Abstract
BackgroundBotswana updated its antiretroviral treatment (ART) guidelines in May 2016 to support breastfeeding for women living with HIV (WLHIV) on ART who have documented HIV RNA suppression during pregnancy.MethodsFrom September 2016 to March 2019, we evaluated feeding method at discharge among WLHIV at eight government maternity wards in Botswana within the Tsepamo Study. We validated the recorded feeding method on the obstetric record using the prevention of mother-to-child transmission of HIV (PMTCT) counsellor report, infant formula dispensing log or through direct observation. Available HIV RNA results were recorded from the obstetric record, and from outpatient HIV records (starting February 2018). In a subset of participants, we used electronic laboratory records to verify whether an HIV RNA test had occurred. Univariable and multivariable logistic regression analyses were performed to identify factors associated with infant feeding choice.ResultsAmong 13,354 WLHIV who had a validated feeding method at discharge, 5303 (39.7%) chose to breastfeed and 8051 (60.3%) chose to formula feed. Women who had a documented HIV RNA result in the obstetric record available to healthcare providers at delivery were more likely to breastfeed (50.8%) compared to women who did not have a documented HIV RNA result (35.4%) (aOR 0.59; 95% CI 0.54, 0.65). Among women with documented HIV RNA, 2711 (94.6%) were virally suppressed (< 400 copies/mL). Breastfeeding occurred in a substantial proportion of women who did not meet criteria, including 46 (30.1%) of 153 women with HIV RNA > 400 copies/mL, and 134 (27.4%) of 489 women with no reported ART use. A sub-analysis of electronic laboratory records among 150 women without a recorded result on the obstetric record revealed that 93 (62%) women had an HIV RNA test during pregnancy.ConclusionsIn a setting of long-standing use of suppressive ART, with majority of WLHIV on ART from the time of conception, requiring documentation of HIV RNA suppression in the obstetric record to inform infant feeding decisions is a barrier to breastfeeding but unlikely to prevent a substantial amount of HIV transmission.
Highlights
Botswana updated its antiretroviral treatment (ART) guidelines in May 2016 to support breastfeeding for women living with Human Immunodeficiency Virus (HIV) (WLHIV) on ART who have documented HIV Ribonucleic acid (RNA) suppression during pregnancy
Despite outstanding ART coverage in pregnancy (95%), with 64.5% of WLWHIV conceiving on ART and very low (< 1.5%) mother-to-child HIV transmission (MTCT) [6, 7], Botswana has been slow to adopt a policy of universal breastfeeding for HIV-exposed infants
Study design and setting Tsepamo study overview We performed an analysis of infant feeding and HIV RNA data collected in the Tsepamo Study, an ongoing non-interventional birth outcomes surveillance study that collects data from obstetric records at large public maternity wards throughout Botswana [13]
Summary
Botswana updated its antiretroviral treatment (ART) guidelines in May 2016 to support breastfeeding for women living with HIV (WLHIV) on ART who have documented HIV RNA suppression during pregnancy. With over 20% of infants in the country HIVexposed [8, 9] the lack of breastfeeding for these children contributes substantially to Botswana’s high under-five mortality (41.6 deaths per 1000 live births) compared to the Sustainable Development Goal target to reduce under-five mortality to at least as low as 25 deaths per 1000 live births [10, 11] In recognition of this problem, Botswana chose to align its guidelines with those of the WHO in May 2016 to encourage greater breastfeeding for women living with HIV (WLHIV) on ART [12]. The updated guidelines retain an individualised approach to feeding, recommending counselling during pregnancy to ensure each woman makes the best decision for her situation
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