The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this "PMTCT cascade". Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence.

Disclosure of one's HIV status can help to improve uptake and retention in prevention of mother-to-child transmission of HIV services; yet, it remains a challenge for many women. This systematic review evaluates disclosure rates among pregnant and postpartum women in sub-Saharan Africa, timing of disclosure, and factors affecting decisions to disclose. PubMed and EMBASE databases were searched to identify relevant studies published between January 2000 and April 2014. Rates of HIV serostatus disclosure to any person ranged from 5.0% to 96.7% (pooled estimate: 67.0%, 95% CI: 55.7%-78.3%). Women who chose to disclose their status did so more often to their partners (pooled estimate: 63.9%; 95% CI: 56.7%-71.1%) than to family members (pooled estimate: 40.1; 95% CI: 26.2%-54.0%), friends (pooled estimate: 6.4%; 95% CI: 3.0%-9.8%), or religious leaders (pooled estimate: 7.1%; 95% CI: 4.3%-9.8%). Most women disclosed prior to delivery. Decisions to disclose were associated with factors related to the woman herself (younger age, first pregnancies, knowing someone with HIV, lower levels of internalized stigma, and lower levels of avoidant coping), the partner (prior history of HIV testing and higher levels of educational attainment), their partnership (no history of domestic violence and financial independence), and the household (higher quality of housing and residing without co-spouses or extended family members). Interventions to encourage and support women in safely disclosing their status are needed.

Disclosure of HIV serostatus among pregnant and postpartum women in sub-Saharan Africa: a systematic review

The most recent World Health Organization (WHO) guidelines on Human Immunodeficiency Virus (HIV) and infant feeding promotes exclusive breastfeeding (EBF) in resource limited settings for the prevention of mother to child transmission (PMTCT) of HIV. Literature reveals poor uptake of WHO feeding guidelines, with mixed feeding being a regular practice. In light of the limited success in EBF promotion, a realist review was conducted, analysing the use of feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa, where the majority of HIV childhood infections occur. We considered what mechanisms were at play, for whom and in what circumstances they led to exclusive breastfeeding. Because infant feeding counselling is a complex social intervention with a non-linear causal pathway for preventing mother to child HIV transmission, a realist methodology was chosen for this study. Using Pawson’s five stage sequence for conducting realist reviews, the results are presented as a set of identified and refined context-mechanism-outcome (CMO) configurations. These CMO configurations were used to show how particular outcomes occurred in specific contexts due to a generative mechanism and were developed through identifying a review question and program theory, searching for primary studies, quality appraisal, data extraction and data synthesis. From an initial 1010 papers, 27 papers met the inclusion criteria and were used to refine the program theory. Exclusive breastfeeding occurred when a woman was motivated regarding motherhood, had correct learning and understanding about infant feeding practices through counselling, no fear of breastfeeding or the impact of opposing feeding related cultural beliefs, and the support from others to be assertive about their feeding choices when faced with pressure to mix-feed. An additional CMO configuration was added during the refinement of the program theory identifying that mothers needed to not just understand but also prioritize EBF advice over cultural beliefs and stigma. The intended audience for this review are researchers and health care workers in PMTCT, particularly sub-Saharan Africa, who may benefit from the work that has been done to identify contexts for the success and failures of EBF.

/pdf/a-realist-review-of-infant-feeding-counselling-to-increase-3lobibhr9d.pdf

A realist review of infant feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa: what works for whom and in what contexts.

Background: Exclusive breastfeeding (EBF) means giving only breast milk to an infant. Although it is the optimal mode of feeding for infants younger than 6 months, its prevalence is low in HIV-endemic regions. Extensive promotion of EBF for 6 months in prevention of mother-to-child HIV transmission (PMTCT) programs could inadvertently result in stigma due to women's perceived association of EBF with HIV infection. In this qualitative study, we describe how stigma impacts the uptake of EBF among HIV-positive and -negative women. Methods: Pregnant and postpartum women and their male partners were recruited to participate in a total of 22 focus group discussions (FGDs). Transcripts were analyzed using ATLAS.ti. Codes were identified both a priori and inductively using the open coding approach. Major themes and subthemes were identified. Results: There was a broad and strong consensus among some FGD participants that HIV-related stigma was a barrier to EBF. EBF was perceived as a practice for HIV-pos...

/pdf/the-stigma-of-exclusive-breastfeeding-among-both-hiv-3a7s2hnfiz.pdf

The Stigma of Exclusive Breastfeeding Among Both HIV-Positive and HIV-Negative Women in Nairobi, Kenya.

Prevention of mother-to-child HIV transmission (PMTCT) programs usually test pregnant women for HIV without involving their partners. Non-disclosure of maternal HIV status to male partners may deter utilization of PMTCT interventions since partners play a pivotal role in decision-making within the home including access to and utilization of health services. Mothers attending routine 6-week and 9-month infant immunizations were enrolled at 141 maternal and child health (MCH) clinics across Kenya from June–December 2013. The current analysis was restricted to mothers with known HIV status who had a current partner. Multivariate logistic regression models adjusted for marital status, relationship length and partner attendance at antenatal care (ANC) were used to determine correlates of HIV non-disclosure among HIV-uninfected and HIV-infected mothers, separately, and to evaluate the relationship of non-disclosure with uptake of PMTCT interventions. All analyses accounted for facility-level clustering, Overall, 2522 mothers (86% of total study population) met inclusion criteria, 420 (17%) were HIV-infected. Non-disclosure of HIV results to partners was higher among HIV-infected than HIV-uninfected women (13% versus 3% respectively, p < 0.001). HIV-uninfected mothers were more likely to not disclose their HIV status to male partners if they were unmarried (adjusted odds ratio [aOR] = 3.79, 95% CI: 1.56–9.19, p = 0.004), had low (≤KSH 5000) income (aOR = 1.85, 95% CI: 1.00–3.14, p = 0.050), experienced intimate partner violence (aOR = 3.65, 95% CI: 1.84–7.21, p < 0.001) and if their partner did not attend ANC (aOR = 4.12, 95% CI: 1.89–8.95, p < 0.001). Among HIV-infected women, non-disclosure to male partners was less likely if women had salaried employment (aOR = 0.42, 95%CI: 0.18–0.96, p = 0.039) and each increasing year of relationship length was associated with decreased likelihood of non-disclosure (aOR = 0.90, 95% CI: 0.82–0.98, p = 0.015 for each year increase). HIV-infected women who did not disclose their HIV status to partners were less likely to uptake CD4 testing (aOR = 0.32, 95% CI: 0.15–0.69, p = 0.004), to use antiretrovirals (ARVs) during labor (OR = 0.38, 95% CI 0.15–0.97, p = 0.042), or give their infants ARVs (OR = 0.08, 95% CI 0.02–0.31, p < 0.001). HIV-infected women were less likely to disclose their status to partners than HIV-uninfected women. Non-disclosure was associated with lower use of PMTCT services. Facilitating maternal disclosure to male partners may enhance PMTCT uptake.

/pdf/prevalence-and-correlates-of-non-disclosure-of-maternal-hiv-2ecsz8px2u.pdf

Prevalence and correlates of non-disclosure of maternal HIV status to male partners: a national survey in Kenya

The World Health Organization (WHO) recommends that HIV-infected women practice exclusive breastfeeding (EBF) for the first 6 months postpartum to reduce HIV transmission. The aim of this study was to determine the effects of HIV/AIDS knowledge and other psychosocial factors on EBF practice among pregnant and postpartum women in rural Nyanza, Kenya, an area with a high prevalence of HIV. Data on baseline characteristics and knowledge during pregnancy, as well as infant feeding practices 4–8 weeks after the birth were obtained from 281 pregnant women recruited from nine antenatal clinics. Factors examined included: fear of HIV/AIDS stigma, male partner reactions, lack of disclosure to family members, knowledge of prevention of mother-to-child transmission (PMTCT) and mental health. In the analysis, comparisons were made using chi-squared and t-test methods as well as logistic multivariate regression models. There were high levels of anticipated stigma 171(61.2%), intimate partner violence 57(20.4%) and postpartum depression 29(10.1%) and low levels of disclosure among HIV positive women 30(31.3%). The most significant factors determining EBF practice were hospital delivery (aOR = 2.1 95% CI 1.14-3.95) HIV positive serostatus (aOR 2.5 95% CI 1.23-5.27), and disclosure of HIV-positive serostatus (aOR 2.9 95% CI 1.31-6.79). Postpartum depression and PMTCT knowledge were not associated with EBF (aOR 1.1 95% CI 0.47-2.62 and aOR 1.2 95% CI 0.64-2.24) respectively. Health care workers and counselors need to receive support in order to improve skills required for diagnosing, monitoring and managing psychosocial aspects of the care of pregnant and HIV positive women including facilitating disclosure to male partners in order to improve both maternal and child health outcomes.

/pdf/hiv-serostatus-and-disclosure-implications-for-infant-3c44sf8g28.pdf

HIV serostatus and disclosure: implications for infant feeding practice in rural south Nyanza, Kenya

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HIV serostatus and disclosure: implications for infant feeding practice in rural south Nyanza, Kenya