The Ditrame Plus project conducted in Abidjan, Côte d'Ivoire, is aimed at the prevention of mother-to-child transmission of HIV in combining perinatal antiretroviral interventions with a systematic proposal of alternatives to prolonged breast-feeding: formula feeding from birth, or exclusive breast-feeding for 3 months then early cessation of breast-feeding. We surveyed all health care workers involved in this project in November 2003 using a self-administered anonymous questionnaire to investigate their knowledge, attitudes, and beliefs regarding the infant feeding interventions proposed since March 2001. Their knowledge regarding infant practices proposed within the study was consistent and their attitude was in accordance with the study protocol. However, proposing alternatives to prolonged breast-feeding causes difficulties for health care workers that should be taken into account when tailoring such complex interventions.
From *Unité INSERM 593, Institut de Santé Publique Epidémiologie Développement, Université Victor Segalen, Bordeaux, France; and †Projet ANRS Ditrame Plus, Programme PAC-CI, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire.
Received for publication June 16, 2004; accepted January 24, 2005.
The primary sponsor of the ANRS 1201/1202 Ditrame Plus study was the Agence Nationale de Recherches sur le Sida (ANRS). Renaud Becquet was a fellow of the French Ministry of Education, Research and Technology. Didier K. Ekouevi was a fellow of the French charity Ensemble Contre le Sida. Laurence Bequet was supported by the French Ministry of Foreign Affairs.
Presented in part at the 15th International AIDS Conference, July 11-16, 2004, Bangkok, Thailand. Abstract ThPeC7294.
Reprints: Renaud Becquet, Unité INSERM 593, Institut de Santé Publique Epidémiologie Développement, Université Victor Segalen Bordeaux 2, 146 rue Léo Saignat, 33076 Bordeaux Cedex, France (e-mail: Renaud.Becquet@isped.u-bordeaux2.fr).
Mother-to-child transmission of HIV is a major public health problem in sub-Saharan Africa, where 55% of HIV-infected adults are women, all of child-bearing age.1 In these settings, predominant and prolonged breast-feeding is widely practiced (World Health Organization infant feeding definitions are detailed in Table 1) and is responsible for at least one-third of perinatally acquired HIV infections.2 This postnatal HIV transmission risk considerably reduces the effect of peripartum antiretroviral interventions aimed at the prevention of mother-to-child transmission of HIV (PMTCT).3 Several alternatives to prolonged breast-feeding, lowering the risk of breast milk HIV transmission, are conceivable and are currently being evaluated within several research projects.4 The evaluation of these postnatal nutritional interventions is complex and includes the assessment of their uptake: ie, the prenatal acceptability by pregnant women and the long-term compliance after birth. Yet, the assessment of this uptake could be impaired by the way health care workers actually give advice on infant feeding practices.5 The aim of this study was to investigate, within a PMTCT project in Abidjan, Côte d'Ivoire, knowledge of health care workers concerning infant feeding practices and their attitudes and beliefs regarding the alternatives to prolonged and predominant breast-feeding proposed within this project.
SUBJECTS AND METHODS
The Ditrame Plus study was an intervention cohort implemented in Abidjan, Côte d'Ivoire, in 2001, proposing to HIV-infected pregnant women a prenatal PMTCT antiretroviral treatment combined with postnatal nutritional interventions.6,7 Pregnant women were included after having been diagnosed as HIV infected in 1 of the 6 participating community-run health facilities located in the 2 most densely populated districts of Abidjan. There were no other selection criteria than being at least 18 years old, having accepted the study protocol, and signing an informed consent.8 The postnatal interventions were systematically proposed antenatally by health care workers. Women were asked to either completely avoid breast-feeding, use infant formula from birth, or to exclusively breast-feed with the aim to wean in a relatively short period (not exceeding 2 weeks) and to have completely ceased breast-feeding when the infant was between 3 and 4 months of age. Replacement feeding until 9 months of age and the equipment needed were provided free of charge by the project in both instances. Mother-infant pairs were followed up over 2 years in 2 clinics exclusively dedicated to the Ditrame Plus study. All transport costs were reimbursed and all care expenses related to any scheduled visit or clinical event were entirely supported by the project.
A total of 60 health care workers recruited from the local area were employed for this study: medical doctors, nutritionists, midwives, nurses, social workers, psychologists, pharmacists, and biologists. Before the beginning of the Ditrame Plus study, they had all received training that consisted of courses on PMTCT and mother and child health, along with a detailed presentation of the Ditrame Plus study protocol, including specific counseling on volunteer counseling and testing, family planning, and nutritional procedures. All were involved in the infant feeding intervention process: prenatal and postnatal nutritional counseling on infant feeding, infant nutritional, clinical and biologic follow-up, or provision of the breast milk substitutes.
In November 2003 we performed a cross-sectional survey using a self-administered anonymous questionnaire among all health care workers involved in the Ditrame Plus project. Information was colleted about their knowledge and attitudes concerning infant feeding alternatives to prolonged and predominant breast-feeding proposed within the project as well as their beliefs regarding these practices. They were also interviewed on conceivable infant feeding practices in the context of the future implementation of operational PMTCT activities with free provision of care and treatment to HIV-infected women and their children.9
Differences regarding beliefs between infant feeding practices were investigated using χ2 or Fisher exact test for qualitative variables when appropriate. Analysis was performed using the SAS software version 8.2 (SAS Institute, Inc., Cary, NC).
The ANRS (Agence Nationale de Recherches sur le Sida) 1201/1202 Ditrame Plus study was granted ethical permission in Côte d'Ivoire from the ethical committee of the National AIDS Control Programme and in France from the institutional review board of the ANRS.
All but 3 health care workers in the Ditrame Plus project (n = 57) filled in the questionnaire on November, 18, 2003; the remainder were on sick leave.
Concerning the infant feeding interventions proposed within the project, 43% knew the exact proportion of women who had initiated artificial feeding from birth (ie, half of the cohort), 24% overestimated this proportion, 9% underestimated it, and the remainder acknowledged they did not know. Within the Ditrame Plus project, the presentation of alternatives to prolonged and predominant breast-feeding was supposed to be hierarchical, ie, firstly complete avoidance of breast-feeding, then exclusive breast-feeding with early cessation from 3 months of age completed. We asked health care workers to explain how these interventions were presented to the women; 76% reported that this presentation was systematically done hierarchically as planned in the protocol; 10% mentioned the protocol was not followed; and 14% recognized it depended on the individual situations.
Overall, 96% of health care workers knew the price of a formula feeding tin (2000 CFA, ie, around 3 Euros), and 65% knew the number of feeds needed daily for a 3-month formula-fed child. According to 69% of health care workers, free provision of breast milk substitutes till 9 months of age within the project was a good strategy since the mothers could not afford it and to avoid the practice of mixed feeding; 21% believed the substitutes should have been given until 12 months of age; and 10% emphasized that the mothers should have purchased them by themselves. At the time of the study, 92% of health care workers were aware of the fact that some children included had acquired HIV infection through breast milk, and of these, 43% knew the exact number of cases.
Beliefs of health care workers and difficulties reported to them by mothers concerning infant feeding practices proposed within the Ditrame Plus project are reported in Table 2. According to health care workers, both of the nutritional interventions proposed were difficult to implement and practice, even in the well-monitored context of the project. Moreover, 83% emphasized that mothers included in the project reported to them at least once that these practices were difficult to carry out. Two-thirds of the health care workers surveyed emphasized that these 2 nutritional interventions were responsible for stigmatization problems with the partner or the family. According to health care workers, early breast-feeding cessation carried higher risk of infant malnutrition and illness than complete avoidance of breast-feeding.
In an operational context of PMTCT activities with free provision of care and treatment to HIV-infected women and their children, 76% of health care workers believed breast milk substitutes should be freely provided. They also mentioned that complete avoidance of breast-feeding would be more acceptable and feasible for children born to HIV-infected mothers, rather than exclusive breast-feeding with early cessation (94% vs. 20%, P < 0.01). In such an operational context, the choice of the feeding practice should be guided by the socioeconomic situation of the mother (45%); whether or not the partner is informed of the mother's serostatus (21%); the level of understanding of the mother (19%); the maternal CD4 count (13%); and the availability of nutritional management (2%). If a mother decided to breast-feed her child, health care workers proposed to wean at a median at 4 months of age (interquartile range: 3-5 months), emphasizing that the sooner the mother ceases breast-feeding, the lower the risk of postnatal transmission, and that at that age the children would be old enough for the introduction of complementary foods.
To our knowledge this study is the first to report on health care workers' points of view regarding infant feeding practices aimed at reducing breast milk HIV transmission. We conducted this study within a research project in Abidjan (Côte d'Ivoire), among health care workers specifically trained to propose to HIV-infected women infant feeding alternatives to prolonged breast-feeding. This survey was anonymous to limit the information bias that could have induced health providers to report favorable outcomes that reflect themselves in a positive light. Our purpose was to better understand how they used our research protocol in a real-life situation.
First, PMTCT health care workers' knowledge regarding infant practices proposed within the project was consistent and their attitude was in accordance with the study protocol.
Second, these nutritional interventions were perceived overall as difficult to carry out, especially because of the stigmatization and infant health problems for which they could be responsible. The risk of stigmatization was perceived as extremely high for the 2 alternatives to prolonged breast-feeding proposed within the project.
Third, according to health care workers, the practice of formula feeding appears safer than early cessation of breast-feeding, considering child health outcomes. This belief should be interpreted cautiously as it could underline a misconception of health care workers concerning the alternatives to prolonged breast-feeding that needs to be taken into account. In this context, it could indeed reveal difficulties in implementing early cessation of breast-feeding, a practice that was found to be less common than formula feeding among the general population of women attending community-run health facilities in Abidjan.10 Further analysis is ongoing to evaluate the acceptability of these alternatives to prolonged breast-feeding, as well as infant severe morbidity, mortality, and growth problems associated with infant feeding practices.
Health care workers were concerned by breast milk HIV infections. They urged the implementation of alternatives to prolonged and predominant breast-feeding, underscoring that the provision of breast milk substitutes would be crucial. Health care workers advisedly pointed out the complexity of the dilemma of infant feeding practices they face on a day-to-day basis in the context of HIV infection in resource-constrained countries. Nevertheless, it would have been useful to know in a more balanced way how health workers' attitudes affect their counseling practices.
The formation of staff involved in PMTCT programs is essential and should at least include specific training on mother and child health issues in the context of HIV, correct knowledge of the risk of MTCT, the advantages and disadvantages of each conceivable alternative to prolonged breast-feeding, and appropriate infant feeding counseling and support methods for HIV-infected women. Our study provides useful information that should be taken into account in the training of the staff proposing PMTCT infant feeding interventions in resource-limited settings.
The authors thank the health care workers of the Ditrame Plus team who participated in the study. This study is dedicated to the memory of Mrs. Pierrette Kassi.
Composition of the ANRS 1201/1202 Ditrame Plus Study Group
Principal Investigators: François Dabis, Valériane Leroy, Marguerite Timite-Konan, Christiane Welffens-Ekra. Coordination in Abidjan: Laurence Bequet, Didier K. Ekouévi, Besigin Tonwe-Gold, Ida Viho. Methodology, Biostatistics, and Data Management: Gérard Allou, Renaud Becquet, Katia Castetbon, Laurence Dequae-Merchadou, Charlotte Sakarovitch, Dominique Touchard. Clinical Team: Clarisse Amani-Bosse, Ignace Ayekoe, Gédéon Bédikou, Nacoumba Coulibaly, Christine Danel, Patricia Fassinou, Apollinaire Horo, Ruffin Likikouët, Hassan Toure. Laboratory Team: André Inwoley, François Rouet, Ramata Touré. Psychosocial Team: Hortense Aka-Dago, Hermann Brou, Annabel Desgrées-du-Loû, Alphonse Sihé, Benjamin Zanou. Scientific Committee: Stéphane Blanche, Jean-François Delfraissy, Philippe Lepage, Laurent Mandelbrot, Christine Rouzioux, Roger Salamon.
1. Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in Africa. Lancet
2. John-Stewart G, Mbori-Ngacha D, Ekpini R, et al. Breast-feeding and transmission of HIV-1. J Acquir Immune Defic Syndr
3. Leroy V, Karon JM, Alioum A, et al. Postnatal transmission of HIV-1 after a maternal short-course zidovudine peripartum regimen in West Africa. AIDS
4. Rollins N, Meda N, Becquet R, et al. Preventing postnatal transmission of HIV-1 through breast-feeding: modifying infant feeding practices. J Acquir Immune Defic Syndr
5. de Paoli MM, Manongi R, Klepp KI. Counsellors' perspectives on antenatal HIV testing and infant feeding dilemmas facing women with HIV in northern Tanzania. Reprod Health Matters
6. Becquet R, Ekouevi DK, Viho I, et al. Acceptability of exclusive breast-feeding with early cessation to prevent HIV transmission through breast milk, ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d'Ivoire. J Acquir Immune Defic Syndr
. 2005; (In press).
7. Dabis F, Bequet L, Ekouevi DK, et al. Field efficacy of zidovudine, lamivudine and single-dose nevirapine to prevent peripartum transmission of HIV. The ANRS 1201/1202 Ditrame Plus study, Abidjan, Côte d'Ivoire. AIDS
8. Ekouevi DK, Becquet R, Bequet L, et al. Obtaining informed consent in HIV-1 infected pregnant women participating in a PMTCT study in Abidjan, Côte d'Ivoire. AIDS
9. Mitka M. MTCT-Plus program has two goals: end maternal HIV transmission + treat mothers. JAMA
10. Becquet R, Castetbon K, Viho I, et al. Infant feeding practices before implementing alternatives to prolonged breast-feeding to reduce HIV transmission through breast milk in Abidjan, Côte d'Ivoire. J Trop Pediatr
. June 20, 2005:fmi050 (epub).
11. World Health Organization. Indicators for Assessing Breast-Feeding Practices: Report of an Informal Meeting. WHO/CDD/SER/91.14. Geneva: World Health Organization; 1991.
12. World Health Organization. UNICEF. Breastfeeding Counselling, a Training Course. WHO/CDR/93.5 - UNICEF/NUT/93.3. Geneva & New York: World Health Organization, UNICEF; 1993.
13. World Health Organization. UNICEF, UNAIDS. HIV and Infant Feeding: A Review of HIV Transmission Through Breast milk. Geneva: World Health Organization; 1998.