The new World Health Organisation (WHO) recommendation that HIV-positive mothers on antiretroviral therapy (ARVs) can exclusively breastfeed their babies for up to twelve months without infecting them has created confusion among HIV-positive mothers in Uganda as information about the new guidelines struggles to reach them.
For the last decade the policy in Uganda had been to advise HIV-positive mothers to exclusively breastfeed for three months.
But phone calls during a television talk show on the benefits of breastfeeding exposed the confusion among HIV-positive mothers about the new recommendations. Many mothers said they needed to clarify and understand how best they can protect their babies from HIV infection.
"I am now confused," said Maria Sebadukka, an HIV-positive mother, "we are being given conflicting information on how to feed our children. Some health workers say we should not breastfeed. But now you say we can?" she asked.
"I am HIV-positive and my child is negative. Should I start breastfeeding her now?" another caller asked.
During the 2010 HIV Conference in Vienna in July, the WHO passed new recommendations saying mothers may safely breastfeed provided they or their infants receive ARVs during the breastfeeding period of up to one year. This has been shown to give infants the best chance of protection against HIV transmission.
Dr. Elizabeth Madraa, head of Food and Nutrition at the ministry of health explained that six to 12 months of breast feeding is adequate to cover the initial immunity a baby needs. However, mixed feeding is not recommended as a baby’s gut is vulnerable to infection.
But Madraa admits that it may be difficult to convince some mothers of the new guidelines. "People are not ready for the new guidelines. We really need to come out and sensitise pregnant HIV-positive mothers very well on these new recommendations because they are still not yet convinced," she said.
Dr Lydia Mungherera, executive director of The AIDS Support Organisation (TASO) and patron of Mamas Club, an organisation for HIV-positive mothers agrees. "Many are still very scared of infecting their children. Many are not yet aware of these new guidelines so this needs a lot of awareness raising and the training of health workers, including midwives," she said.
She also said that new policies are not as widely circulated in Uganda as they should be: "Community nurses and midwives should be trained and any new policies should be quickly circulated."
Lack of access to antenatal care, ARVs and information also affects the implementation of the new guidelines.
While antenatal visits are vital for prevention of mother-to-child transmission (PMTCT), 58 percent of births in Uganda still take place at home, according to the Uganda Demographic Health Survey (UDHS) 2006. There are also rural-urban disparities with the proportion of births occurring in a health facility being higher in urban areas (79 percent) than rural areas (36 percent) thus leaving a dilemma of how rural women can be sensitised about the new guidelines.
Access to health care is also a challenge with 86 percent of women saying they encounter at least one serious problem in accessing it. Sixty five percent of women say they have financial constraints while 55 percent find the distance to their nearest health facility is very far.
Florence Mukhaye Buluba, programme officer for the International Community of Women living with HIV and AIDS Eastern Africa added that stigma also discouraged women from following clinical instructions of exclusive breastfeeding following pressures from in-laws and spouses.
In Uganda mother-to-child transmission is estimated to have contributed to 20,500 new HIV infections, according to the 2009 Uganda AIDS Commission report. Without treatment, around 15 to 30 percent of babies born to HIV-positive women will become infected with HIV during pregnancy and delivery. A further five to 20 percent will become infected through breastfeeding, says the 2009 UNAIDS Epidemic Update.
The health ministry said they are doing something about this. "We have planned for a massive public awareness campaign. The plans are there to make sure that women get access to information and understand these new guidelines," said Samalie Namukosa Bananuka, Head of Nutrition, PMTCT department in the health ministry.
The new WHO guidelines recommend that national authorities in each country decide which infant feeding practice should be promoted and supported by their maternal and child health services. Uganda is yet to take an official stand based on its capacity to universally roll out the PMTCT programme and sensitise women countrywide about the new recommendations.
"Government is to hold a meeting next month to discuss the implementation of the new guidelines. If we (Uganda) do not find its implementation feasible, then we shall not adopt it but rather stick to the current policy. That’s what we are yet to discuss," National PMTCT Coordinator, Dr. Godfrey Esiru told IPS.
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