Understanding mother-to-child transmission of HIV among mothers engaged in HIV care in Kenya: a case report.

BACKGROUND: Mother-to-child transmission of HIV, which may occur in utero, during birth, or through breastmilk, is now largely preventable with the advancement of HIV testing and treatment for women and their infants. Globally, great progress has been recorded over the years, with a 58% decline in new infections in children from 2010 to 2022. Currently, Kenya is among the countries with the highest rates of mother-to-child transmission of HIV despite consistent efforts to promote prevention of mother to child transmission strategies. METHODS: This case report presents the experiences of a woman, engaged in HIV care in Kenya, whose baby contracted HIV. The data used to describe this case come from surveys, provider notes, health records, observational notes, notes from phone call consultations, and one in-depth interview. All data sources were carefully reviewed, compared and complied to describe the timeline of events and context of the participant's experience. RESULTS: We found multiple factors which may have contributed to this case of mother-to-child transmission of HIV. Antenatal care was initiated late in pregnancy (during the third trimester), and as a result, HIV diagnosis and treatment also occurred late in pregnancy. In addition, a lack of coordination between the clinic providing antenatal care and HIV treatment, and the hospital providing labor and delivery services led to breastfeeding initiation prior to the administration of infant HIV prophylaxis medications. Finally, poor maternal adherence to HIV medications went undetected and unaddressed until it was revealed by routine viral load monitoring three months after initiating HIV treatment (more than two months postpartum). CONCLUSIONS: Our case report shows the continued need for more intensive and integrated care for mothers living with HIV and their infants including support for pregnant women newly diagnosed with HIV, coordination of perinatal and HIV care, provisions for routine monitoring of HIV medication adherence, intensive follow-up care including point of care testing for HIV exposed infants and in person breastfeeding support. Our case report contributes an important perspective especially in light of the current UNAIDS Global AIDS Strategy which recently inspired the Global Alliance to end AIDS in Children.

Resilient Mothering: An Application of Transitions Theory From Pregnancy to Motherhood Among Women Living With HIV in Western Kenya.

Efficacious strategies can now prevent the transmission of HIV from mother to child. However, transmission rates remain unacceptably high, especially in sub-Saharan Africa. Understanding women's perinatal transitions can inform interventions to support adherence to preventive strategies. Therefore, we applied Transitions Theory in a longitudinal qualitative study to explore perinatal transitions among women living with HIV in western Kenya. We conducted in-depth interviews with 30 women living with HIV at 3 key time points and, using our findings, described the theory's concepts in terms of participants' experiences. We then proposed theory-based interventions that could support smooth transition processes and positive outcomes.

"It has changed my life": unconditional cash transfers and personalized infant feeding support- a feasibility intervention trial among women living with HIV in western Kenya.

BACKGROUND: The syndemic effects of poverty, food insecurity and living with HIV are recognized as global health priorities, including through the United Nations Sustainability Goals 1, 2 and 3. Today, women and girls account for 63% of all new HIV infections in eastern and southern Africa, including Kenya. Pregnant and postpartum women living with HIV in this setting face unique challenges including increased financial insecurity as women leave the work force to care for their newborn infants. This contributes to poverty, food scarcity and stress. METHODS: To address financial insecurity, improve infant feeding and reduce stress among mothers living with HIV in this setting, we developed a multilevel intervention, Supporting Healthy Mothers, consisting of 10 monthly unconditional cash transfers (10,000 KES, ~$75 USD/month) and personalized infant feeding support from pregnancy to 7 months postpartum. We conducted a non-randomized feasibility trial of this intervention among women engaged in HIV care in Kisumu, Kenya. From February 23, 2022 to March 23, 2022, we enrolled a total of 40 women who were 20-35 weeks pregnant-20 women to the intervention group at a public clinic, and 20 women to the control group at a similar clinic. Our aim was to assess feasibility, acceptability, and the potential impact of the intervention on food security, infant feeding and maternal mental health. RESULTS: Analyzing data from all 40 participants, we found a significant reduction in food insecurity scores from baseline for the intervention group when compared to the control group at 6 weeks and 6 months postpartum (p = 0.0008 and p < 0.0001, respectively). Qualitative exit interviews with intervention group participants confirmed women felt more financially secure and had newly acquired practical knowledge and skills related to infant feeding. Women found the two intervention components highly acceptable and described an overall positive impact on wellbeing. CONCLUSIONS: The Supporting Healthy Mothers intervention has potential to positively impact women across the perinatal period and beyond by increasing financial security and supporting women to overcome infant feeding challenges and should be assessed in larger trials. TRIAL REGISTRATION: Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, initially published on February 1, 2022. CLINICALTRIALS: gov ID: NCT05219552 Protocol ID: K23MH116807.

Feasibility, acceptability and lessons learned from an infant feeding intervention trial among women living with HIV in western Kenya.

BACKGROUND: The World Health Organization recommends mothers breastfeed exclusively for the first six months of their infant's life. However, women living with HIV in low resource settings face many barriers to recommended infant feeding practices such as fear of HIV transmission and perceived milk insufficiency. Moreover, current support for breastfeeding in this context is often insufficient to overcome these barriers. To support women's infant feeding experience, we tested a personalized infant feeding support program among perinatal women living with HIV in Kenya. METHODS: Supporting Healthy Mothers is a theory and evidence-based multilevel intervention designed to address the mental health burden associated with financial and food insecurity and provide personalized support for optimal infant feeding postpartum. As part of the Supporting Healthy Mothers intervention feasibility trial, between February 23, 2022 and November 9, 2022, twenty mothers received five personalized infant feeding support sessions delivered by a local professional lactation specialist from pregnancy until three months postpartum. Through detailed observations of these sessions, clinical notes and repeated team discussions, we aimed to describe and provide a limited evaluation of these sessions. We identified the strengths and limitations of the lactation support sessions as well as areas for future development. RESULTS: Participation in the sessions was high and at three months postpartum all participants reported exclusive breastfeeding as recommended despite experiencing a myriad of challenges. Having face-to-face and frequent early postpartum sessions, being available to field participant concerns between sessions and measuring infant weights at each session were key strengths. Continuing sessions beyond three months postpartum and incorporating family planning and general maternal health counseling topics would enhance these supportive sessions. CONCLUSIONS: The personalized professional infant feeding support sessions were highly acceptable and feasible to implement. In-person sessions, in a clinic setting provided opportunities to evaluate and adjust breastfeeding technique and led to successful exclusive breastfeeding practice. Future interventions should consider integrating with other perinatal care services and offering support on demand and immediately postpartum. TRIAL REGISTRATION: Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, posted on February 2, 2022. Identifiers: NCT05219552 Unique Protocol ID: K23MH116807.

Financial and Food Insecurity are Primary Challenges to Breastfeeding for Women Living with HIV in Western Kenya: A Longitudinal Qualitative Investigation.

Exclusive breastfeeding for the first 6 months and continued breastfeeding for 24 months or longer is recommended for all mothers world-wide, including women living with HIV (WLWH). Given evidence of suboptimal infant feeding and the need to understand context specific barriers, we explored experiences of perinatal WLWH in Kisumu, Kenya. We applied a longitudinal qualitative approach (4 in-depth interviews) with 30 women from pregnancy to 14-18 months postpartum. Cross-sectional profiling led to a narrative description of infant feeding across time. The majority of women breastfed exclusively for 6 months and weaned by 18 months. Severe financial and food insecurity were primary challenges as women worked through when/how to breastfeed or stop breastfeeding in the setting of multiple competing priorities/pressures across time. Financial and food support and increased support for breastfeeding beyond 18 months have the potential to reduce women's stress and uncertainty associated with infant feeding as well as optimize infant health and nutrition in this setting.

RESUMEN: Se recomienda la lactancia materna exclusiva durante los primeros 6 meses y la continuación de la lactancia durante 24 meses o más para todas las madres en todo el mundo, incluidas las mujeres que viven con el VIH (WLWH). Debido a la evidencia de alimentación infantil subóptima y la necesidad de comprender las barreras específicas del contexto, exploramos las experiencias de WLWH perinatal en Kisumu, Kenia. Aplicamos un enfoque cualitativo longitudinal (4 entrevistas en profundidad) con 30 mujeres desde el embarazo hasta los 14-18 meses posparto. El perfil transversal resultó en una descripción narrativa de la alimentación infantil a través del tiempo. La mayoría de las mujeres amamantaron exclusivamente durante 6 meses y dejó de amamantar a los 18 meses. La grave inseguridad financiera y alimentaria fueron los principales desafíos cuando las mujeres analizaban cuándo y cómo amamantar o dejar de amamantar en el contexto de múltiples prioridades y presiones en competencia a través del tiempo. El apoyo financiero y alimentario y un mayor apoyo para la lactancia más allá de los 18 meses tienen el potencial de reducir el estrés y la incertidumbre de las mujeres asociados con la alimentación infantil, así como optimizar la salud y la nutrición infantil en este entorno.

"I Found Out I was Pregnant, and I Started Feeling Stressed": A Longitudinal Qualitative Perspective of Mental Health Experiences Among Perinatal Women Living with HIV.

Globally, depressive symptoms among pregnant and postpartum (i.e., perinatal) women living with HIV (WLWH) are alarmingly high and associated with poor outcomes such as suboptimal adherence to antiretroviral therapy (ART), and early cessation of exclusive breastfeeding (EBF). Few qualitative studies have described the experience of perinatal depression among WLWH to identify the underlying social-structural determinants of poor mental health and potential strategies to intervene. We conducted a longitudinal qualitative study applying semi-structured interviews with 30 WLWH at three timepoints (28-38 weeks pregnant, 6-weeks postpartum and 5-7 months postpartum) to understand mental health experiences of perinatal WLWH in western Kenya. Financial insecurity emerged as the central theme impacting the mental health of women across time. Financial insecurity was often attributed to the loss of employment, related to pregnancy and the demands of breastfeeding and caring for an infant, as well as a lack of support from male partners. The loss of income and subsequent financial strain contributed to worsening levels of food insecurity and relationship stress and challenged engagement in HIV care. In this way, increased financial strain during the perinatal period negatively impacted the mental health of perinatal WLWH. Our findings suggest support to meet basic needs and remain engaged in HIV care during pregnancy and postpartum could improve perinatal mental health for WLWH in this setting.

Perinatal depressive symptoms and breastfeeding behaviors: A systematic literature review and biosocial research agenda.

BACKGROUND: Breastfeeding is recommended to improve maternal and infant health globally. Depression has been posited to negatively impact breastfeeding, although potential causal and bidirectional pathways between these two phenomena have not been sufficiently characterized. We therefore conducted a systematic review to critically evaluate available evidence on the relationship between perinatal depressive symptoms and breastfeeding behaviors; to identify knowledge gaps and propose a biosocial research agenda to advance our understanding of this topic. METHODS: A systematic search strategy was applied across seven databases. Data were extracted and aggregated using the matrix method to provide a narrative synthesis of findings. RESULTS: Thirty-eight studies from 20 countries spanning 1988 through 2018 fit the inclusion criteria. In general, methods across studies were heterogeneous. Fourteen different tools were used to measure perinatal depressive symptoms. Nearly half the studies did not provide breastfeeding definitions. No studies from low-income countries met inclusion criteria. More than half (63%) of studies demonstrated a negative association between depressive symptoms across the perinatal period and less exclusive breastfeeding and/or shorter breastfeeding durations. LIMITATIONS: Heterogeneity in study design, definitions, assessment tools, and measurement time points limited the comparability of study findings. Causality cannot be assessed. CONCLUSIONS: Available evidence suggests perinatal depressive symptoms negatively associated with breastfeeding exclusivity and duration, which can lead to suboptimal infant nutrition and detrimental impacts on maternal mental and physical health. To better understand this relationship, we propose including consistent operationalization and assessment of depression and breastfeeding globally and concurrent repeated measures of key biological and social factors.

Persistent Food Insecurity, but not HIV, is Associated with Depressive Symptoms Among Perinatal Women in Kenya: A Longitudinal Perspective.

Food insecurity (FI) is an understudied risk factor for depression among perinatal women in sub-Saharan Africa. We therefore explored the longitudinal relationship between FI and depressive symptoms among a cohort of perinatal women of mixed HIV status (n = 371) in Kenya (NCT02974972, NCT02979418). Using longitudinal linear and logistic regressions with random effects, we assessed bivariate and adjusted associations between maternal FI and depressive symptoms. HIV status was also assessed as a potential effect modifier. At baseline, 58% of pregnant women had probable depression (CES-D score > 16) and 84% were severely food insecure. In adjusted analyses, severely food-insecure women had 5.90 greater odds (95% CI 2.32, 15.02, p < 0.001) of having probable depression and scored 4.58 points higher on the CES-D scale (SE: 1.04, p < 0.001) relative to food-secure women. HIV status did not modify the association between FI and depressive symptoms. Interventions to reduce FI may reduce perinatal depression, benefiting mothers and their infants.

RESUMEN: La inseguridad alimentaria es un factor de riesgo del estrés en el periodo de posparto entre mujeres en África Sub-sahariana que es poco estudiado. Por lo tanto exploramos la relación entre la seguridad alimentaria y los síntomas de depresión con un estudio longitudinal entre un cohorte de mujeres en diferentes etapas perinatal y con diferentes estatus de VIH (n=371) en Kenia (NCT02974972, NCT02979418). Se evaluaron asociaciones bi-variadas y asociaciones ajustadas entre la inseguridad alimentaria y las síntomas de depresión usando regresión lineal y logística con efectos aleatorios. El estatus de VIH también se evaluó como modificador de efecto. Al inicio del estudio el 58% de mujeres embarazadas tenían depresión probable (CES-D score >16) y el 84% tenían un nivel de inseguridad alimentaria severa. Mujeres con un nivel de inseguridad alimentaria severa tenían mayores posibilidades del 5.90 (95% IC: 2.32, 15.02, p < 0.001) de depresión probable y una puntuación mas alta del 4.58 en el CES-D (EE: 1.04, p < 0.001) en comparación a las mujeres con un nivel de inseguridad alimentaria seguro. El estatus de VIH no modifico la asociación entre la inseguridad alimentaria y los síntomas de depresión. Intervenciones destinadas para mitigar la inseguridad alimentaria podrían reducir la depresión en el periodo perinatal, proporcionando beneficios a las mamas y sus bebes.

HIV infection, hunger, breastfeeding self-efficacy, and depressive symptoms are associated with exclusive breastfeeding to six months among women in western Kenya: a longitudinal observational study.

BACKGROUND: Exclusive breastfeeding for the first six months of life is recommended for all infants. However, breastfeeding rates remain suboptimal; around 37% of infants are exclusively breastfed for the first six months globally. In Nyanza region, western Kenya, numerous challenges to breastfeeding have been identified, including food insecurity, hunger, depressive symptoms, and HIV infection. Yet, evidence to inform our understanding of how these problems influence women's breastfeeding behaviors across time is lacking. We therefore sought to examine these factors and how they interact to affect the initiation and duration of exclusive breastfeeding in this region. We hypothesized that women experiencing greater food insecurity, hunger, and/or depressive symptoms would be less likely to maintain exclusive breastfeeding for six months than women who were food secure or not depressed. We also hypothesized that women living with HIV would be more likely to maintain exclusive breastfeeding to six months compared to HIV-uninfected women. METHODS: Women in Pith Moromo, a longitudinal cohort study in western Kenya, were surveyed at two antenatal and three postpartum timepoints (n = 275). Data were collected on breastfeeding behavior and self-efficacy, maternal food insecurity and hunger, maternal psychosocial health, and HIV status. Cox proportional hazards models were used to identify predictors of early exclusive breastfeeding cessation. RESULTS: The majority of women (52.3%) exclusively breastfed for the first six months. In the final multivariable Cox proportional hazards model, living with HIV was associated with a 64% decrease in the rate of early exclusive breastfeeding cessation. Additionally, the rate of early exclusive breastfeeding cessation increased by 100 and 98% for those experiencing probable depression or hunger, respectively. Although there was no main effect of breastfeeding self-efficacy, the interaction between breastfeeding self-efficacy and hunger was significant, such that the rate of early exclusive breastfeeding cessation was predicted to decrease by 2% for every point increase in breastfeeding self-efficacy score (range: 0-56). CONCLUSIONS: This study contributes to previous work demonstrating that women living with HIV more consistently exclusively breastfeed and suggests that rates of exclusive breastfeeding could be increased through targeted support that promotes maternal mental health and breastfeeding self-efficacy, while reducing maternal hunger. TRIAL REGISTRATION: Study registration NCT02974972.

Longitudinal Qualitative Methods in Health Behavior and Nursing Research: Assumptions, Design, Analysis and Lessons Learned.

Longitudinal qualitative research (LQR) is an emerging methodology in health behavior and nursing research. Researchers are turning to LQR to understand experiences across time as well as identify facilitators and inhibitors of health/illness behaviors and transitions. Currently, a lack of information exists to guide researchers on LQR techniques and considerations. Our objective was to provide a methodological resource for health behavior and nursing researchers conducting LQR. LQR may be applied to understand any human experience, as well as the sequalae of the experience and is well suited for studying transitions and developmental or behavioral changes. Conducting LQR is resource intensive and requires flexibility and complex analyses. We discuss multiple components of LQR such as design considerations, analysis options, and our lessons learned. Despite complexities, LQR provides the opportunity to understand experiences across time within an individual and among a group resulting in holistic, in-depth understandings beyond a cross-sectional time point.

Perinatal Food Insecurity and Postpartum Psychosocial Stress are Positively Associated Among Kenyan Women of Mixed HIV Status.

Stress and food insecurity (FI) are associated with poor perinatal and HIV outcomes. We hypothesized that FI would increase postpartum stress among women in Kenya, and that the impact would be greater in women with HIV. Among 371 pregnant women, we identified latent FI trajectories across the perinatal period, and estimated their association with postpartum stress. Stress metrics included the Perceived Stress Scale (PSS) and hair cortisol concentrations (HCC). We identified two FI trajectories: persistent moderate FI and persistent mild FI. Moderate FI (vs. mild) was associated with higher PSS; this association was stronger among HIV-negative women. We observed a trend towards higher HCC associated with moderate FI, which did not differ by HIV status. HCC and PSS were not correlated. In summary, moderate FI (vs. mild) was associated with increased stress. The lack of PSS-HCC correlation could reflect different physiological pathways. Interventions to mitigate FI could alleviate postpartum stress.

A Dyadic Investigation of Relationship Dynamics and Depressive Symptoms in HIV-Affected Couples in Malawi.

Depression is the leading cause of disability worldwide with health implications for people living with HIV. Primary partnerships like marriage could be protective against depression but may worsen depression depending on the relationship quality. We examined depression and its association with relationship dynamics in a cross-sectional sample of 211 HIV-affected married couples in Malawi. We fit multivariable multilevel linear regression models for depressive symptoms. Men and women reported similar levels of depressive symptoms; 28% had a score indicative of probable depression. Almost half of couples had at least one partner with probable depression. In the adjusted models, equality (B = - 0.22; p < 0.01) and unity (B = - 0.94; p < 0.05) were associated with fewer depressive symptoms while individuals with more experiences of physical (B = 0.81; p < 0.01), sexual (B = 0.87; p < 0.01), and emotional violence (B = 1.52; p < 0.001) had higher levels of depressive symptoms. Couples-based interventions aiming to improve relationships may address depression, especially in settings with inadequate mental health services.

Persistent Food Insecurity Is Associated with Adverse Mental Health among Women Living with or at Risk of HIV in the United States.

BACKGROUND: Food insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time. OBJECTIVE: We investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States. METHODS: We used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables. RESULTS: Among 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P < 0.001) higher depression scores, respectively. In models adjusting for both current and previous FS, previous marginal, low, and very low FS were associated with 0.2-, 0.93-, and 1.52-point higher scores, respectively (all P < 0.001). Women with very low FS at both time points (persistent food insecurity) had a 6.86-point higher depression score (P < 0.001). In the mental health models, there was a dose-response relation between current FS and worse mental health even when controlling for previous FS (all P < 0.001). Previous low FS was associated with worse mental health. These associations did not differ by HIV status. CONCLUSIONS: Food insecurity placed women at risk of depression and poor mental well-being, but the risk was substantially higher for women experiencing persistent food insecurity. Future interventions to improve women's mental health call for multilevel components that include addressing food insecurity.

Adaptation and psychometric evaluation of the breastfeeding self-efficacy scale to assess exclusive breastfeeding.

BACKGROUND: Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess exclusive breastfeeding self-efficacy, but rather self-efficacy for any breastfeeding. Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy. METHODS: We modified and added items from Dennis' Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1 (n = 239) and 3 (n = 238) months postpartum ( clinicaltrials.gov NCT02925429). We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge. RESULTS: The modification of the original BSES-SF to target exclusive breastfeeding produced 19 items, which were reduced to 9 based on item correlations and factor loadings. Two dimensions of the adapted scale, the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding BSES-EBF emerged: Cognitive and Functional subscales, with alpha coefficients of 0.85 and 0.79 at 3 months postpartum. Predictive and discriminant validity and known group comparisons assessments supported its validity. CONCLUSIONS: This version of the Breastfeeding Self-Efficacy scale, the BSES-EBF Scale, is valid and reliable for measuring exclusive breastfeeding self-efficacy in northern Uganda, and ready for adaptation and validation for clinical and programmatic use elsewhere.

"In the United States, we say, 'No breastfeeding,' but that is no longer realistic": provider perspectives towards infant feeding among women living with HIV in the United States.

INTRODUCTION: Currently, the United States (U.S.) recommends that infants born to women living with HIV (WLHIV) be fed formula, whereas many low-resource settings follow the World Health Organization's recommendation to exclusively breastfeed with ongoing antiretroviral therapy. Evidence on infant feeding among WLHIV in high-resource countries suggest that these contrasting recommendations create challenges for providers and patients. Our study used multiple methods to understand providers' infant feeding perspectives on caring for their pregnant and post-partum WLHIV in the U.S. METHODS: We sent a survey (n = 93) to providers across the U.S. who have cared for WLHIV. A subset of survey participants opted into a follow-up qualitative interview (n = 21). These methods allowed us to capture a broad understanding of provider attitudes via the survey and more nuanced qualitative interviews. The study was completed prior to an updated breastfeeding section of the U.S. Perinatal Guidelines. RESULTS: The majority of providers (66.7%) discussed infant feeding intent with their patients using open-ended questions. Many also discussed alternative feeding methods (37.6%) and disclosure avoidance strategies (34.4%). Over 75% (95% confidence interval (CI): 65.1 to 84.2) of participants reported that a WLHIV asked if she could breastfeed her child, and 29% (95% CI 20 to 40.3) reported caring for a patient who breastfed despite recommendations against breastfeeding. Providers reported that their patients' primary concern was stigma associated with not breastfeeding (58%), while providers were primarily concerned about medication adherence during breastfeeding (70%). Through qualitative analysis, four overarching categories emerged that reflect providers' sentiments, including (1) U.S. guidelines inadequately addressing WLHIV's desire to breastfeed; (2) negotiating patient autonomy amidst complex feeding situations; (3) harm reduction approaches to supporting WLHIV in breastfeeding; and (4) providers anticipating multilayered patient stigmatization. CONCLUSIONS: The majority of provider respondents cared for a WLHIV who desired to breastfeed, and a third had WLHIV who breastfed despite recommendations against it. Providers found that the status of U.S. guidelines and their incongruity with WHO guidelines left them without adequate resources to support WLHIV's infant feeding decisions. Our findings provide important insight to inform professional associations' discussions about public health policy as they consider future directions for infant feeding guidelines among WLHIV.

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV.

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

Exclusive breast-feeding promotion among HIV-infected women in South Africa: an Information-Motivation-Behavioural Skills model-based pilot intervention.

OBJECTIVE: Exclusive breast-feeding (EBF) provides optimal nutrition for infants and mothers. The practice of EBF while adhering to antiretroviral medication decreases the risk of mother-to-child transmission of HIV from approximately 25 % to less than 5 %. Thus the WHO recommends EBF for the first 6 months among HIV-infected women living in resource-limited settings; however, EBF rates remain low. In the present study our aim was to design and implement a pilot intervention promoting EBF among HIV-infected women. DESIGN: The Information-Motivation-Behavioural Skills (IMB) model was applied in a brief motivational interviewing counselling session that was tested in a small randomized controlled trial. SETTING: Pietermaritzburg, South Africa, at two comparable rural public health service clinics. SUBJECTS: Sixty-eight HIV-infected women in their third trimester were enrolled and completed baseline interviews between June and August 2014. Those randomized to the intervention arm received the IMB-based pilot intervention directly following baseline interviews. Follow-up interviews occurred at 6 weeks postpartum. RESULTS: While not significantly different between trial arms, high rates of intention and practice of EBF at 6-week follow-up were reported. Findings showed high levels of self-efficacy being significantly predictive of breast-feeding initiation and duration regardless of intervention arm. CONCLUSIONS: Future research must account for breast-feeding self-efficacy on sustaining breast-feeding behaviour and leverage strategies to enhance self-efficacy in supportive interventions. Supporting breast-feeding behaviour through programmes that include both individual-level and multi-systems components targeting the role of health-care providers, family and community may create environments that value and support EBF behaviour.

A Critical Review of Instruments Measuring Breastfeeding Attitudes, Knowledge, and Social Support.

BACKGROUND: Breastfeeding provides beneficial health outcomes for infants and their mothers, and increasing its practice is a national priority in many countries. Despite increasing support to exclusively breastfeed, the prevalence at 6 months remains low. Breastfeeding behavior is influenced by a myriad of determinants, including breastfeeding attitudes, knowledge, and social support. Effective measurement of these determinants is critical to provide optimal support for women throughout the breastfeeding period. However, there are a multitude of available instruments measuring these constructs, which makes identification of an appropriate instrument challenging. Research aim: Our aim was to identify and critically examine the existing instruments measuring breastfeeding attitudes, knowledge, and social support. METHODS: A total of 16 instruments was identified. Each instrument's purpose, theoretical underpinnings, and validity were analyzed. RESULTS: An overview, validation and adaptation for use in other settings was assessed for each instrument. Depth of reporting and validation testing differed greatly between instruments. CONCLUSION: Content, construct, and predictive validity were present for most but not all scales. When selecting and adapting instruments, attention should be paid to domains within the scale, number of items, and adaptation.

Perinatal Depression Among HIV-Infected Women in KwaZulu-Natal South Africa: Prenatal Depression Predicts Lower Rates of Exclusive Breastfeeding.

Exclusive breastfeeding (EBF) provides infants with optimal nutrition, and together with appropriate antiretroviral therapy has also been shown to decrease mother-to-child transmission of HIV from 45 to less than 1 %. However, rates of EBF are particularly low in South Africa, where rates of HIV are some of the highest in the world. Although perinatal depression has been identified as a potential barrier to EBF, little is known about its impact on EBF among HIV-infected women. A cohort study was conducted as part of a pilot randomized controlled trial (RCT) examining the effect of an Information, Motivation and Behavioral skills-based intervention promoting EBF among South African women living with HIV in their third trimester (28-42 weeks) of pregnancy. At baseline and follow-up, participants were interviewed on depression symptoms (PHQ-9), and breastfeeding intentions and behavior. Multivariate logistic regressions were conducted to determine predictors of EBF at 6-weeks postpartum. A total of 68 women were enrolled and 58 women completed both baseline and follow-up assessments. Most (80.9 %) of the sample reported at least some symptoms of depression prenatally. Rates of depression were lower postpartum (47.1 %). In multivariate models, higher prenatal depression scores significantly predicted lower likelihood of EBF at 6-weeks postpartum after adjusting for demographics, condition, and intentions (AOR = 0.68, p < 0.05). Postpartum depression was not a significant predictor of EBF rates (AOR = 0.99, p = 0.96). These findings demonstrate the negative impact of prenatal depression on breastfeeding behavior. Future interventions focused on depression are warranted to identify those at risk for sub-optimal EBF. Improving maternal psychosocial well-being could be a new frontier to improving infant and young child feeding and reducing pre/postnatal transmission.

Breastfeeding Self-efficacy: A Critical Review of Available Instruments.

Increasing breastfeeding rates in the United States is a national priority. Yet, initiation and duration of breastfeeding remains below national targets. Breastfeeding self-efficacy has been shown to be a strong predictor of both breastfeeding initiation and duration and is therefore an important characteristic to be able to measure. However, there is currently a myriad of instruments for measuring breastfeeding self-efficacy, which makes selection of an appropriate instrument difficult. Thus, our aim was to identify, compare, and critically review available breastfeeding self-efficacy instruments. In a systematic review, 6 breastfeeding self-efficacy instruments were identified. The instruments' purposes, theoretical framework, final scale development, and application in 5 most recent settings were analyzed. The 6 breastfeeding self-efficacy instruments apply a number of theoretical and conceptual frameworks in their development, with Bandura's social cognitive theory being most common. Content, construct, and predictive validity were strong for most scales. Some, but not all, have been successfully adapted to novel settings. In sum, there are several measurements of breastfeeding self-efficacy that can and should be employed to better understand reasons for suboptimal breastfeeding rates and the effects of interventions on breastfeeding self-efficacy. Instrument selection should be based on domains of primary interest, time available, peripartum timing, and assessment of previous adaptations. Failure to apply appropriate measures in research may garner results that are inconclusive, inaccurate, or nonrepresentative of true study effects.