Balancing Breastfeeding and HIV Management in Africa: Addressing the Challenges of Mother-to-Child Transmission

Abstract

Human immunodeficiency virus (HIV)-positive mothers still breastfeed their infants, despite substantial evidence against this practice. This lingers on due to the age-long embracing of arcane conjectures and pity-partying. Studies have shown that the risk of HIV transmission through breastfeeding increases over time. Despite significant progress in reducing mother-to-child transmission (MTCT) of HIV globally, breastfeeding still accounts for nearly 50% of pediatric HIV infections each year.1 In one study conducted in Tanzania, the cumulative incidence of infection among children not receiving antiretroviral drugs was 10.2 cases per 100 children.2 The risk of infection by age 4 months was 3.8%, increasing to 17.9% by age 24 months.2 Several factors contribute to the transmission of HIV through breastfeeding. High maternal viral load, low CD4 cell count, and high maternal erythrocyte sedimentation rate have been identified as significant predictors of transmission.2 Mothers with breast lesions during pregnancy are also more likely to transmit the virus during breastfeeding.1,2 Globally, breastfeeding is responsible for approximately 300,000 HIV infections per year.3 The majority of cases of HIV transmission in children continue to be through MTCT, with breastfeeding accounting for as many as 50% of new infections.1 The burden of HIV in Africa is immense with about 25 million people living with the virus out of the global 40 million approximate.4 This has undoubtedly led to numerous morbidity and mortality. Infants and young children infected with HIV occupy roughly a tenth of Africa’s people living with HIV headcount.4 Up to 60% of children die before the age of two and five years, respectively, in the absence of any intervention.2,4 Interplay of multifactorial patterns Breastfeeding, by its inherent nature, facilitates intimate mother-child bonding and offers numerous health benefits to the infant. In resource-limited settings like rural African communities, breastfeeding is intrinsically linked to maternal caregiving and, due to socio-economic constraints, is frequently the primary feasible nutritional strategy.5 However, when juxtaposed with the risk of HIV transmission from an infected mother to her child, the benefits become a subject of intense debate. Unlike developed countries where the converse is advised, in low and middle-income countries, the World Health Organization advises mothers with HIV, who are undergoing combined antiretroviral therapy, to breastfeed their babies for a duration of 12 to 24 months. This guidance is based on the heightened risks of illnesses, such as gastroenteritis and pneumonia, as well as malnutrition observed in infants fed with formula. The challenges of limited access to clean water and the high cost of formula milk make breastfeeding a more viable option for these economically disadvantaged communities.5 This lapse can no longer be relegated to a mere oversight. It is a potent reflection of the chasm between contemporary medical counsel and on-ground practices, especially within both rural and urban locales of Africa. Such discrepancies not only jeopardize concerted efforts to combat and end the HIV epidemic but also underscore a more significant systemic issue - the deficit in the sensitivity and knowledge update among HIV caregivers and counselors in both urban and rural African regions. Recent studies, predicated on cumulative evidence suggest that the risk of transmission when the parent is on treatment and has an undetectable viral load is very low but not zero.6 Yet, the observed rise in pediatric HIV infections strongly hints at the discord between existing guidelines and the practices promoted in caregiving settings. Thus, it is advisable not to leave things to chance when safer and sounder alternatives like formula feeds are available. Clinicopathology The clinical presentation of HIV in the pediatric age group which comprises recurrent infections, growth failure, failure to thrive, and so on usually arises from the transmission of the virus from an infected mother to a child during pregnancy, labor, and delivery or breastfeeding.5 HIV transmission via breastfeeding is surmised to occur when an infant’s mucosal membranes, present in the throat and stomach, come into contact with HIV-containing breast milk. Once in the infant’s body, the virus can proliferate, leading to a permanent infection. Given their inchoate immune systems, newborns are especially susceptible to HIV and other infections.5,6 The viral load, or the concentration of HIV in bodily fluids, of the breastfeeding individual plays a crucial role in transmission. An undetectable viral load significantly reduces transmission risks.7 Immune cells, even when treated, may harbor the virus, which can reactivate under specific conditions, like a breast infection or during mixed feeding, releasing the virus into the breast milk and potentially infecting the infant.7 Other transmission risk factors include breast inflammation, extended breastfeeding duration, and introducing solid foods alongside breastfeeding.6 Militating Factors Several underlying factors might contribute to the persistence of this concerning practice, despite conspicuous evidence necessitating corrective action. Sociocultural nuances Firstly, the ancient reliance on breastfeeding as a primary mode of infant nutrition in many African communities may create resistance to change. Coupled with this is the possibility of stigmatization faced by mothers who opt against breastfeeding, perceived as neglecting their maternal duties or courting some insidious secret that may ignite suspicion and create acrimony among couples-seropositive and serodiscordant alike.8 However, these socio-cultural innuendos, while important, should not overshadow the risks associated with HIV transmission, a disease that is still incurable. Knowledge Distribution lag There is a palpable lag in transmitting updated medical guidelines to primary caregivers. The knowledge retention and dissemination capacity of our healthcare providers need introspection. It is a matter of grave concern if caregivers, the very torchbearers of medical wisdom in communities, remain oblivious to or choose to disregard updated guidelines. Their roles transcend mere caregiving; they influence societal norms, perceptions, and practices. When these caregivers encourage HIV-positive mothers to breastfeed, they inadvertently become contributors to the perpetuation of the historically notorious epidemic. Economic Downturns Women living with HIV, particularly those from low socioeconomic backgrounds, often face immense economic challenges that hinder their ability to adopt alternative infant feeding methods. The financial burden of purchasing formulas or accessing healthcare services can be overwhelming, leading to a reluctance to embrace new practices that may further strain their limited resources. To achieve elimination in resource-poor settings, it is essential to implement strategies that empower women living with HIV economically, provide support during the nursing period, and address the systemic issues that perpetuate poverty and inequality. The Religious Barriers In many African countries, religion plays a profound role in shaping cultural beliefs and practices. Unfortunately, some religious leaders have perpetuated harmful misconceptions and myths about HIV/AIDS, creating a significant barrier to improving infant feeding practices among women living with HIV. These misconceptions not only hinder the adoption of alternative feeding methods but also contribute to stigma, discrimination, and social exclusion. To overcome these challenges, it is crucial to engage with religious leaders and communities, promote accurate information, and address the cultural and religious barriers that hinder progress toward elimination. Recommendations Addressing this socioeconomic predicament requires a multi-pronged, intervention-integrated approach. Educational initiatives It is imperative to periodically update caregivers with the latest research findings and guidelines. Workshops, seminars, and training programs tailored for both urban and rural settings can serve as effective platforms. Train caregivers on safe water practices, such as boiling or using chlorine tablets, especially where formula feeding is necessary due to HIV. In Nigeria’s Niger Delta, workshops should address petroleum pollution mitigation (e.g., using filtered water for formula preparation). Community engagement Working closely with community leaders and religious influencers can aid in reshaping societal perceptions around breastfeeding and HIV.9 Culturally sensitive awareness campaigns can alleviate stigma and foster understanding. Monitoring and accountability Establishing a system that periodically assesses the knowledge and practices of caregivers can deter complacency. Those found to deviate from established guidelines should be given the opportunity for remedial training. Support systems for mothers Providing HIV-positive mothers with resources, counseling, and alternative feeding options can empower them to make informed choices. Better still, government-funded formula feed subsidization should be instituted as this will go a long way in ensuring nil MTCT. It will be safe to also distribute water filters or purification tablets alongside subsidized formula to HIV-positive mothers. Even more, interventions that enhance immune reconstitution, such as micronutrient supplements, may be beneficial against transmission.2 Towards HIV-free infants rethinking feeding approaches The observed rise in pediatric HIV infections due to breastfeeding emphasizes the need for a holistic reevaluation of our current strategies. To combat HIV infection in rural African children, methods include prenatal screening and treatment of HIV-positive pregnant women, early infant HIV diagnosis using PCR testing within six weeks, community education on HIV, increasing healthcare access, and promoting contraceptives. These measures have reduced pediatric HIV rates, but further efforts are needed. Even more, a zero risk is not guaranteed, even with an undetectable viral load; this is because HIV can reside undetected within immune cells.10 While the global health community is tirelessly working towards an HIV-free generation, it is counterproductive if our ground-level practices remain trapped in outdated paradigms such as promoting exclusive breastfeeding for the first six months even if the mother is HIV-positive. Therefore, ensuring that grassroots healthcare practices align with evidence-based recommendations is a non-negotiable imperative. Most importantly, the global focus is transitioning from the Prevention of Mother-to-Child Transmission to the more ambitious goal of Elimination of Mother-to-Child Transmission (EMTCT). However, adhering to traditional exclusive breastfeeding practices for women living with HIV may hinder progress toward achieving the target of zero new pediatric HIV infections by 2030. Exclusive breastfeeding, while crucial for infant health, may not be sufficient to prevent transmission in all cases, particularly if the mother’s viral load is not adequately suppressed. To reach the EMTCT goal, it is essential to adopt a more comprehensive approach that includes optimal antiretroviral therapy adherence, viral load monitoring, and safe breastfeeding practices i.e. formula feeding with adequate support and guidance. It is high time we bridge the knowledge gap, ensuring that every HIV-positive mother is equipped and counseled to make safe choices that prioritize the health of her child/children in all ramifications. Acknowledgments The authors acknowledge The Lind League, Nigeria, for providing resources that supported the initiation, execution, and successful completion of this research project, while also enhancing our research capacity. Funding None. Conflicts of Interest None. Data Availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.