Breastfeeding cessation in the era of Elimination of Mother to Child Transmission of HIV in Uganda: a retrospective cohort study

Background To recommends that breastfeeding should cease at one year for infants born to HIV infected mothers but data are limited. We examined the magnitude and factors associated with breastfeeding cessation at one year among HIV infected postpartum mothers at Ndejje Health Center IV, a large peri-urban health facility in Uganda. Methods We conducted a retrospective cohort study involving all HIV infected postpartum mothers enrolled on EMTCT program for at least 12 months, between June 2014 and June 2018, abstracted data from EMTCT registers, held four focused group discussions with HIV infected postpartum mothers and four key informant interviews with healthcare providers. Breastfeeding cessation was defined as the proportion of HIV infected postpartum mothers who stopped breastfeeding an HIV exposed infant (HEI) at one year. We summarized quantitative data descriptively, tested differences in outcome with the Chi-square and t-tests, and established factors independently associated with breastfeeding cessation using modified Poisson regression analysis at 5% statistical significance level, and thematically analyzed qualitative data to enrich and triangulate the quantitative results.

3 might increase the risk of mother to child transmissions of HIV. Breastfeeding cessation at one year was more likely when the HEI was female than male and when the HIV infected postpartum mother was multiparous than primparous, but less likely when breastfeeding was initiated on same-day as birth. Interventions to enhance breastfeeding cessation at one year should target these areas.

Background
In sub-Sahara African region (SSA), an estimated 60% of infants born to Human Immunodeficiency Virus (HIV) infected mothers acquire HIV during pregnancy, delivery, or breastfeeding.(1) The rates of mother to child transmission of HIV (MTCT) in SSA range from 5% to as high as 30%. HIV infected mothers is therefore recommended as per the WHO EMTCT guidelines. (6) Ndejje Health Center IV is one of the several health facilities accredited in Wakiso district to provide prevention of mother to child transmission of HIV (PMTCT) Option B Plus, a strategy for elimination of MTCT of HIV. However, there is still a report on infants sero-converting to HIV infection due to the mother's persistence to breastfeed her exposed infant after the recommended one year cessation of breastfeeding. Data are limited on factors associated with breastfeeding cessation at one year among HIV infected postpartum mothers.
Our study examined these factors to inform the implementation of breastfeeding practices as per the recommended EMTCT guideline.

Study design and setting
We designed a retrospective cohort study using available data within the EMTCT program in which exposure to breastfeeding had occurred at some time in the past. The cohort consisted of all HIV infected postpartum mothers enrolled on EMTCT program between June 2014 and June 2018 at Ndejje Health Center IV, a large peri-urban health facility in Makindye Division, Wakiso district, Uganda. We chose this health facility because it serves a greater proportion of HIV infected mothers in the division and it has a high number of patient load. Ndejje Health Center (HC) IV implements the Uganda national and World Health Organization's Option B Plus (7), a policy we have fully described elsewhere. (8,9) Under this policy, all HIV infected pregnant mothers are started on Anti-retroviral Therapy (ART for life irrespective of their immunological and clinical status while an HEI receive Nevirapine syrup as prophylaxis from birth until six weeks adjusted according to weight and age bands. Once Nevirapine syrup is stopped at six weeks, Cotrimoxazole prophylaxis is introduced, a dry blood spot is obtained for HIV test using Deoxyribonucleic Acid-Polymerase Chain Reaction (DNA-PCR). At one year, breastfeeding ceases and another dry blood spot is obtained at exactly six weeks after breastfeeding cessation for the second DNA-PCR test. A final HIV test is performed at 18 months using a rapid HIV test.
However, should the HEI test HIV positive at any of the testing time points, ART is started and 5 Cotrimoxazole prophylaxis is continued for life. It is important to note that HEIs receive exclusive breastfeeding for the first six months of life and complementary feeding commences thereafter.

Study population and sample size
The study population consisted of all HIV infected postpartum mothers enrolled on EMTCT program for one year or more, and all of them were still receiving HIV care at the health facility at the time of data abstraction. We excluded HIV infected postpartum mothers with an HEI below one year of age because it would be erroneous to measure breastfeeding cessation in such mother-baby pairs, and those transferred to other health facilities because it was infeasible to obtain data on breastfeeding cessation. We did not calculate a sample size but used census sampling as a retrospective cohort study that consisted of records review was conducted. Accordingly, exposures had occurred at a time in the past and outcomes were determined at the time of data analysis. The cohort consisted of all HIV infected postpartum mothers enrolled on EMTCT program in the period June 2014 to June 2018, followed for at least 12 months to establish exposures and outcome.

Study variables
Our outcome variable was breastfeeding cessation at one year, measured on a binary scale (yes and no). We defined breastfeeding cessation at one year as the proportion of HIV infected postpartum mothers documented in the early infant diagnosis of HIV (EID) register to have stopped breastfeeding at one year. The independent variables included: maternal variables such as age in years but later dichotomized as below 25 and 25 years and beyond, monthly income measured in Ugandan Shillings, marital status measured as single or never married, currently married and divorced, stigma and discrimination measured independently as yes and no, disclosure of HIV sero-status measured as yes and no, knowledge of MTCT during pregnancy, labour, and delivery measured as yes and no, antenatal care attendance at last pregnancy measured as yes and no, number of antenatal care attendances at last pregnancy, ART regimen measured as Tenofovir (TDF) or Zidovudine (AZT) containing regimen, parity measured as nulliparous, secundiparous, and multiparous, nutrition status measured by maternal body mass index (BMI) as weight in kilograms per height in meters squared and later categorized as malnourished (BMI≤18.1 kg/m 2 ), well nourished (BMI 18.2-24.9 kg/m 2 ), 6 overweight (BMI 25.0-30.0 kg/m 2 ), mild obese (BMI 30.1-34.9 kg/m 2 ) and over obese (BMI ≥35.0 kg/m 2 ), and place of delivery measured as health facility and home. The infant variables we studied included age in months, sex measured as male and female, and nutritional status measured using mid-upper arm circumference (MUAC) categorized as malnourished (MUAC <11.5 cm), at risk of malnutrition (MUAC 11.5-12.4 cm), and well-nourished (MUAC ≥12.5 cm). We questioned HIV infected postpartum mothers on modes of mother to child transmission of HIV and the likely preventive measures, the importance of breastfeeding, when to stop breastfeeding in an HEI, and the reasons for stopping to breastfeeding and HEI before one year of age or after one year of age.

Data collection
We used two methods of data collection: quantitative and qualitative. For quantitative data, we reviewed the PMTCT and EID registers and abstracted data using a standardized checklist. We corroborated all entries in the registers with that in the electronic database (Open-MRS) to ensure data integrity. To enrich and triangulate the quantitative results, we conducted qualitative interviews with HIV infected postpartum mothers and healthcare providers. In particular, we held four focus group discussions (FGDs), each consisting of eight to 12 HIV infected postpartum mothers selected randomly from amongst those attending the EMTCT clinic. The FGDs were held within the premises of the health facility in the local language "Luganda" by two research assistants (JGP and MN, both female MPH postgraduate students trained in qualitative research methods).

Qualitative data
We audio-recorded all interviews and transcribed them verbatim. To ensure accuracy in transcription, we correlated the audio-recordings with the transcripts by replaying the audio-recordings. We exported the transcripts to Nvivo, a qualitative data analysis software, for thematic analysis where two reviewers (JGP and SO) read the transcripts thoroughly and coded them independently for common patterns. The independent coding prevented selective perception and interpretive biases in the coding process. The codes were then compared and discrepancies resolved by consensus and a final codebook was developed. The codes were used to enrich and triangulate the quantitative results.

Quantitative data
We single-entered quantitative data in Epi-Data version 3.1 (11) with quality control measures namely skip patterns, alerts, range and legal values, and then exported the data to Stata version 15 for analysis.(12) We analyzed numeric data using descriptive statistics of means and standard deviations, and categorical data using frequencies and percentages.
To determine breastfeeding cessation at one year, the numerator was the number of HIV infected postpartum mothers who stopped breastfeeding at one year expressed as a percentage of the sample size, coded as "1" and "0" to denoted "yes" and "no" respectively. We tested differences in proportions of breastfeeding cessation at one year with categorical variables using the Chi-squared test for large cell counts (five and more counts) and the Fisher's exact test for smaller cell counts (less than five counts). To test for differences in means of breastfeeding cessation at one year with numerical variables such as age, we used the student's t-test. We considered variables with probability values (p values) less than five percent as statistically significant for univariable and multivariable analyses. Our data showed that the outcome variable was frequent (more than 10%). Accordingly, the odds ratio (OR) was not an appropriate measure of association because of overestimation. (13,14) We hence used risk ratios (RR) for both unadjusted and adjusted analysis computed using a modified Poisson regression analysis with robust error variance to control for mild violations of the assumptions of Poisson regression analysis. We reported each RR with subsequent 95% confidence intervals (CI). We noted that five (2.1%) HEIs had missing data on sex but 8 we did not imputed them at multivariate analysis because the missing observations were fewer than 10%.

Human subject issues
Clarke International University Research Ethics Committee, CIU-REC (reference #CIU-REC/0136), approved this study. We received administrative approval from the Health Department of Wakiso district (reference # CR: MSMC 220/1). Key informants and focus group participants provided a written informed consent after explaining the purpose, benefits and risks of the research.
Participation in the study was voluntary and participants were free to withdraw at any stage if they so wished. All participant data were handled with confidentiality and privacy, and individual identifiers were anonymized.

Socio-demographic characteristics of HIV infected mothers
Of the 235 HIV infected mothers in the cohort, 138 (58.7%) were aged 16 to 25 years, 69 (29.4%) multiparous, 107 (43.5%) well nourished, and 27 (11.5%) initiated breastfeeding on same day as birth (Table 1). We observed a statistically significant difference in breastfeeding cessation with respect to breastfeeding initiation on same day as birth (p<0.01), ever attending antenatal care visits at recent pregnancy (p = 0.02), time of initiation of Cotrimoxazole prophylaxis (p = 0.04) and and infant sex (p = 0.002). There was no statistically significant difference in breastfeeding cessation at one year with regards to maternal age, parity, place of delivery, and ART regimen (all p>0.05).

Level of breastfeeding cessation at one year and the rationale
Our data showed that 150 (63.8%) HIV infected postpartum mothers' ceased breastfeeding at one year. In FGDs, HIV infected postpartum mothers mentioned several reasons for breastfeeding cessation before one year. In particular, they reported that work demands could not allow them breastfeed up to one year as illustrated in the below quotes.
"I am just 23 years with my child, I had to leave him at home with his grandmother and go to work to support him so he did not get consistence breast milk and ended up leaving to breast feed completely by himself "(FGD with HIV infected mothers) "I have also seen some other young girls leaving their children with the grand mothers and go work in other houses as house workers, they end up leaving the child from breast feeding at even 6months

Factors associated with breastfeeding cessation at one year.
In unadjusted analysis (Table 2), our data showed that breastfeeding cessation at one year was more likely when the HEI was female than male (Unadjusted RR (URR), 1.35, 95% CI, 1.10-1.66), and when the HIV infected postpartum mothers was 25 years of age or more compared to when she was below 24 years (URR, 1.21, 95% CI, 1.00-1.46). Conversely, breastfeeding cessation at one year was less likely when Cotrimoxazole prophylaxis was initiated at or after six weeks of birth relative to before six weeks of birth (URR 0.87; 95% CI, 0.79-0.95) and when HIV infected postpartum mothers had initiated breastfeeding on same day as birth (URR, 0.10; 95% CI, 0.03-040). However, ever attending antenatal care at recent pregnancy was not associated with breastfeeding cessation at one year (URR, 1.05; 95% CI, 0.87-1.28).
After adjusting for all statistically significant and clinically relevant factors (Table 2), our results showed that breastfeeding cessation at one year was more likely in female than male HEIs (Adjusted RR (aRR), 1.25; 95% CI, 1.04, 1.50) and when the HIV infected postpartum mothers was multiparous than primparous (aRR, 1.26; 95% CI, 1.04-1.53). In FGDs, HIV infected postpartum mothers noted that male HEIs breastfeed more than their female counterparts. For this reason, male HEIs were stopped from breastfeeding earlier than female HEIS as illustrated in the below excerpts.

"Those boys can feed, they want to breastfeed every second and I feared my breast may get torn.
Personally, I stopped breast feeding boys at 9 months because feeding them needs too much" (FGD with HIV infected mothers).

"They [meaning male HEIs] feed so much. We [meaning HIV infected postpartum mothers] don't get
peace at all, the girls feed a bit less and we can manage our daily activates while breast feeding "(FGD with HIV infected mothers) "The boys, once they get teeth, they can bite so hard and it's so painful and so I had to stop him from breast feeding" (FGD with HIV infected mothers).
We also found that HIV infected postpartum mothers who initiated breastfeeding on same day as birth were less likely to cease breastfeeding at one year compared to those who delayed breastfeeding initiation on same day as birth (aRR, 0.06, 95% CI, 0.01-0.41). In KIIs, a healthcare provider reported that primarous and secundiparous mothers have less interest in breastfeeding compared to multiparous mothers as demonstrated in the below quotation.
"The girls who have one or two children do not want to breast feed, they say that they do not want their breasts to fall" (KII, Healthcare provider)

Discussion
We studied breastfeeding cessation at one year among infants born to HIV infected mothers in a large peri-urban ART clinic in Wakiso district, Uganda. Our data shows 64% of HEIs ceased breastfeeding at one year contrary to the WHO and Uganda National EMTCT policy recommendations of ceasing all HEIs from breastfeeding at one year.(6) In Ethiopia,(15) a study reports that 34% of HIV infected postpartum mothers ceased to breastfeed at one year, which is substantially lower that what we report in this study. Another Ethiopian study reports 45.5% breastfeeding cessation at one year which is also lower than our finding. (16) The observed differences could possibly be attributed to cultural differences between the two countries. In Uganda, breastfeeding is a norm and is embraced by almost all cultures.
Our study shows that a HIV infected mother is more likely to cease breastfeeding at one year when the HEI is female than male. This finding is surprising because one would not expect differences in breastfeeding duration between male and female HEIs. Our finding contradicts earlier study which reports lack of association between sex and breastfeeding cessation at one year among HEIs. (17) However, the previous study reports that female HEIs are less likely to be HIV infected compared to males because the later are started on complementary feeding at an earlier age thus placing them at increased risk of HIV acquisition, (17) suggesting female HEIs are breastfed for a longer period than male HEIs. This is consistent with our results. Although we did not find biologically plausible reasons for the association between sex and breastfeeding cessation, in FGDs with HIV infected mothers, male HEIs were reported to breastfeed more often than females and this reason is hypothesized to have a 11 draining and exhausting effect on mothers hence the early breastfeeding cessation. Despite the differences, our finding seem to emphasis that routine provision of health education on benefits of breastfeeding HEIs until one year of age to HIV infected mothers is important in implementing EMTCT guideline.
We found multiparous HIV infected postpartum mothers were more likely to cease breastfeeding at one year relative to primparous mothers. This might have resulted from differences in experience with the EMTCT program, with multiparous mothers having gained sufficient knowledge and experience compared to nulliparous mothers. Our finding is consistent with that of Hackman et al (2015) (16) who observed that the number of children ever born to a woman determines the time at which breastfeeding is ceased. In their study, (16) Hackman et al (2015) found that multiparous HIV infected mothers had a significantly longer breastfeeding duration as compared to primiparous mothers.
Another study in Ethiopia shows that mothers who are deficient in EMTCT knowledge are less likely to adhere to breastfeeding guidelines(18), a demonstration that experience with EMTCT program is a crucial factor in determining the time at which HIV infected mothers cease to breastfeed an HEI. In general, our result signals that primparous HIV infected mothers might benefit from targeted health education messages compared to multiparous mothers.
Our study shows that HIV infected postpartum mothers who initiated breastfeeding on same-day as birth were less likely to cease breastfeeding at one year compared to those who initiated breastfeeding on another day. Although no previous findings are consistent with this result, several reasons could explain the non-initiation of breastfeeding on same-day as birth namely, insufficiency of breast milk, low birth weight, and premature birth among others.(19) Another plausible explanation could be differences in knowledge on breastfeeding practices. It is even possible that those who initiated breastfeeding on same-day as birth were those who actually had knowledge of importance of breastfeeding within the first hour of birth. Consequently, in providing EMTCT interventions, healthcare providers should emphasize the importance of early initiation of breastfeeding within the first hour of birth.

Study Strengths And Limitations
This study has several strengths. First, it is among the first study in Uganda to examine the implementation of the WHO policy recommendation on breastfeeding cessation at one year among HIV infected mothers following its adoption in 2016. Second, the use of qualitative data to enrich and triangulate the quantitative findings is another strength. However, a number of limitations should be considered in the interpretation of the results. We used a retrospective cohort study design and this design by default does not demonstrate causation rather association. Our study was conducted in a peri-urban health facility so the results might not be generalizable to rural health facilities. We did not study several potential confounders because we used secondary data and this was an important limiting factor. However, we tried to overcome this problem by incorporating qualitative data to enrich the data. Besides, there is a possibility that data recorded in the registers might have recording biases as well as transcription errors although we made efforts to verify all the data for accuracy. Our study could not conclude on the outcomes of HEIs transferred to other health facilities because it was logistically impractical to obtain such data. Lastly, our sample size was relatively small despite the inclusion of all mother-baby pairs in the cohort.

Conclusions And Recommendations
Our study shows that approximately 64% of HIV infected postpartum mothers cease breastfeeding at one year, which is substantially lower that the WHO recommended target in the EMTCT policy. The healthcare system should therefore strengthen the implementation and adoption of the EMTCT policy.
We found breastfeeding cessation at one year was more likely when an HEI was female than male, when the HIV infected mother was multiparous than primaparous, and less likely when breastfeeding was initiated on same-day as birth relative to when it was after the first day of birth. We recommend the strengthening of health education messages on infant feeding in the context of HIV among every

Ethics and consent to participate
This study was approved by Clarke International University Research Ethics Committee, CIU-REC (reference # CIU-REC/0136) and received administrative approval from the Health Department of Wakiso district (reference # CR: MSMC 220/1). All participants interviewed provided written informed consent and were free to withdraw at any stage if they so wished.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.