RESUMEN

Objetivo

Evaluar la bibliografía científica disponible sobre los factores que pueden influir en la alimentación adecuada de lactantes expuestos a la transmisión vertical del VIH.

Métodos

En febrero del 2017, se realizó una revisión integradora de la bibliografía en las bases de datos LILACS, PubMed y Scopus. La búsqueda fue orientada por la pregunta “¿cuáles son los factores involucrados en la alimentación de los lactantes expuestos a la transmisión vertical del VIH?”. Los estudios seleccionados cumplían el criterio de inclusión de ser artículos de investigación publicados en inglés, portugués o español. Se excluyeron los artículos sobre la lactancia materna exclusiva. No fue necesario establecer un límite temporal para los estudios.

Resultados

En total, los 32 estudios primarios seleccionados mostraron que intervinieron factores de tres tipos: individuales, como los sentimientos y deseos maternos, las creencias y las dificultades prácticas; sociales, como las condiciones socioeconómicas, el apoyo social y el estigma; y políticos, como la estructura y organización de los servicios de salud, los suministros, la orientación sobre la atención de salud y los conocimientos y actitudes de los profesionales de la salud.

Conclusiones

Los factores que interfieren en la nutrición de los lactantes expuestos a la transmisión vertical del VIH pueden ser independiente o estar asociados entre sí. A fin de reducir el riesgo de una nutrición inadecuada y las enfermedades asociadas con ella, se deben tomar medidas para establecer y reducir al mínimo esos factores, garantizar una mejor calidad de vida y reducir la morbilidad y la mortalidad de los lactantes.

Palabras clave
VIH; síndrome de inmunodeficiencia adquirida; transmisión vertical de enfermedad infecciosa; nutrición del lactante; fórmulas infantiles; revisión

RESUMO

Objetivo

Avaliar a literatura científica existente quanto aos fatores que podem interferir na alimentação adequada de lactentes expostos à transmissão vertical do HIV.

Métodos

Estudo de revisão integrativa da literatura conduzido nas bases de dados LILACS, PubMed e Scopus em fevereiro de 2017. A busca foi norteada pela seguinte pergunta: “Quais são os fatores intervenientes na alimentação de lactentes expostos à transmissão vertical do HIV?”. Os estudos selecionados satisfizeram os critérios de inclusão, a saber: artigos de pesquisa publicados em inglês, português ou espanhol. Foram excluídos os artigos sobre aleitamento materno exclusivo. Não foi necessário fazer um recorte temporal dos estudos.

Resultados

Os 32 estudos originais selecionados revelaram três tipos de fatores intervenientes: individuais, como sentimentos e desejos, crenças e dificuldades práticas das mães; sociais, como nível socioeconômico, apoio social e estigma, e políticos, como estrutura e organização dos serviços de saúde, provisões, orientação de cuidados da saúde e conhecimento e atitudes dos profissionais da saúde.

Conclusões

Os fatores que interferem na alimentação dos lactentes expostos à transmissão vertical do HIV podem ocorrer independentes ou associados entre si. A fim de reduzir o risco de nutrição inadequada e doenças associadas, devem ser tomadas medidas para identificar e minimizar esses fatores, assegurando melhor qualidade de vida e redução da morbidade e mortalidade infantis.

Palavras-chave
HIV; síndrome de imunodeficiência adquirida; transmissão vertical de doença infecciosa; nutrição do lactente; fórmulas infantis; revisão

The global epidemic of human immunodeficiency virus (HIV) has evolved over time—the highest rates of new cases are now among women of childbearing age, thereby increasing the number of infants at risk of infection by vertical transmission (¹1 Joint United Nations Programme on HIV/AIDS. The gap report. Geneva: UNAIDS; 2014.). In 2015, there were approximately 150 000 new HIV cases among infants worldwide (²2 United Nations Children’s Fund. For every child end AIDS. Seventh Stocktaking Report. New York: UNICEF; 2016.).

HIV vertical transmission can happen at three points: during pregnancy, during labor and childbirth, and during each breastfeeding session (²2 United Nations Children’s Fund. For every child end AIDS. Seventh Stocktaking Report. New York: UNICEF; 2016.). In order to ensure the protection of life and to reduce the chances of vertical transmission (³3 Alvarenga WA, Silva MR, Nascimento LC, Wernetd M, Oliveira FFD, Dupas G. Experience of family members providing care for HIV-exposed children: beginning of the trajectory. Rev Gaúcha Enferm. 2014;35(3):68–4.), timely access to prophylactic and antiretroviral treatment is imperative (⁴4 Newell ML. HIV transmission through breastfeeding: a review of available evidence. Geneva: UNAIDS; 2014.).

According to the World Health Organization (WHO), breastfeeding accounts for 30%–50% of HIV vertical transmission when prophylactic measures and treatment are not adhered to; breastfeeding also reduces the positive impact of preventive interventions during pregnancy and parturition (⁴4 Newell ML. HIV transmission through breastfeeding: a review of available evidence. Geneva: UNAIDS; 2014.). While breastfeeding carries the risk of HIV transmission, alternatives have significant health risks for the infant, including malnutrition, morbidity, and mortality (⁵5 World Health Organization. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000;355(9209):1104.).

The most appropriate feeding choice depends on various factors, such as the individual mother’s health status and socioeconomic conditions and the availability of health services that offer counseling and support. For HIV positive mothers, the WHO recommends breastfeeding only until 6 months of age; however, if the replacement food meets the criteria of being acceptable, viable, accessible, sustainable, and safe, the exclusion of breastfeeding is recommended (⁴4 Newell ML. HIV transmission through breastfeeding: a review of available evidence. Geneva: UNAIDS; 2014.). This guideline is justified by the increased risk of morbidity and mortality due to malnutrition and infectious diseases that can result when breastmilk substitutes lack sufficient nutrients and/or when basic sanitation and safe food and water are not available (⁵5 World Health Organization. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000;355(9209):1104.).

Post-partum prevention of vertical transmission becomes the responsibility of the caregiver, whether a blood relative or not. When wholly supported and guided by health professionals, the caregiver can be empowered to improve the child’s quality of life (³3 Alvarenga WA, Silva MR, Nascimento LC, Wernetd M, Oliveira FFD, Dupas G. Experience of family members providing care for HIV-exposed children: beginning of the trajectory. Rev Gaúcha Enferm. 2014;35(3):68–4.). However, when guidance and support are insufficient or inadequate, the infant may have unmet nutritional needs, as reported by Freitas and colleagues (⁶6 Freitas JG, Cunha GH, Lemos LA, Barroso LMM, Galvão MTG. Feeding of children exposed to the human immunodeficiency virus at birth. Text Context Nursing. 2014;23(3):617–25.) who found that information on appropriate feeding of this at-risk group was lacking.

The effectiveness of any recommendations is directly related to the psychosocial, cultural, and biological specifics of each family; and to wholly comprehend the reality of each, it is imperative that health professionals take an approach that fosters a relationship of caring and mutual respect (⁷7 Padoin SMM, Paula CC, Hoffmann IC, Valadão MC, Rodrigues AP, Langendorf TF. Alimentação de crianças que convivem com a aids: vivências de familiares/cuidadores em atividade grupal. Rev Enferm UFSM. 2012;2(1):213–1.).

Given that there is wide variation in the factors that both positively and negatively influence the food choices made for infants vertically-exposed to HIV, the objective of this study was to evaluate the available evidence on intervening factors when breastfeeding was not exclusive.

MATERIALS AND METHODS

This was an integrative review (⁸8 Mendes KDS, Silveira RCCP, Galvão CM. Integrative literature review: a research method to incorporate evidence In health care and nursing. Text Context Nursing. 2008;17(4):758–4.) that aimed to gather and summarize research results to answer the question, “What are the social, political, and individual intervening factors in the feeding of infants vertically-exposed to HIV who were not exclusively breastfed?”

A bibliographic search was conducted in February 2017 of the Latin American and Caribbean Health Science Literature (LILACS), the United States National Library of Medicine (PubMed), and Elsevier SciVerse Scopus (Scopus) databases. The following keywords were used on PubMed and Scopus: “HIV or acquired immunodeficiency syndrome” and “infant nutritional physiological phenomena or feeding practices or bottle feeding or infant formula.” The following keywords were used on LILACS: “HIV or AIDS or Sindrome da imunodeficiência adquirida or vírus da imunodeficiência humana or Soropositividade para HIV” and “neonato or criança or pediatria or materno-infantil or materno-fetal” and “nutrição or alimentação or alimentação artificial or cuidadores or cuidado or cuidado infantil.”

Initially, the search resulted in 2 827 papers. For the feasibility of the analysis, in PubMed and Scopus, the following filters were applied: article type (clinical trial, comparative study, controlled clinical trial, multicenter study, observational study, controlled randomized clinical trial); species: human; language: English, Portuguese, or Spanish; ages: infant (birth – 23 months) and child (birth – 18 years). The total search results were 531 publications.

The following selection process was followed: establishing the integrative review’s objective, applying inclusion and exclusion criteria, defining the information to be extracted from the selected articles, analysis of results, discussion of results, and presentation (⁸8 Mendes KDS, Silveira RCCP, Galvão CM. Integrative literature review: a research method to incorporate evidence In health care and nursing. Text Context Nursing. 2008;17(4):758–4.). For this review, articles that met the inclusion criteria were research papers published in peer-reviewed journals, in Portuguese, English, or Spanish. Articles excluded were those whose study population was exclusively breastfed. There was no need to perform a temporal cut off the studies.

To minimize error or omission, each of two researchers independently reviewed the 531 possible studies. According to the titles, abstracts, and lastly, the entire text, those that did not respond to the research question and objectives were eliminated. A third researcher read any articles where there was a discrepancy between the first and second researcher’s recommendation (Figure 1). Critical evaluation was performed in accordance with the Melnyk and Fineout-Overholt’s hierarchy of evidence levels (⁹9 Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. 2 ed. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins; 2011.) through the analysis of the type of clinical question and of each study’s methodology. The classification was carried out according to whether the study was (a) directed at treatment or intervention, (b) directed at prognosis or etiology, or (c) directed at understanding emotional or qualitative aspects.

There were 32 publications that addressed the research question and review objective. Each of the 32 studies was recorded in an instrument that collected bibliographic information, country(ies) of focus, knowledge subarea, objectives, methodology, results, and level of evidence.

RESULTS

Regarding the characteristics of the analyzed articles (n = 32), there was a predominance of studies conducted in Africa (72%; n = 23) probably due to the large number of HIV cases among the population. In the knowledge area, there was a concentration of papers by multi-professional teams (57%; n = 18). The temporal distribution showed that 50% were published in 2003 – 2007 (n = 16). This shows that research during the most recent decade has be waning at a time when the need for information on safe feeding among the study population has grown (Table 1).

Analysis of the 32 publications enabled identification of intervening factors in the feeding of infants vertically-exposed to HIV (Figure 2). Results of these studies contemplated three interdependent groups of factors— individual, social, and political. The individual factors refers to biological, emotional, cognitive, attitudinal, and social relationships; the social, to cultural, community, and economic aspects that determine access to goods and services; and the political, to social resources that protect a citizen’s physical, mental and social well-being. Further details on the different individual and collective situations are available in a Supplementary File.

DISCUSSION

Individual factors

The individual factor group examined behaviors that intervened positively or negatively with feeding of infants vertically-exposed to HIV. These were individual behaviors that point to the need for understanding each particular situation and the specifics for each woman, against a backdrop of cultural heterogeneity.

The studies indicated that depriving an infant of breast milk was a trigger for feelings of guilt, pain, and sorrow (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2.–¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0.). Reasons cited were a mother’s inherent desire to breastfeed, family and social pressure, cultural and religious issues, including rejection of a mother who does not breastfeed and withdrawal of family support (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9.–²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6.). Out of fear, some use reasons deemed more socially acceptable to justify their decision to not breastfeed—e.g., insufficient breast milk, anemia, or using antibiotics (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹²12 Moreno CCGS, Rea MF, Filipe EV. Mães HIV positivo e a não-amamentação. Rev Bras Saude Matern Infant. 2006;6(2):199–8.–¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6., ²³23 Muko KN, Tchangwe GK, Ngwa VC, Njoya L. Preventing mother-to-child transmission: factors affecting mothers’choice of feeding — a case study from Cameroon. J Social Aspects HIV/AIDS. 2004;1(3):132–8., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1.–²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1.). However, the desire to protect the child from HIV, according to these studies, was a factor that facilitated the acceptance of replacement of breastfeeding (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5.–¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²⁰20 Chisenga M, Siame J, Baisley K, Kasonka L, Filteau S. Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study. Matern Child Nutr. 2011;7(1):148–9., ²¹21 Bland RM, Rollins NC, Coovadia HM, Coutsoudis A, Newell ML. Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ. 2007;85(4):289–6., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁷27 Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods Study. Trop Med Int Health. 2013;18(12):1547–4.–³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6.). Related to this, maintaining and strengthening the mother-child bond can be fostered by other forms of physical contact, often provided with greater care and attention (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ³²32 Vasconcelos SG, Galvão MTG, Paiva SS, Almeida PC, Pagliuca LMF. Comunicação mãe-filho durante amamentação natural e artificial na era Aids. Rev Rene. 2010; 11(1):103–9.).

The studies also indicated that the success of strategies for avoiding vertical transmission depended the mother’s understanding of the importance of not breastfeeding and the effects of HIV transmission (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁸28 Oladokun R, Brown B, Osinusi K. Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme. AIDS Care. 2010;22(9):1108–4., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9.–³⁴34 Eide Myhre M, Lindbaek M, Sundby J, Arimi P, Thior I. Social consequences of HIV-positive women’s participation in prevention of mother-to-child transmission programmes. Patient Educ Couns. 2006; 60(1):146–1.). Mothers who adhered to antiretroviral treatment and who were receiving follow-up health care were more likely to comply with the infant feeding recommendations and more likely to prevent vertical transmission (²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6.).

Social factors

The social factor group analyzed access to information, health services, and health and social welfare conditions that intervene in the feeding of infants vertically-exposed to HIV. The studies indicated that these aspects were reflected in the family’s socioeconomic conditions and by the infrastructure of the community where the infant resides (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2.–¹²12 Moreno CCGS, Rea MF, Filipe EV. Mães HIV positivo e a não-amamentação. Rev Bras Saude Matern Infant. 2006;6(2):199–8., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5.–¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6.–²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁷27 Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods Study. Trop Med Int Health. 2013;18(12):1547–4., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6., ³⁵35 Machado MMT, Galvão MTG, Lindsay AC, Cunha AJLA, Leite ÁJM, Leite RD, et al. The socio-demographic conditions of children aged 0 to 2 years born to mothers with HIV/AIDS, in the city of Fortaleza, in the Brazilian State of Ceará. Rev Bras Saude Mater Infant. 2010;10(3):377–2.–³⁸38 Dorosko S, Rollins N. Infant formula preparation by rural and semi-rural women in South Africa. Food Policy. 2003;28(1): 117–20.). Availability of piped, potable water and electricity was pointed out as a factor that facilitated feeding by infant formula, due to the need for clean water and refrigeration (¹⁶16 Nor B, Ahlberg BM, Doherty T, Zembe Y, Jackson D, Ekström 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):448–8.–¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²¹21 Bland RM, Rollins NC, Coovadia HM, Coutsoudis A, Newell ML. Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ. 2007;85(4):289–6., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6., ²⁷27 Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods Study. Trop Med Int Health. 2013;18(12):1547–4., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ³⁶36 Andresen E, Rollins NC, Sturm AW, Conana N, Greiner T. Bacterial contamination and over-dilution of commercial infant formula prepared by HIV-infected mothers in a prevention of mother-to-child transmission (PMTCT) programme, South Africa. J Trop Pediatr. 2007;53(6): 409–4.–³⁸38 Dorosko S, Rollins N. Infant formula preparation by rural and semi-rural women in South Africa. Food Policy. 2003;28(1): 117–20.). A low level of education was found by most studies to affect proper formula preparation, as well as to impede the mother’s understanding of how replacement of breastfeeding can avoid vertical transmission of HIV (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²⁸28 Oladokun R, Brown B, Osinusi K. Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme. AIDS Care. 2010;22(9):1108–4., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ³¹30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ³⁵35 Machado MMT, Galvão MTG, Lindsay AC, Cunha AJLA, Leite ÁJM, Leite RD, et al. The socio-demographic conditions of children aged 0 to 2 years born to mothers with HIV/AIDS, in the city of Fortaleza, in the Brazilian State of Ceará. Rev Bras Saude Mater Infant. 2010;10(3):377–2.–³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6.). Studies also suggested that the higher the level of education and family socioeconomic status, the more likely the mother was to follow health guidelines and introduce solid food after 6 month of age (²⁴24 Wakwoya EB, Zewudie TA, Gebresilasie KZ. Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia. Pan African Med J. 2016;24(338):1–7., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ³³33 Omwega AM, Oguta TJ, Sehmi JK. Maternal knowledge on mother-to-child transmission of HIV and breastmilk alternatives for HIV positive mothers in Homa Bay District Hospital, Kenya. East Afr Med J. 2006;83(11):610–8.).

It is notable that financial difficulties and social precariousness may favor inadequate feeding (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1., ³³33 Omwega AM, Oguta TJ, Sehmi JK. Maternal knowledge on mother-to-child transmission of HIV and breastmilk alternatives for HIV positive mothers in Homa Bay District Hospital, Kenya. East Afr Med J. 2006;83(11):610–8., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6., ³⁹39 Freitas JG, Barroso LMM, Galvão MTG. Maternal ability to take care of children exposed to HIV. Rev Latino-Am Enfermagem. 2013;21(4):964–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). The articles reviewed reveal that the practice of excessive dilution of formula is frequent, often attributed to food insecurity and the need to share any food with siblings (¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁸18 Doherty T, Chopra M, Jackson D, Goga A, Colvin M, Persson LA. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS. 2007;21(1):1791–7., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ³⁶36 Andresen E, Rollins NC, Sturm AW, Conana N, Greiner T. Bacterial contamination and over-dilution of commercial infant formula prepared by HIV-infected mothers in a prevention of mother-to-child transmission (PMTCT) programme, South Africa. J Trop Pediatr. 2007;53(6): 409–4., ³⁸38 Dorosko S, Rollins N. Infant formula preparation by rural and semi-rural women in South Africa. Food Policy. 2003;28(1): 117–20.–⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). In addition, because families have difficulty paying for infant formula, introduction of solid food becomes necessary earlier than recommended. The foods offered are rich in carbohydrates and fats and deficient in proteins, vitamins, and minerals—extremely necessary at this age—and contribute to poor growth and development (¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ¹⁸18 Doherty T, Chopra M, Jackson D, Goga A, Colvin M, Persson LA. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS. 2007;21(1):1791–7., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1., ³⁹39 Freitas JG, Barroso LMM, Galvão MTG. Maternal ability to take care of children exposed to HIV. Rev Latino-Am Enfermagem. 2013;21(4):964–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). Studies conducted in Brazil and in Africa show that when infant formula cannot be purchased or otherwise obtained, family/solid food often starts before 2 months of age (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1., ³²32 Vasconcelos SG, Galvão MTG, Paiva SS, Almeida PC, Pagliuca LMF. Comunicação mãe-filho durante amamentação natural e artificial na era Aids. Rev Rene. 2010; 11(1):103–9., ³³33 Omwega AM, Oguta TJ, Sehmi JK. Maternal knowledge on mother-to-child transmission of HIV and breastmilk alternatives for HIV positive mothers in Homa Bay District Hospital, Kenya. East Afr Med J. 2006;83(11):610–8., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.).

The studies demonstrated that women who opt to substitute with milk formula suffer prejudice and are stigmatized as HIV carriers by the community (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5.–¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²⁰20 Chisenga M, Siame J, Baisley K, Kasonka L, Filteau S. Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study. Matern Child Nutr. 2011;7(1):148–9., ²⁴24 Wakwoya EB, Zewudie TA, Gebresilasie KZ. Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia. Pan African Med J. 2016;24(338):1–7., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1., ²⁸28 Oladokun R, Brown B, Osinusi K. Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme. AIDS Care. 2010;22(9):1108–4., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6.), in addition to experiencing pressure, harassment, isolation, and/or violence from the family (¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²⁰20 Chisenga M, Siame J, Baisley K, Kasonka L, Filteau S. Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study. Matern Child Nutr. 2011;7(1):148–9., ²⁸28 Oladokun R, Brown B, Osinusi K. Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme. AIDS Care. 2010;22(9):1108–4., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6.).

The proximity of health care services where antiretroviral medications and infant formula are provided was mentioned as a complicating factor because of the stigma by the community and the fear of the mother’s HIV status being discovered (¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). However, many mothers stated that when they revealed their HIV diagnosis to friends or family, they continued to receive support, whether emotional or logistical (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3., ²⁴24 Wakwoya EB, Zewudie TA, Gebresilasie KZ. Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia. Pan African Med J. 2016;24(338):1–7., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6.). Revealing the diagnosis to the partner/spouse influenced feeding choices, especially when the couple established strategies to deal with their reasons for not breastfeeding (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5., ¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ²⁴24 Wakwoya EB, Zewudie TA, Gebresilasie KZ. Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia. Pan African Med J. 2016;24(338):1–7., ²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ²⁸28 Oladokun R, Brown B, Osinusi K. Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme. AIDS Care. 2010;22(9):1108–4., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6.).

The studies also showed that health professionals still miss the mark with regard to ethics, by discriminating or not respecting the confidentiality (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). Health professionals must try to understand each woman’s needs, and do their utmost to help each mother feel safe and empowered to care for her infant in a, risk-free and nutritionally appropriate way. Thus, with the professional’s support, it is possible to keep the HIV status confidential and allow the healthy development of any child in a family living with HIV (⁴¹41 Rensburg LJ, Nel R, Walsh CM. Knowledge, opinions and practices of healthcare workers related to infant feeding in the context of HIV. Health Sa Gesondheid. 2016;21:129–6.).

Political factors

The political factor group was configured to gather information on health and educational resources and investments that may intervene in the feeding of infants vertically-exposed to HIV. In this sense, an absence of receptivity was evidenced, and these factors had an influence on the lack of understanding between health professionals and the HIV-positive mothers (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³⁶36 Andresen E, Rollins NC, Sturm AW, Conana N, Greiner T. Bacterial contamination and over-dilution of commercial infant formula prepared by HIV-infected mothers in a prevention of mother-to-child transmission (PMTCT) programme, South Africa. J Trop Pediatr. 2007;53(6): 409–4., ³⁷37 Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, et al. Acceptability of formula-feeding to prevent HIV postnatal transmission of HIV-1 infection in Abidjan, Côte d’Ivoire, Ditrame Plus ANRS 1201/1202. J Acquir Immune Defic Syndr. 2007;44(1):77–6., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). This particular relationship requires acceptance, empathy, respect, cordiality, and patience, so that the health guidelines are effectively adopted (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²⁰20 Chisenga M, Siame J, Baisley K, Kasonka L, Filteau S. Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study. Matern Child Nutr. 2011;7(1):148–9., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). Proper counseling and support can empower mothers, turning recommendations into actions through their decisive and conscious attitudes toward the health of their children, including adequate nutrition (²⁴24 Wakwoya EB, Zewudie TA, Gebresilasie KZ. Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia. Pan African Med J. 2016;24(338):1–7., ³⁹39 Freitas JG, Barroso LMM, Galvão MTG. Maternal ability to take care of children exposed to HIV. Rev Latino-Am Enfermagem. 2013;21(4):964–2., ⁴¹41 Rensburg LJ, Nel R, Walsh CM. Knowledge, opinions and practices of healthcare workers related to infant feeding in the context of HIV. Health Sa Gesondheid. 2016;21:129–6.).

There was also evidence for the need to improve the knowledge of health professionals regarding guidelines for feeding children vertically-exposed to HIV. One study showed that only 14% of professionals felt their knowledge on the subject was adequate (⁴¹41 Rensburg LJ, Nel R, Walsh CM. Knowledge, opinions and practices of healthcare workers related to infant feeding in the context of HIV. Health Sa Gesondheid. 2016;21:129–6.): they were aware that formula feeding increases the risk of infant morbidity and mortality; however, the guidance on safe nutrition for those exposed to HIV is at odds with WHO recommendations (²⁵25 Onubogu CU, Ugochukwu EF, Egbuonu I, Onyeka IN. Adherence to infant-feeding choices by HIV-infected mothers at a Nigerian tertiary hospital: the pre-“rapid advice” experience. S Afr J Clin Nutr 2015;28(4):180–6., ⁴¹41 Rensburg LJ, Nel R, Walsh CM. Knowledge, opinions and practices of healthcare workers related to infant feeding in the context of HIV. Health Sa Gesondheid. 2016;21:129–6.).

Most of the studies reviewed pointed to a need for restructuring and reorganizing health services to guarantee the supply of necessary aids for improving the quality of life and health of HIV-positive mothers and their children (¹¹11 Galvão MTG, Paiva SS. Feelings of pregnant and post-partum women with hiv/aids about not Breastfeeding. Text Context Nursing. 2004;13(3):414–9., ¹⁵15 Muñoz SF, Castro E, Idrobo LMF, Vallejo LEN, Cuéllar JAP, Meneses MCV. Conocimientos, actitudes y prácticas de las mujeres con VIH durante la gestación y crianza (Popayán, 2009). Investig Enferm Imagen Desarro. 2012;14(1):45–5., ¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²³23 Muko KN, Tchangwe GK, Ngwa VC, Njoya L. Preventing mother-to-child transmission: factors affecting mothers’choice of feeding — a case study from Cameroon. J Social Aspects HIV/AIDS. 2004;1(3):132–8., ³⁰30 Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatrica. 2007;96(1): 94–9., ³⁹39 Freitas JG, Barroso LMM, Galvão MTG. Maternal ability to take care of children exposed to HIV. Rev Latino-Am Enfermagem. 2013;21(4):964–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.).

A number of studies revealed that, in some places, infant formula is distributed free of charge to mothers with HIV (¹⁰10 Silva MR, Alvarenga WA, Dupas G. Caregiver experience in preventive treatment for children exposed to Human Immunodeficiency Virus. Rev Rene. 2014;15(5):743–2., ¹⁷17 Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, et al. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care. 2009;21(9):1114–3.–¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6., ²⁶26 Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004;35(1):75–1., ²⁷27 Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods Study. Trop Med Int Health. 2013;18(12):1547–4., ²⁹29 Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J. 2003;93(10):779–1., ³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6., ³²32 Vasconcelos SG, Galvão MTG, Paiva SS, Almeida PC, Pagliuca LMF. Comunicação mãe-filho durante amamentação natural e artificial na era Aids. Rev Rene. 2010; 11(1):103–9., ³⁴34 Eide Myhre M, Lindbaek M, Sundby J, Arimi P, Thior I. Social consequences of HIV-positive women’s participation in prevention of mother-to-child transmission programmes. Patient Educ Couns. 2006; 60(1):146–1., ³⁵35 Machado MMT, Galvão MTG, Lindsay AC, Cunha AJLA, Leite ÁJM, Leite RD, et al. The socio-demographic conditions of children aged 0 to 2 years born to mothers with HIV/AIDS, in the city of Fortaleza, in the Brazilian State of Ceará. Rev Bras Saude Mater Infant. 2010;10(3):377–2., ³⁹39 Freitas JG, Barroso LMM, Galvão MTG. Maternal ability to take care of children exposed to HIV. Rev Latino-Am Enfermagem. 2013;21(4):964–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). However, findings also found that there are flaws in distribution, mostly shortages, that is, quantities insufficient to provide infant formula up to 6 months of age (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5., ¹⁶16 Nor B, Ahlberg BM, Doherty T, Zembe Y, Jackson D, Ekström 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):448–8.–¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6., ²⁷27 Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods Study. Trop Med Int Health. 2013;18(12):1547–4., ³⁵35 Machado MMT, Galvão MTG, Lindsay AC, Cunha AJLA, Leite ÁJM, Leite RD, et al. The socio-demographic conditions of children aged 0 to 2 years born to mothers with HIV/AIDS, in the city of Fortaleza, in the Brazilian State of Ceará. Rev Bras Saude Mater Infant. 2010;10(3):377–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.). Furthermore, there are too often bureaucratic issues that disrupt the availability of the donated infant formula (¹³13 Cames C, Saher A, Ayassou KA, Cournil A, Meda N, Simondon KB. Acceptability and feasibility of infant-feeding options: experiences of HIV-infected mothers in the World Health Organization kesho Bora mother-to-child transmission prevention (PMTCT) trial in Burkina Faso. Matern Child Nutr. 2010;6(1):253–5., ¹⁴14 Sibeko L, Coutsoudis A, Nzuza S, Gray-Donald K. Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–0., ¹⁶16 Nor B, Ahlberg BM, Doherty T, Zembe Y, Jackson D, Ekström 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):448–8.–¹⁹19 Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(1):288–1., ²²22 Doherty T, Chopra M, Nkonki L, Jackson D, Persson LA. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(1):2421–6., ³¹31 Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: “When they see me coming with the tins they laugh at me.” Bull World Health Organ. 2006;84(2):90–6., ³⁵35 Machado MMT, Galvão MTG, Lindsay AC, Cunha AJLA, Leite ÁJM, Leite RD, et al. The socio-demographic conditions of children aged 0 to 2 years born to mothers with HIV/AIDS, in the city of Fortaleza, in the Brazilian State of Ceará. Rev Bras Saude Mater Infant. 2010;10(3):377–2., ⁴⁰40 Machado MMT, Galvão MTG, Kerr-Pontes LRS, Cunha AJLA, Leite ÁJM, Lindsay AC, et al. Access and use of infant formula and other foods among children born to HIV positive mothers. Rev Eletr Enferm. 2007;9(3):699–1.).

Limitations

Most studies on the feeding of HIV-exposed infants have been conducted in Africa; therefore, a lack of studies in countries with distinct socioeconomic and cultural conditions is a limitation of this study.

Conclusions

This review of the literature highlights the interdependence among individual, social, and political factors and their influence on the feeding of infants vertically-exposed to HIV. Training and continuing education for health professionals is needed, as shown by the difficulties reported with attending to families living with HIV. A better understanding of the reality in which these families live is needed in order to improve the effectiveness of health professionals. HIV-positive mothers need to be empowered to provide adequate, safe, accessible, and affordable feeding of their infants, and family support was shown to be imperative. All these intervening factors must be addressed to prevent HIV transmission, reduce the risk of malnutrition and associated diseases, and ensure a better quality of life for infants vertically-exposed to HIV.

Acknowledgements

The authors wish to thank the reviewers for their input on an early version of the manuscript.

REFERENCES

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