Community based peer counsellors for support of exclusive breastfeeding: experiences from rural Uganda

BACKGROUND: Universal exclusive breastfeeding for the first six months could reduce infant mortality by 13%. Although 99% women initiate breastfeeding in Uganda, exclusive breastfeeding rates remain low. Although peer counsellors for support of breastfeeding mothers have been found useful in other countries, they have not been used in Uganda. The aim of this pilot study was to assess the feasibility of training community based peer counsellors to support exclusive breastfeeding in a rural district in Uganda. METHODS: With assistance of the investigators, the local communities selected fifteen women aged 25 to 30 years. These women were trained for five days on breastfeeding counselling using the La Leche League curriculum. After training they returned to their communities and started supporting breastfeeding peers. They were followed up and supported in their work for three months. The programme was evaluated through focus group discussions with the peer counsellors, fathers and mothers. RESULTS: The trainees appreciated the knowledge gained and discussed cultural beliefs which affect breastfeeding. They offered breastfeeding support to 15 mothers each within the first two months. They found time to visit and help their breastfeeding peers despite busy schedules. They identified common breastfeeding problems as "insufficient breast milk", sore nipples, breast engorgement, mastitis and poor positioning at the breast. They further observed that most of these problems were eased by correct positioning of the baby at the breast. The peer counsellors were easily accepted by their communities. The mothers were happy to have someone within their community helping them with their breastfeeding problems. Although the peer counsellors were initially selected as volunteers, soon they demanded remuneration. CONCLUSION: The training and follow up of peer counsellors to support exclusive breastfeeding in this rural district is feasible. The peer counsellors were accepted by their communities

Low adherence to exclusive breastfeeding in Eastern Uganda: A community-based cross-sectional study comparing dietary recall since birth with 24-hour recall

BACKGROUND: Exclusive breastfeeding is recommended as the best feeding alternative for infants up to six months and has a protective effect against mortality and morbidity. It also seems to lower HIV-1 transmission compared to mixed feeding. We studied infant feeding practices comparing dietary recall since birth with 24-hour dietary recall. METHODS: A cross-sectional survey on infant feeding practices was performed in Mbale District, Eastern Uganda in 2003 and 727 mother-infant (0–11 months) pairs were analysed. Four feeding categories were made based on WHO's definitions: 1) exclusive breastfeeding, 2) predominant breastfeeding, 3) complementary feeding and 4) replacement feeding. We analyzed when the infant fell into another feeding category for the first time. This was based on the recall since birth. Life-table analysis was made for the different feeding categories and Cox regression analysis was done to control for potential associated factors with the different practices. Prelacteal feeding practices were also addressed. RESULTS: Breastfeeding was practiced by 99% of the mothers. Dietary recall since birth showed that 7% and 0% practiced exclusive breastfeeding by 3 and 6 months, respectively, while 30% and 3% practiced predominant breastfeeding and had not started complementary feeding at the same points in time. The difference between the 24-hour recall and the recall since birth for the introduction of complementary feeds was 46 percentage points at two months and 59 percentage points at four months. Prelacteal feeding was given to 57% of the children. High education and formal marriage were protective factors against prelacteal feeding (adjusted OR 0.5, 0.2 – 1.0 and 0.5, 0.3 – 0.8, respectively). CONCLUSION: Even if breastfeeding is practiced at a very high rate, the use of prelacteal feeding and early introduction of other food items is the norm. The 24-hour recall gives a higher estimate of exclusive breastfeeding and predominant breastfeeding than the recall since birth. The 24-hour recall also detected improper infant feeding practices especially in the second half year of life. The dietary recall since birth might be a feasible alternative to monitor infant feeding practices in resource-poor settings. Our study reemphasizes the need for improving infant feeding practices in Eastern Uganda

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey

Background: Mother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme. Methods: A cross-sectional survey of 388 men aged 18 years or more, whose spouses were attending antenatal care at Mbale Regional Referral Hospital, was conducted in Mbale district, Eastern Uganda. A male involvement index was constructed based on 6 questions. The survey was complemented by eight focus group discussions and five in-depth interviews. Results: The respondents had a median age of 32 years (inter-quartile range, IQR: 28-37). The majority (74%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. Men who had attained secondary education were more likely to have a high male involvement index (OR: 1.9, 95% CI: 1.1-3.3) than those who had primary or no formal education. The respondents, whose occupation was driver (OR: 0.3, 95% CI: 0.1-0.7) or those who had fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2-0.8), were less likely to have a high male involvement index. Barriers to male involvement in the PMTCT programme were related to both the poor health system, to socio-economic factors and to cultural beliefs. Conclusions: Structural and cultural barriers to men's involvement in the PMTCT programme in Mbale district were complex and interrelated. Community sensitization of men about the benefits of antenatal care and PMTCT and improving client-friendliness in the clinics needs to be prioritised in order to improve low male participation and mitigate the effect of socio-economic and cultural factors

Infant feeding among HIV-positive mothers and the general population mothers: comparison of two cross-sectional surveys in Eastern Uganda

<p>Abstract</p> <p>Background</p> <p>Infant feeding recommendations for HIV-positive mothers differ from recommendations to mothers of unknown HIV-status. The aim of this study was to compare feeding practices, including breastfeeding, between infants and young children of HIV-positive mothers and infants of mothers in the general population of Uganda.</p> <p>Methods</p> <p>This study compares two cross-sectional surveys conducted in the end of 2003 and the beginning of 2005 in Eastern Uganda using analogous questionnaires. The first survey consisted of 727 randomly selected general-population mother-infant pairs with unknown HIV status. The second included 235 HIV-positive mothers affiliated to The Aids Support Organisation, TASO. In this article we compare early feeding practices, breastfeeding duration, feeding patterns with dietary information and socio-economic differences in the two groups of mothers.</p> <p>Results</p> <p>Pre-lacteal feeding was given to 150 (64%) infants of the HIV-positive mothers and 414 (57%) infants of general-population mothers. Exclusive breastfeeding of infants under the age of 6 months was more common in the general population than among the HIV-positive mothers (186 [45%] vs. 9 [24%] respectively according to 24-hour recall). Mixed feeding was the most common practice in both groups of mothers. Solid foods were introduced to more than half of the infants under 6 months old among the HIV-positive mothers and a quarter of the infants in the general population. Among the HIV-positive mothers with infants below 12 months of age, 24 of 90 (27%) had stopped breastfeeding, in contrast to 9 of 727 (1%) in the general population. The HIV-positive mothers were poorer and had less education than the general-population mothers.</p> <p>Conclusion</p> <p>In many respects, HIV-positive mothers fed their infants less favourably than mothers in the general population, with potentially detrimental effects on both the child's nutrition and the risk of HIV transmission. Mixed feeding and pre-lacteal feeding were widespread. Breastfeeding duration was shorter among HIV-positive mothers. Higher educational level and being socio-economically better off were associated with more beneficial infant feeding practices.</p

Pre-exposure Prophylaxis Use by Breastfeeding HIV-Uninfected Women: A Prospective Short-Term Study of Antiretroviral Excretion in Breast Milk and Infant Absorption

<div><p>Background</p><p>As pre-exposure prophylaxis (PrEP) becomes more widely used in heterosexual populations, an important consideration is its safety in infants who are breastfed by women taking PrEP. We investigated whether tenofovir and emtricitabine are excreted into breast milk and then absorbed by the breastfeeding infant in clinically significant concentrations when used as PrEP by lactating women.</p><p>Methods and Findings</p><p>We conducted a prospective short-term, open-label study of daily oral emtricitabine–tenofovir disoproxil fumarate PrEP among 50 HIV-uninfected breastfeeding African mother–infant pairs between 1–24 wk postpartum (ClinicalTrials.gov Identifier: NCT02776748). The primary goal was to quantify the steady-state concentrations of tenofovir and emtricitabine in infant plasma ingested via breastfeeding. PrEP was administered to women through daily directly observed therapy (DOT) for ten consecutive days and then discontinued thereafter. Non-fasting peak and trough samples of maternal plasma and breast milk were obtained at drug concentration steady states on days 7 and 10, and a single infant plasma sample was obtained on day 7. Peak blood and breast milk samples were obtained 1–2 h after the maternal DOT PrEP dose, while maternal trough samples were obtained at the end of the PrEP dosing interval (i.e., 23 to 24 h) after maternal DOT PrEP dose. Tenofovir and emtricitabine concentrations were quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays.</p><p>Of the 50 mother–infant pairs enrolled, 48% were ≤12 wk and 52% were 13–24 wk postpartum, and median maternal age was 25 y (interquartile range [IQR] 22–28). During study follow-up, the median (IQR) daily reported frequency of infant breastfeeding was 15 times (12 to 18) overall, 16 (14 to 19) for the ≤12 weeks, and 14 (12 to 17) for the 13–24 wk infant age groups. Overall, median (IQR) time-averaged peak concentrations in breast milk were 3.2 ng/mL (2.3 to 4.7) for tenofovir and 212.5 ng/mL (140.0 to 405.0) for emtricitabine. Similarly, median (IQR) time-averaged trough concentrations in breast milk were 3.3 ng/mL (2.3 to 4.4) for tenofovir and 183.0 ng/mL (113.0 to 250.0) for emtricitabine, reflecting trough-to-peak breast milk concentration ratios of 1.0 for tenofovir and 0.8 for emtricitabine, respectively. In infant plasma, tenofovir was unquantifiable in 46/49 samples (94%), but emtricitabine was detectable in 47/49 (96%) (median [IQR] concentration: 13.2 ng/mL [9.3 to 16.7]). The estimated equivalent doses an infant would ingest daily from breastfeeding were 0.47 μg/kg (IQR 0.35 to 0.71) for tenofovir and 31.9 μg/kg (IQR 21.0 to 60.8) for emtricitabine, translating into a <0.01% and 0.5% relative dose when compared to the 6 mg/kg dose that is proposed for therapeutic treatment of infant HIV infection and for prevention of infant postnatal HIV infection; a dose that has not shown safety concerns. No serious adverse effects were recorded during study follow-up.</p><p>The key study limitation was that only a single infant sample was collected to minimize venipunctures for the children. However, maternal daily DOT and specimen collection at drug concentration steady state provided an adequate approach to address the key research question. Importantly, there was minimal variation in breast milk concentrations of tenofovir and emtricitabine (respective median trough-to-peak concentration ratio ~1), demonstrating that infants were exposed to consistent drug dosing via breast milk.</p><p>Conclusion</p><p>In this short-term study of daily directly observed oral PrEP in HIV-uninfected breastfeeding women, the estimated infant doses from breast milk and resultant infant plasma concentrations for tenofovir and emtricitabine were 12,500 and >200-fold lower than the respective proposed infant therapeutic doses, and tenofovir was not detected in 94% of infant plasma samples. These data suggest that PrEP can be safely used during breastfeeding with minimal infant drug exposure.</p><p>Trial Registration</p><p>ClinicalTrials.gov, Identifier: <a href="https://clinicaltrials.gov/ct2/show/NCT02776748" target="_blank">NCT02776748</a></p></div

Emtricitabine concentrations and infant exposure.

<p>Emtricitabine concentrations and infant exposure.</p

General characteristics.

<p>General characteristics.</p

Box plot of maternal and infant tenofovir concentrations.

<p>Non-fasting maternal blood and breast milk samples were obtained concurrently (i.e., within 30 min) at the seventh and tenth visits (corresponding to seventh and tenth maternal DOT PrEP doses). A single infant blood sample was obtained after the seventh maternal DOT PrEP dose. Peak maternal blood, breast milk, and infant blood samples were obtained a median (IQR) of 63 (60 to 68), 70 (65 to 77), and 80 (45 to 90) min after the maternal DOT PrEP dose, respectively. Trough samples were obtained at close of the dosing interval, a median of 23 h (IQR range 23 to 24) after the previous maternal DOT PrEP. One outlier peak maternal plasma tenofovir concentration (1,040 ng/ml) was out of the assay analytic range (0.31–1,000.0 ng/mL). This record was imputed to the upper limit of the assay analytic range and was included in the computation of the displayed summary estimate. Middle box line represents the median. Upper box line represents the 75th percentile and the lower box line represents the 25th percentile. The top whisker denotes the maximum data value or the third quartile plus 1.5 times the interquartile range, whichever is smaller. The lower whisker denotes the minimum data value or the third quartile plus 1.5 times the interquartile range, whichever is larger. The notches display the 95% confidence interval around the median. Small circles represent outlier data points (i.e., observations that are as extreme as ±1.5 of interquartile range). Only 3 of 49 infant plasma samples had quantifiable tenofovir concentration in plasma (infants aged 11 and 13 wk [both 0.9 ng/mL] and 17 wks [17.4 ng/mL]). NA, not applicable; BLQ, below assay limit of quantification for tenofovir: <0.31 ng/mL in plasma and <1 ng/mL in whole milk.</p

Tenofovir concentrations and infant exposure.

<p>Tenofovir concentrations and infant exposure.</p