non-adherence to We are grateful to Lira regional referral hospital, the study
ART will lead to higher viral loads and advanced HIV participants and the research assistants for their contribu­
disease which poses a high risk for transmission of HIV tion to this survey.
from a mother to her baby during breastfeeding. Few
studies have examined antiretroviral adherence during Author contributions
pregnancy and its association with infant feeding prac­
tices. However, pregnancy in itself has been associated Conception and design of work – AN, JKT, GN, PW and TT;
Drafting of work, data acquisition, analysis and interpretation –
with low ART adherence [28]. Drug-related factors
AN, JKT, TT, GN and DM; Funding acquisition JKT, GN, PW
such as side effects and pill burden as well as physio­ and TT; Methodology, AN, JKT and TT; Project administra­
logical changes during pregnancy are barriers to ART tion, JKT, GN, PW and TT; Resources, JKT, GN, PW and TT;
adherence [29]. More qualitative studies should be Supervision, JKT, GN, PW and TT; Writing – original draft,
done to shed more light on the association between AN; Writing – review & editing, final approval of version to be
ART adherence and breastfeeding. approved – AN, JKT, DM, GN, PW and TT. Accountable for
all aspects of the work - AN, JKT, DM, GN, PW

Strengths and limitations

Disclosure statement
This study had some strength. The fact that this is No potential conflict of interest was reported by the authors.
a prospective cohort study has helped to establish caus­
ality between various covariates and non-exclusivity of
breastfeeding. Most studies that have been conducted Ethics and consent
on this subject matter have been cross-sectional in Approval to conduct the study was granted by the Makerere
nature and only show associations. Showing causality University School of Medicine Research and Ethics Committee
for inappropriate infant feeding paves the way to the SOMREC: Ethical approval number: REC REF No. 2017-004;
8 A. NAPYO ET AL.

Date of approval: 10 January 2018; the Uganda National or formula-feeding. Paediatr Int Child Health.
Council for Science and Technology: Ethical approval number: 2016;36:189–197.
HS222ES; Date of approval: 24 September 2018; and the [3] Sankar MJ, Sinha B, Chowdhury R, et al. Optimal
Norwegian Regional Committee for Medical and Health breastfeeding practices and infant and child mortality:
Research Ethics in the West (Ethical approval number: 2017/ a systematic review and meta-analysis. Acta Paediatr.
2489/REK vest; Date of approval: 26 January 2018) 2015;104:3–13.
Administrative clearance was granted by the Lira district health [4] Taha TE, Hoover DR, Chen S, et al. Effects of cessa­
office and LRRH. Service providers/counselors at the PMTCT tion of breastfeeding in HIV-1-exposed, uninfected
clinic were introduced to the study and its procedures and were children in Malawi. Clin Infect Dis. 2011;53:388–395.
requested to identify, mobilize and link willing participants [5] Ásbjörnsdóttir KH, Slyker JA, Maleche-Obimbo E,
with the research team. Participants received verbal and written et al. Breastfeeding is associated with decreased risk
information detailing the purpose and process of the study. All of hospitalization among HIV-exposed, uninfected
participants provided written informed consent confirming Kenyan infants. J Hum Lact. 2016;32:NP61–6.
their voluntary participation in the study. Those that declined [6] Goga AE, Doherty T, Jackson DJ, et al. Infant feeding
participation were not penalized or denied standard healthcare practices at routine PMTCT sites, South Africa: results
Confidentiality and privacy of all data collected were observed of a prospective observational study amongst HIV
during the course of the study through restricted access. exposed and unexposed infants - birth to 9 months.
Int Breastfeed J. 2012;7:4–15.
[7] Rollins NC, Ndirangu J, Bland RM, et al. Exclusive
Funding information breastfeeding, diarrhoeal morbidity and all-cause
mortality in infants of HIV-infected and HIV unin­
The study was funded by the Norwegian Programme for fected mothers: an intervention cohort study in
Capacity Development in Higher Education and Research KwaZulu natal, South Africa. PLoS One. 2013;8:
for Development (NORHED) by the Norwegian Agency e81307.
for Development Cooperation (Norad), Norway through [8] Palmeira P, Carneiro-Sampaio M. Immunology of
the Survival Pluss Project at Makerere University (no. breast milk. Rev Assoc Med Bras. 2016;62:584–593.
UGA-13-0030). [9] World Health Organization. WHO guidelines ON
HIV and infant feeding. 2010.
[10] Ugandan Minitry of Health. Consolidated guidelines
Paper context for prevention and treatment of HIV in Uganda.
Kampala (Uganda); 2016.
Exclusive breastfeeding reduces the risk of morbidity, mor­ [11] Ejara D, Mulualem D, Gebremedhin S. Inappropriate
tality and increases HIV-free survival of infants. Evidence infant feeding practices of HIV-positive mothers
on risk factors for inappropriate breastfeeding in Northern attending PMTCT services in Oromia regional state,
Uganda is limited. We therefore aimed to study risk factors Ethiopia: a cross-sectional study. Int Breastfeed J.
for non-exclusivity of breastfeeding among HIV-exposed 2018;13:37–47.
infants. Findings from this study have identified high-risk [12] Alebel A, Tesma C, Temesgen B, et al. Exclusive breast­
women for inappropriate breastfeeding. These women can feeding practice in Ethiopia and its association with
now be targeted for counselling during the implementation antenatal care and institutional delivery: a systematic
of infant feeding policies in the context of HIV. review and meta-analysis. Int Breastfeed J. 2018;13:
31–43.
[13] Lang’at PC, Ogada I, Steenbeek A, et al. Infant feeding
Data availability practices among HIV-exposed infants less than 6
months of age in Bomet County, Kenya: an in-depth
The datasets used and/or analysed during the current study
qualitative study of feeding choices. Arch Dis Child.
are available from the corresponding author on reasonable
2018;103:470–473.
request.
[14] Onah S, Osuorah DIC, Ebenebe J, et al. Infant feeding
practices and maternal socio-demographic factors that
influence practice of exclusive breastfeeding among
ORCID
mothers in Nnewi South-East Nigeria: a cross-sectional
Agnes Napyo http://orcid.org/0000-0003-4333-3588 and analytical study. Int Breastfeed J. 2014;9:6–15.
James K. Tumwine http://orcid.org/0000-0002-3422- [15] Yenit MK, Genetu H, Tariku A. Infant feeding coun­
7460 seling and knowledge are the key determinants of
Paul Waako http://orcid.org/0000-0001-8964-8775 prelacteal feeding among HIV exposed infants attend­
Thorkild Tylleskär http://orcid.org/0000-0003-4801- ing public hospitals in Ethiopia. Arch Public Heal.
4324 2017;75:23–30.
Grace Ndeezi http://orcid.org/0000-0001-5557-2733 [16] Belay GM, Wubneh CA. Infant feeding practices of HIV
positive mothers and its association with counseling and
HIV disclosure status in Ethiopia: a systematic review
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