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Field ArticleKACODI, Kenya, 2003Infant Feeding Alternatives forHIV Positive Mothers in KenyaBy Tom Oguta, Abiud Omwega and Jaswant SehmiA mother engaged in pottery as an economicactivity in Obera VillageHOMA BAYDISTRICTTom Oguta is currently a PhD student ofNutrition at the University of Nairobi. He hasworked as a Research Officer at KIRDI (KenyaIndustrial Research & Development Institute) inseveral research programmes, includingHIV/AIDS & Infant Feeding studies, food securityevaluations and micronutrient-fortified foodefficacy studies in Kenyan children.Dr. Abiud Omwega is a Senior Lecturer in theApplied Nutrition Programme, Department ofFood Technology and Nutrition, University ofNairobi. He has worked with many NGOs andCBOs to develop community based nutritionprogrammes, including those for the care andsupport of people affected with HIV/AIDS.Dr. Jaswant Sehmi is a Lecturer in theDepartment of Food Technology & Nutrition atthe University of Nairobi. She has wide experiencein food analysis, nutrition surveys, epidemiologicalstudies (including HIV/AIDS) andmonitoring of clinical & malnutrition cases.Based on Reliefweb Map centreKENYAThe co-authors would like to express sincere thanks to UNICEF-Eastern & Southern Africa Regional Office (ESARO) for financingthis study, and to Homa Bay District Hospital Management for thelogistical support they provided during the study.The HIV pandemic sweeping southern Africa and other parts of sub-Saharan Africa is increasingly being perceived and described as a chronicemergency. Innovative and relatively new types of nutrition/food security/HIVprogramming are emerging to address the growing HIV crisis.These include PMTCT, MTCT plus, OVC and NCP programming andhome based care. Many of these programmes are being rolled out underProtracted Relief and Recovery Operation (PRRO) arrangements inregions recovering from recent emergencies, i.e. southern Africa. However,as these programmes are relatively new, there is enormous headway to bemade in defining optimal design and practice.The article below describes astudy undertaken to help inform PMTCT programming practice. It highlightsthe dilemma for HIV positive mothers between using home preparedformula (in this case using cow’s milk) which is extremely poor in micronutrientcontent, and infant formula which is nutritionally better but maybe impractical for many contexts in terms of cost, supply and sustainability(ed).Mother-to-child Transmission (MTCT)rates for HIV are estimated at 25-45% in the primarily breastfedpopulation of Sub-Saharan Africa.In Kenya, an estimated 300,000 newborn babiesare at risk if HIV infection every year, withbetween 75,000 and 135,000 infants actuallyinfected. Over 75% of these do not even celebratetheir fifth birthday. If a mother is infected withHIV, it may thus be preferable to replace breastmilkto reduce the risk of HIV transmission toher infant.For infected mothers living in poor conditionsin developing countries, however, it is importantto consider very carefully the risks related to notbreastfeeding and whether there are alternativefeeding methods. In a rural community, whereaccess to clean water and sanitation is inadequate,where families are too poor to afford enoughfuel to prepare food and to sterilise feedingbottles or to buy sufficient infant formula, deathsfrom diarrhoea and respiratory infections couldfar outnumber those from HIV. The problem isfurther aggravated by cultural or social stigmasthat a community may attach to substitutefeeding and to HIV/AIDS in general. Hitherto,there has not been good data available on therelative risks and benefits of different feedingoptions.As part of a concerted effort within Kenya toprevent MTCT of HIV, a collaborative programmewas initiated in three pilot sites where HIVpositive pregnant women were identified andprovided with free anti-retroviral (ARV) drugand infant formula feed regimens. In order toinform this study, the Applied NutritionProgramme at the University of Nairobi wasasked to conduct a study on alternative feedingpractices in one of the project sites (Homa-BayDistrict) 1,2 .The purpose of this study was to assess thefeeding alternatives for infants born to HIVpositivemothers in the context of vertical transmissionof HIV. The specific objectives of thestudy were:• To explore the prevailing alternative feedingpractices in the community and among theHIV- positive mothers.• To explore the factors affecting mother’sdecision and choice of the various feedingoptions.ARVMTCTNCPOVCPMTCTList of abbreviationsAnti-retroviralMother To Child TransmissionNeighbourhood Care ProgrammesOrphans and Vulnerable ChildrenPrevention of Mother to ChildTransmission1Other parts of the study, not including this article, havebeen accepted for publication in the East African MedicalJournal.2Case Study: Infant Feeding Alternatives for HIV positivemothers in Homa Bay District, South Western Kenya.OGUTA Tom J, OMWEGA Abiud M and Sehmi Jaswant K.26
Profile of study groupThe study population consisted of an observationgroup of HIV positive mothers with childrenaged 0-2 years old in Homa-Bay DistrictHospital, and selected respondents from therural population as case studies, key informantsor focus discussion members. Homa-Bay district(with a population of about 350,000) is inhabitedby the Luo ethnic group and is one of the Kenyandistricts with the highest HIV prevalence (24%).A number of socio-economic factors are thoughtto have contributed to the rapid spread ofHIV/AIDS in this community:• Widow inheritance/remarriageAs the majority of the population do not knowtheir sero-status, the cultural practice of remarriageis likely to favour the spread ofHIV/AIDS.• Fishing industry and migrant fishermenMost people involved in the fishing industry inthe district either stay away from their familiesor are single. Others are widowed having losttheir spouses, probably from AIDS, and gone toseek a source of livelihood at the beaches.• Concept/ belief of ChiraBelief in the concept of chira (death or cursearising from failure to abide by traditions) isrampant and even when death occurs as a resultof AIDS, some people still believe that it was as aresult of chira and therefore no special precautionsare taken against possible transmission ofHIV by prospective sexual partners.• PolygamyThe cultural ideal that a man should have manywives is still widely held by many people in thedistrict and more than 50% of married womenField Articlelive in polygamous unions. Having multiplepartners is one of the recognised risk factors forspread of HIV/AIDS.Information gatheringUsing qualitative research tools, four focusgroup discussion (FGD) sessions were conducted,with eight members in each session (16women and 16 men). The women participantswere aged 18-45 years while their male counterpartswere between 20-54 years old. Five experiencedand/or elderly women, aged 45-75years, participated in key-informant interviewson areas related to traditional and contemporaryalternative feeding practices.Eleven HIV-positive mothers were observedand monitored. An additional four women participatedas case studies who, for various reasons,Table 1Alternatives to maternal breastfeeding considered for feeding infants of HIV positive mothers in Homa-Bay DistrictOption Characteristics Indications/ Contra-indicationsCommercial infantformula/ formula milkHome prepared formulaUnmodified cow’s milkEarly cessation ofbreastfeeding and heattreatmentof expressedbreastmilkPasteurised breastmilkWet nursingBreastmilk banksBased on modified cow’s milk or soy protein.Closest in nutrition composition to breastmilkMade with fresh animal milks, dried milk powder or withevaporated milk.Additional micronutrients, like iron, zinc and vitaminsA, C and folic acid are requiredUnmodified cow’s milk is not recommended for infantsunder six months of ageEarly cessation of breastfeeding and heat-treatment ofexpressed breastmilk reduces the risk of MTCT. Earlycessation reduces the length of time for which an infantis exposed to HIV through breast milk.The optimum time for early cessation of breastfeeding isnot known.Pasteurisation of expressed breastmilk involves heatingto about 65oC for 30 minutes, or boiling and thencooling in a refrigerator or cold water.Heat-treated expressed breast milk is still nutritionallysuperior to other milks, though heat-treatment reducesthe level of the antibodies.Wet-nursing is practicable in some traditional settingswhere a relative breastfeeds the infantMay be an option in some settings, for example as asource of breastmilk for a short time especially for thesick and LBW newborn.The family has reliable access to sufficient formula, cleanwater, fuel, utensils, skills and time to prepare itaccurately and hygienically.Care is needed to avoid over-concentration orover-dilution.Unmodified cow’s milk could be considered as anexceptional option by the HIV positive mother when thesupply of cow’s milk is reliable and affordable for the sixmonths; the family lacks resources, time and fuel tomodify cow’s milk to make home prepared formula; thefamily will be able to offer extra water and monitordehydration; and commercial infant formula is notavailable/affordable for the family.It is advisable for an HIV positive mother to stop breastfeedingas soon as she is able to prepare and give herinfant adequate and hygienic alternative feed (WHO,1998)*. It could be a good option for those who find itdifficult for social and cultural reasons to avoid breastfeedingcompletely.May be a good option especially for sick and low birthweight (LBW) babies in a hospital settingUNICEF/UNAIDS/WHO recommends that wet-nursing beconsidered only when a potential nurse is informed ofher risk of acquiring HIV from the infant in question;she has been offered HIV counselling & testing; shevoluntarily takes a test and is found to be HIV negative;and when wet-nursing takes place in a family contextwith no payment involved.7It should be certain that donors are screened for HIVand that donated milk is correctly pasteurised.* HIV and Infant Feeding. UNAIDS/WHO/UNICEF. Guidelines for Decision Makers. WHO, Geneva, 1998. Recently updated 2003. Full text available at http://www.who.intTable 2Comparisons and Contrast between AIDS and Chira1.2.3.4.5.6.7.AIDSIs recent, never heard of or hardly known 20 years ago.Mostly caused by sexual contact with an infected person irrespectiveof the social approval of the relationship between the persons.Has no known cure. It is a final clearance to death (fatal).Treatment cannot prevent the resulting death.Has multiple rather than single opportunistic infections (associatedillnesses) including diarrhoea, TB, skin infections, loss of hair, etc.Can be diagnosed in the hospital.Is prevalent among the sexually active youth and reproductive age.There is severe weight loss (wasting).ChiraIs traditional and is as old as the Luo tradition itself.Results from a divergence/deviance from the social norms, eventhough this can be, but not necessarily related to, sexual contact.Is curable, by administration of manyasi – a herbal preparation tocleanse against social/cultural evil done by an individual.Mono-symptomatic, the commonest being gradual weight loss by aseemingly healthy individual, but if many, then comes sequentiallywith diarrhoea only coming in advanced stages.Cannot be scientifically diagnosed in medical laboratory, but thevictim’s health continues deteriorating.Knows no age. Even children can suffer because of their parents’misdeeds.There is severe weight loss (wasting).27
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