After their wives have delivered, a lot of men like going out: Perceptions of HIV transmission risk and support for HIV prevention methods during breastfeeding in sub-Saharan Africa

Valerie L Flax, Imogen Hawley, Julia Ryan, Miria Chitukuta, Florence Mathebula, Rita Nakalega, Linly Seyama, Frank Taulo, Ariane van der Straten, MTN-041/MAMMA Study Team, Valerie L Flax, Imogen Hawley, Julia Ryan, Miria Chitukuta, Florence Mathebula, Rita Nakalega, Linly Seyama, Frank Taulo, Ariane van der Straten, MTN-041/MAMMA Study Team

Abstract

Female-initiated HIV prevention methods, such as oral pre-exposure prophylaxis (PrEP) and the vaginal ring, may be important risk reduction strategies for breastfeeding women. Given their novelty, information about the sociocultural context and how it influences perceptions of and support for their use during breastfeeding is lacking. To address this gap, we conducted 23 focus group discussions separately with pregnant and breastfeeding women, male partners and grandmothers (N = 196) and 36 in-depth interviews with key informants in Malawi, South Africa, Uganda and Zimbabwe. We analysed the data using a framework analysis method. Overall, breastfeeding was the norm, and participants described the transference of health (e.g., nutrition) and disease (e.g., HIV) to children through breast milk. Participants considered the early breastfeeding period as one of high HIV transmission risk for women. They explained that male partners tend to seek outside sexual partners during this period because women need time to recover from delivery, women focus their attention on the child, and some men are disgusted by breast milk. Participants highlighted concerns about the drugs in oral PrEP transferring to the child through breast milk, but fewer worried about the effects of the vaginal ring because the drug is localized. Women, grandmothers and key informants were supportive of women using these HIV prevention methods during breastfeeding, while male partners had mixed opinions. These findings can be used to tailor messages for promoting the use of PrEP or the vaginal ring during breastfeeding in sub-Saharan Africa.

Keywords: HIV prevention; breast milk; breastfeeding; qualitative; sub-Saharan Africa.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Study sample by country and type of participant

References

    1. Aboud, S. , Msamanga, G. , Read, J. S. , Wang, L. , Mfalila, C. , Sharma, U. , … Fawzi, W. W. (2009). Effect of prenatal and perinatal antibiotics on maternal health in Malawi, Tanzania, and Zambia. International Journal of Gynaecology and Obstetrics, 107(3), 202–207. 10.1016/j.ijgo.2009.07.037
    1. Baeten, J. M. , Palanee‐Phillips, T. , Brown, E. R. , Schwartz, K. , Soto‐Torres, L. E. , Govender, V. , … MTN‐020 ASPIRE Study Team . (2016). Use of a vaginal ring containing dapivirine for HIV‐1 prevention in women. New England Journal of Medicine, 375(22), 2121–2132. 10.1056/NEJMoa1506110
    1. Bongaarts, J. (2017). Africa's unique fertility transition. Population and Development Review, 43(S1), 39–58. 10.1111/j.1728-4457.2016.00164.x
    1. Buskens, I. , Jaffe, A. , & Mkhatshwa, H. (2007). Infant feeding practices: Realities and mind sets of mothers in South Africa. AIDS Care, 19(9), 1101–1109. 10.1080/09540120701336400
    1. Cabral, A. , Baeten, J. M. , Ngure, K. , Velloza, J. , Odoyo, J. , Haberer, J. E. , … Heffron, R. (2018). Intimate partner violence and self‐reported pre‐exposure prophylaxis interruptions among HIV‐negative partners in HIV serodiscordant couples in Kenya and Uganda. Journal of Acquired Immune Deficiency Syndromes, 77(2), 154–159. 10.1097/QAI.0000000000001574
    1. Chinkonde, J. R. , Hem, M. H. , & Sundby, J. (2012). HIV and infant feeding in Malawi: Public health simplicity in complex social and cultural contexts. BMC Public Health, 12(1), 700. 10.1186/1471-2458-12-700
    1. Chinkonde, J. R. , Sundby, J. , & Martinson, F. (2009). The prevention of mother‐to‐child HIV transmission programme in Lilongwe, Malawi: Why do so many women drop out. Reproductive Health Matters, 17(33), 143–151. 10.1016/S0968-8080(09)33440-0
    1. Desclaux, A. , & Alfieri, C. (2009). Counseling and choosing between infant‐feeding options: Overall limits and local interpretations by health care providers and women living with HIV in resource‐poor countries (Burkina Faso, Cambodia, Cameroon). Social Science and Medicine, 69(6), 821–829. 10.1016/j.socscimed.2009.06.007
    1. Drake, A. L. , Wagner, A. , Richardson, B. , & John‐Stewart, G. (2014). Incident HIV during pregnancy and postpartum and risk of mother‐to‐child HIV transmission: A systematic review and meta‐analysis. PLoS Medicine, 11(2), e1001608. 10.1371/journal.pmed.1001608
    1. Dunn, D. T. , Newell, M. L. , Ades, A. E. , & Peckham, C. S. (1992). Risk of human immunodeficiency virus type 1 transmission through breastfeeding. The Lancet, 340(8819), 585–588.
    1. Dyer, S. J. (2007). The value of children in African countries: Insights from studies on infertility. Journal of Psychosomatic Obstetrics and Gynaecology, 28(2), 69–77. 10.1080/01674820701409959
    1. Fonner, V. A. , Dalglish, S. L. , Kennedy, C. E. , Baggaley, R. , O'Reilly, K. R. , Koechlin, F. M. , … Grant, R. M. (2016). Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. Aids, 30(12), 1973–1983. 10.1097/QAD.0000000000001145
    1. Fowler, M. G. , Qin, M. , Fiscus, S. A. , Currier, J. S. , Flynn, P. M. , Chipato, T. , … Mofenson, L. M. (2016). Benefits and risks of antiretroviral therapy for perinatal HIV prevention. New England Journal of Medicine, 375(18), 1726–1737. 10.1056/NEJMoa1511691
    1. Hartmann, M. , Palanee‐Phillips, T. , O'Rourke, S. , Adewumi, K. , Tenza, S. , Mathebula, F. , … Montgomery, E. T. (2019). The relationship between vaginal ring use and intimate partner violence and social harms: Formative research outcomes from the CHARISMA study in Johannesburg, South Africa. AIDS Care, 31(6), 660–666. 10.1080/09540121.2018.1533227
    1. Human Sciences Research Council (HSRC) . (2018). The fifth South African national HIV prevalence, incidence, behaviour and communication survey, 2017: HIV impact assessment summary report. Cape Town, South Africa: HSRC Press.
    1. Jamieson, D. J. , Chasela, C. S. , Hudgens, M. G. , King, C. C. , Kourtis, A. P. , Kayira, D. , … van der Horst, C. (2012). Maternal and infant antiretroviral regimens to prevent postnatal HIV‐1 transmission: 48‐week follow‐up of the BAN randomised controlled trial. Lancet, 379(9835), 2449–2458. 10.1016/S0140-6736(12)60321-3
    1. Kinuthia, J. , Drake, A. L. , Matemo, D. , Richardson, B. A. , Zeh, C. , Osborn, L. , … John‐Stewart, G. (2015). HIV acquisition during pregnancy and postpartum is associated with genital infections and partnership characteristics: A cohort study. Aids, 29(15), 2025–2033–2033. 10.1097/QAD.0000000000000793
    1. Kinuthia, J. , Richardson, B. A. , Drake, A. L. , Matemo, D. , Unger, J. A. , McClelland, R. S. , & John‐Stewart, G. (2017). Sexual behavior and vaginal practices during pregnancy and postpartum: Implications ofr HIV prevention strategies. Journal of Acquired Immune Deficiency Syndromes, 74(2), 142–149. 10.1097/QAI.0000000000001225
    1. Langen, T. T. (2005). Gender power imbalance on women's capacity to negotiate self‐protection against HIV/AIDS in Botswana and South Africa. African Health Sciences, 5(3), 188–197. 10.5555/afhs.2005.5.3.188
    1. Leddy, A. , Chakravarty, D. , Dladla, S. , de Bruyn, G. , & Darbes, L. (2016). Sexual communication self‐efficacy, hegemonic masculine norms and condom use among heterosexual couples in South Africa. AIDS Care, 28(2), 228–233. 10.1080/09540121.2015.1080792
    1. Leshabari, S. C. , Blystad, A. , & Moland, K. M. (2007). Difficult choices: Infant feeding experiences of HIV‐positive mothers in northern Tanzania. SAHARA‐J: Journal of Social Aspects of HIV/AIDS, 4(1), 544–555. 10.1080/17290376.2007.9724816
    1. Maman, S. , Cathcart, R. , Burkhardt, G. , Omba, S. , Thompson, D. , & Behets, F. (2012). The infant feeding choices and experiences of women living with HIV in Kinshasa, Democratic Republic of Congo. AIDS Care, 24(2), 259–265. 10.1080/09540121.2011.597708
    1. Mbekenga, C. K. , Pembe, A. B. , Darj, E. , Christensson, K. , & Olsson, P. (2013). Prolonged sexual abstinence after childbirth: Gendered norms and perceived family health risks. Focus group discussion in a Tanzanian suburb. BMC International Health and Human Rights, 13, 4. 10.1186/1472-698X-13-4
    1. Mofenson, L. M. , Baggaley, R. C. , & Mameletzis, I. (2017). Tenofovir disoproxil fumurate safety for women and their infants during pregnancy and breastfeeding. Aids, 31(2), 213–232. 10.1097/QAD.0000000000001313
    1. Montgomery, E. T. , Roberts, S. T. , Nel, A. , Malherbe, M. , Torjesen, K. , Bunge, K. , … Palanee‐Phillips, T. (2019). Social harms in female‐iniatated HIV prevention method research: State of the evidence. Aids, 33(14), 2237–2244. 10.1097/QAD.0000000000002346
    1. Mugwanya, K. K. , Hendrix, C. W. , Mugo, N. R. , Marzinke, M. , Katabira, E. T. , Ngure, K. , … Baeten, J. M. (2016). Pre‐exposure prophylaxis use by breastfeeding HIV‐uninfected women: A prospective short‐term study of antiretroviral excretion in breast milk and infant absorption. PLoS Medicine, 13(9), e1002132. 10.1371/journal.pmed.1002132
    1. Nagot, N. , Kankasa, C. , Tumwine, J. K. , Meda, N. , Hofmeyr, G. J. , Vallo, R. , … Rekacewicz, C. (2016). Extended pre‐exposure prophylaxis with lopinavir‐ritonavir versus lamivudine to prevent HIV‐1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): A randomised controlled trial. Lancet, 387(10018), 566–573. 10.1016/S0140-6736(15)00984-8
    1. National Statistical Office [Malawi] , & ICF . (2017). Malawi demographic and health survey 2015–2016 . Zomba, Malawi and Rockville, Maryland, USA: NSO and ICF.
    1. Nel, A. , van Niekerk, N. , Kapiga, S. , Bekker, L. G. , Gama, C. , Gill, K. , … Ring Study Team . (2016). Safety and efficacy of a dapivirine vaginal ring for HIV prevention in women. New England Journal of Medicine, 375(22), 2133–2143.
    1. Noguchi, L. M. , Hoesley, C. , Kelly, C. , Scheckter, R. , Bunge, K. , Nel, A. , … Beigi, R. H. (2019). Pharmacokinetics of dapivirine transfer into blood plasma, breast milk, and cervicovaginal fluid of lactating women using the dapivirine ring. Antimicrobial Agents and Chemotherapy, 63(3), e01930–e01918. 10.1128/AAC.01930-18
    1. Noguchi, L. M. , Montgomery, E. T. , Biggio, J. R. , Hendrix, C. W. , Bogen, D. L. , Hillier, S. L. , … Beigi, R. H. (2016). Detectable tenofovir levels in breastfeeding infants of mothers exposed to topical tenofovir. Antimicrobial Agents and Chemotherapy, 60(9), 5616–5619. 10.1128/AAC.00645-16
    1. Østergaard, L. R. , & Bula, A. (2010). “They call our children ‘Nevirapine babies?’”: A qualitative study about exclusive breastfeeding among HIV positive mothers in Malawi. African Journal of Reproductive Health, 14(3), 213–222.
    1. Palanee‐Phillips, T. , Roberts, S. T. , Reddy, K. , Govender, V. , Naidoo, L. , Siva, S. , … Montgomery, E. T. (2018). Impact of partner‐related social harms on women's adherence to the dapivirine vaginal ring during a Phase III trial. Journal of Acquired Immune Deficiency Syndromes, 79(5), 580–589. 10.1097/QAI.0000000000001866
    1. Ramjee, G. , & Daniels, B. (2013). Women and HIV in sub‐Saharan Africa. AIDS Research and Therapy, 10(1), 30. 10.1186/1742-6405-10-30
    1. Sia, D. , Onadja, Y. , Hajizadeh, M. , Heymann, S. J. , Brewer, T. F. , & Nandi, A. (2016). What explains gender inequalities in HIV/AIDS prevalence in sub‐Saharan Africa? Evidence from the demographic and health surveys. BMC Public Health, 16(1), 1136. 10.1186/s12889-016-3783-5
    1. Srivastava, A. , & Thomson, S. B. (2009). Framework analysis: A qualitative method for applied policy research. Journal of Administration and Governance, 4(2), 72–79.
    1. van der Straten, A. , Ryan, J. H. , Reddy, K. , Etima, J. , Taulo, F. , Mutero, P. , … MTN‐041/MAMMA Study Team . (2020). Influences on willingness to use vaginal or oral PrEP during pregnancy and breastfeeding in Africa: The Multisite MAMMA study. Journal of the International AIDS Society, 23, e25536.
    1. The World Bank . (2019). Fertility rate, total (births per woman)—Sub‐Saharan Africa. Retrieved from
    1. Tuthill, E. , McGrath, J. , & Young, S. (2014). Commonalities and differences in infant feeding attitudes and practices in the context of HIV in Sub‐Saharan Africa: A metasynthesis. AIDS Care, 26(2), 214–225. 10.1080/09540121.2013.813625
    1. Uganda Bureau of Statistics (UBOS) , & ICF . (2018). Uganda demographic and health survey 2016. Kampala, Uganda and Maryland, USA: UBOS and ICF.
    1. UNAIDS . (2016). More investment needed in developing female‐controlled HIV prevention options. Retrieved from
    1. Waitt, C. J. , Garner, P. , Bonnett, L. J. , Khoo, S. H. , & Else, L. J. (2015). Is infant expsoure to antiretroviral drugs during breastfeeding quantitatively important? A systematic review and meta‐analysis of pharmacokinetic studies. Journal of Antimicrobial Chemotherapy, 70(7), 1928–1941. 10.1093/jac/dkv080
    1. WHO , UNICEF , UNFPA , & UNAIDS . (2003). HIV and infant feeding: A guide for health‐care managers and supervisors. Geneva, Switzerland: WHO.
    1. WHO , UNICEF , UNFPA , & UNAIDS . (2007). HIV and infant feeding: New evidence and programmatic experience: Report of atechnical consultation held on behalf of the Inter‐agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants, Geneva, Switzerland, 25–27 October 2006. Geneva, Switzerland: WHO.
    1. World Health Organization . (2016). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Retrieved from
    1. Young, S. L. , Mbuya, M. N. N. , Chantry, C. J. , Geubbels, E. P. , Israel‐Ballard, K. A. , Cohan, D. , … Latham, M. C. (2011). Current knowledge and future research on infant feeding in the context of HIV: Basic, clinical, behavioral, and programmatic perspectives. Advances in Nutrition, 2(3), 225–243. 10.3945/an.110.000224
    1. Zimbabwe National Statistics Agency and ICF International . (2016). Zimbabwe demographic and health survey 2015: Final report. Rockville, Maryland, USA: Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International.

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