Postpartum

Gaps in Research

1.: HIV-positive mothers, fathers, grandmothers and the larger community need clear, consistent, non-contradictory and nonjudgmental counseling on infant feeding practices. Health care providers need training based on accurate information.
2.: Further research is needed to understand the links between mastitis and vertical transmission. Studies found that maternal HIV infection was correlated with mastitis and the potential for vertical transmission.
3.: Accurate testing techniques for infants may inform infant feeding.
4.: Stigma reduction interventions are needed so that women with HIV can choose replacement feeding, breastfeeding and weaning schedules.
5.: Additional efforts are needed to provide postpartum women with contraception information and methods so they may space or prevent their next pregnancy and use condoms to reduce the likelihood of HIV transmission upon resumption of sexual activity.
6.: Further efforts are needed to educate families about HIV transmission so that infants are not abandoned.
7.: Interventions are needed to scale up CD4 count screening, especially for pregnant women.
8.: Interventions are needed to encourage male partners to refrain from sexual activity during the postpartum period of time that women cannot have sex.
9.: Increased efforts are needed to retain women on HAART following birth.
10.: More research is needed to understand the relationship between maternal single-dose nevirapine administered during delivery and postpartum nevirapine resistance found in breastmilk, and its impact on postnatal transmission to infants.
11.: Screening for post-partum depression among HIV-positive women may be warranted.
12.: Further efforts are needed to assess the feasibility of wet-nursing for HIV-positive mothers.
13.: Further efforts are needed to encourage counseling to help HIV-positive mothers with exclusive breastfeeding.

1. HIV-positive mothers, fathers, grandmothers and the larger community need clear, consistent, non-contradictory and nonjudgmental counseling on infant feeding practices. Health care providers need training based on accurate information. Studies found that health care providers gave HIV-positive women conflicting information and that simplified structured counseling tools are needed. Studies found that women reported that providers accused them of killing their infants if they breastfed. Women lack access to infant formula but have been told by providers that it is the only way for their infant to survive. Women were told that breastfeeding is a mode of HIV transmission and exclusive breastfeeding is a mode of prevention. Women fear HIV more than diarrheal disease, even though more deaths occur from diarrheal disease. Women were not given choices. Women did not give providers accurate information on how they were feeding their infant for fear of being denied health care. Women were told to feed their infants formula yet did not have adequate food support, most mothers could not do so with few having an income and most with no access to safe drinking water. Women lacked autonomy to decide infant feeding, which was decided by male partners or grandmothers. "Despite the current WHO recommendations to use extended infant prophylaxis as long as the infant is breastfed, no data are yet available from a clinical trial to confirm effectiveness and safety of this regimen beyond the first six months postpartum" (Taha, 2011: 919).

Gap noted, for example, in Burkina Faso (Cames et al., 2010a); Zambia (Chisenga et al., 2011); Vietnam (Sethuraman et al., 2011); Malawi (Ostergaard and Bula, 2010; Kerr et al., 2008); Jamaica (Cooper et al., 2010); Burkina Faso, Cambodia and Cameroon (Desclaux and Alfieri, 2009); Malawi, Kenya and Zambia (Chopra et al., 2009a); Lesotho (Towle and Lende, 2008); Botswana, Kenya, Malawi and Uganda (Chopra and Rollins, 2008; Coutsoudis et al., 2002 cited in Chopra and Rollins, 2008); Cameroon (Kakute et al., 2005); South Africa (Doherty et al., 2006) and Uganda (Fadnes et al., 2010).

2. Further research is needed to understand the links between mastitis and vertical transmission. Studies found that maternal HIV infection was correlated with mastitis and the potential for vertical transmission.

Gap noted, for example, in Zimbabwe (Lunney et al., 2010); Zambia (Kasonka et al., 2006), Tanzania (Kantarci et al., 2007) and Malawi (Nussenblatt et al., 2006).

3. Accurate testing techniques for infants may inform infant feeding. Studies note that rapid scale up of early infant diagnosis is needed in low-resource settings in order to access treatment and care as soon as possible. [For WHO guidance on HIV testing in infants see: www.who.int/hiv/topics/vct/toolkit/additional_resources/children/en/]

Gap noted, for example, in Tanzania (Finnegan et al., 2009: 216); Kenya (Inwani et al., 2009: 492); South Africa (Rollins et al., 2009:1855); Vietnam (Sohn et al., 2009); West Africa (Msellati, 2009) and globally in resource-limited settings (Painstil and Andiman, 2009).

4. Stigma reduction interventions are needed so that women with HIV can choose replacement feeding, breastfeeding and weaning schedules. Studies found that HIV-positive women feared that if they used infant formula or abruptly weaned, they would be stigmatized for their HIV-positive serostatus.

Gap noted, for example, in Burkina Faso (Cames et al., 2010a); Kenya (Morgan et al., 2010); Burkina Faso, Cambodia and Cameroon (Desclaux and Alfieri, 2009); Ethiopia (Greenblott, 2011); Tanzania (Falnes et al., 2011); Nigeria (Oladokun et al., 2010b; Maru et al., 2009); Zambia (Chisenga et al., 2011); Vietnam (Sethuraman et al., 2011); Malawi (Ostergaard and Bula, 2010; Chinkonde et al., 2009; Thorsen et al., 2008) and South Africa (Doherty et al., 2006).

5. Additional efforts are needed to provide postpartum women with contraception information and methods so they may space or prevent their next pregnancy and use condoms to reduce the likelihood of HIV transmission upon resumption of sexual activity. [See also Meeting the Sexual and Reproductive Health Needs of Women Living With HIV] Studies found that women were not given contraceptive counseling or contraceptives postpartum and that transport costs restricted their ability to gain access to their contraceptive method of choice. Studies also found an unmet need for postpartum contraception among women living with HIV. Studies found that sexuality and condom use need to be addressed when sexual activity resumes postpartum. Family planning services are most often not provided postpartum in PMTCT programs. Providers and women did not know that clinically well HIV-positive women can use IUDs. Women lacked the full range of available contraception. No study to date has measured pregnancy intention prospectively in an HIV-discordant couple cohort and measured the effect of desired pregnancy on HIV transmission.

Gap noted, for example, in Ukraine (Saxton et al., 2010); Ghana (Achana et al., 2010); Kenya (Brubaker et al., 2010; Chersich et al., 2008b); Uganda (Were and Hasunira, 2010): Tanzania (Keogh et al., 2009); Kenya, Rwanda, Tanzania, Botswana, South Africa and Zambia (Heffron et al., 2010); Malawi (Makanani et al., 2010); South Africa (Crede et al., 2012); Côte d’Ivoire (Brou et al., 2008); Kenya and Zambia (Thea et al., 2006) and globally in resource-limited settings (Baek and Rutenberg, 2010).

6. Further efforts are needed to educate families about HIV transmission so that infants are not abandoned. [See also Orphans and Vulnerable Children] A study found that families forced HIV-positive women to abandon their infants due to erroneous fears that the infants could transmit HIV.

Gap noted, for example, in Russia (Zabina et al., 2009).

7. Interventions are needed to scale up CD4 count screening, especially for pregnant women. A study found that several barriers limited CD4 cell count screening in rural areas, including “availability of laboratories equipped to perform CD4 cell count enumeration, reagent stockouts, and lack of sample transport systems” (Carter et al., 2010: 408). For mothers with CD4 counts above 500, there may be a low risk of HIV transmission through breastfeeding, though further research is necessary.

Gap noted, for example, in Cameroon, Cote d’Ivoire, Kenya, Mozambique, Rwanda, South Africa, Thailand, Uganda and Zambia (Carter et al., 2010); Burkina Faso and Kenya (Kesho Bora Study Group, 2010).

8. Interventions are needed to encourage male partners to refrain from sexual activity during the postpartum period of time that women cannot have sex. A study found that it is common for men to have multiple sexual partners once their wives have given birth until the women can again engage in sexual activity.

Gap noted, for example, in Ghana (Achana et al., 2010).

9. Increased efforts are needed to retain women on HAART following birth. Studies found that women who initiated ART during pregnancy were more likely to be lost to follow up than non-pregnant women or that pregnant women who were eligible for HAART according to national guidelines were not provided HAART.

Gap noted, for example, in Swaziland (Bacheno et al., 2010); Vietnam (Sethuraman et al., 2011); Tanzania (Arreskov et al., 2010); South Africa (Myer et al., 2012; Clouse et al., 2012; Westreich et al., 2012); Latin America (Kreitchmann et al., 2012); Kenya (Otieno et al., 2010) and Nigeria (Rawizza et al., 2012).

10. More research is needed to understand the relationship between maternal single-dose nevirapine administered during delivery and postpartum nevirapine resistance found in breastmilk, and its impact on postnatal transmission to infants. [See also Antenatal Care - Treatment] A study detected nevirapine resistance in 40% of breast milk samples collected from 30 HIV-positive mothers after four weeks of single-dose nevirapine exposure. Breastmilk samples were collected from 19 mothers whose infants tested HIV negative and 11 mothers who infants tested HIV positive by 6 weeks of age.

Gap noted, for example, in Uganda (Hudelson et al., 2010).

11. Screening for post-partum depression among HIV-positive women may be warranted. [See also Women and Girls] A study found high rates of postpartum depression among HIV-positive women.

Gap noted, for example, in Thailand (Ross et al., 2011) and Zimbabwe (Chibanda et al., 2010).

12. Further efforts are needed to assess the feasibility of wet-nursing for HIV-positive mothers. A study surveyed 300 women during routine healthcare visits on their knowledge of HIV and breastfeeding, and found that HIV-specific knowledge was poor, but also that the option of using a wet nurse or being a wet nurse was agreeable among 70% and 75% of women, respectively.

Gap noted, for example, in Burkina Faso (Nacro et al., 2010).

13. Further efforts are needed to encourage counseling to help HIV-positive mothers with exclusive breastfeeding. A study followed 61 HIV-positive mothers and their infants and found that after counseling and breastfeeding support, mothers exclusively breastfed for an average of 3.3 months, at which point 96% were exclusively breastfeeding compared to 23.5% in the general population.