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

Jackslina Gaaniri Ngbapai Institute of Public Health and Management, Clarke International University, , Uganda Jonathan Izudi (  [email protected] ) Clarke International University, University of and https://orcid.org/0000- 0001-9065-0389 Stephen Okoboi Institute of Public Health and Management, Clarke International University, Kampala, Uganda

Research

Keywords: Breastfeeding, HIV exposed infant, Mother to child transmission of HIV, and Option B Plus

Posted Date: March 25th, 2020

DOI: https://doi.org/10.21203/rs.3.rs-19025/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License

Version of Record: A version of this preprint was published on September 7th, 2020. See the published version at https://doi.org/10.1186/s13006-020-00323-7.

Page 1/14 Abstract

Background To eliminate mother to child transmission of HIV (EMTCT), the World Health Organization (WHO) 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 defned 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 modifed Poisson regression analysis at 5% statistical signifcance level, and thematically analyzed qualitative data to enrich and triangulate the quantitative results. Results Of 235 HIV infected postpartum mothers, 150 (63.8%) ceased breastfeeding at one year and this was independently associated with the HEI being female than male (Adjusted risk ratio (aRR): 1.25, 95% confdence interval (CI), 1.04, 1.50), the mother being multiparous than primparous (aRR, 1.26; 95% CI, 1.04-1.53), and breastfeeding initiation on same day as birth (aRR, 0.06; 95% CI, 0.01-0.41). Qualitative results showed that maternal demands of work, high demand for breastfeeding among male HEIs, and low breastfeeding interest among primarous mothers were reasons for cessation of breastfeeding before one year. Conclusion Breastfeeding cessation at one year among HIV infected postpartum mothers was suboptimal. This 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 Immunodefciency 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%.(1) In Uganda, UNAIDS estimates that 1.4 million people were living with HIV, with 740,000 being women aged 15 years and above in 2018.(2) Due to the scale up of PMTCT plus, over 90% of women living with HIV who were pregnant are now on lifelong anti-retroviral therapy (ART).(3) The increasing number of women on prevention of mother to child transmission of HIV (PMTCT) program is attributed to accreditation of many lower level health facilities to provide ART to HIV infected pregnant and breastfeeding women.(4) Despite the scale up of EMTCT that led to an estimated 86% reduction in HIV infection among children between 2010 and 2016, the proportion of HIV exposed infants (HEIs) getting infected with HIV during breastfeeding is on the rise.(5) Difculties in implementing infant feeding practices, limited follow-up of

Page 2/14 mothers after delivery and stigma associated with replacement feeding were factors found to hinder breastfeeding cessation at one year among women living with HIV.(5)

There are four strategies to prevent mother to child transmission of HIV according to the World Health Organization (WHO): 1) Prevention of HIV infection in general, especially in young women and pregnant women; 2) Prevention of unintended pregnancy among HIV infected women; 3) prevention of HIV transmission of HIV infected women to their infants; and, 4) the provision of care treatment and support to HIV infected women and their infants and families.(1) Breastfeeding among HIV infected mothers is recommended because it protects infants from morbidity and mortality. However, the chance of the infant being infected with HIV through breastfeeding is cumulative with increased duration of breastfeeding by a HIV infected mother. Cessation of breastfeeding at one year among 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.

Methods

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 fnal HIV test is performed at 18 months using a rapid HIV test.

Page 3/14 However, should the HEI test HIV positive at any of the testing time points, ART is started and Cotrimoxazole prophylaxis is continued for life. It is important to note that HEIs receive exclusive breastfeeding for the frst 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 defned 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/m2), well nourished (BMI 18.2-24.9 kg/m2), overweight (BMI 25.0-30.0 kg/m2), mild obese (BMI 30.1-34.9 kg/m2) and over obese (BMI ≥35.0 kg/m2), 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.

Page 4/14 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).

One research assistant (JGP) moderated all the FGDs while the other (MN) audio-recorded the responses and probed where necessary. Each FGD lasted for about 40-60 minutes on average. For key informant interviews (KII), four healthcare providers namely, two Midwives and two nursing ofcers engaged in the provision of EMTCT services at the health facility were interviewed to elicit their expert opinions on practices of breastfeeding cessation among HIV infected mothers. The KII lasted for 30-45 minutes, also conducted within the health facility premises in English language, but in a quiet and convenient room. Both FGDs and KIIs were held until saturation was reached.(10)

Data processing and analysis

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 fnal 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.

Page 5/14 We tested differences in proportions of breastfeeding cessation at one year with categorical variables using the Chi-squared test for large cell counts (fve and more counts) and the Fisher’s exact test for smaller cell counts (less than fve 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 fve percent as statistically signifcant 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 modifed 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% confdence intervals (CI). We noted that fve (2.1%) HEIs had missing data on sex but 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, benefts 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 confdentiality and privacy, and individual identifers were anonymized.

Results

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 signifcant 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 signifcant 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.

Page 6/14 “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 once they start eating, this is very common” (FGD with HIV infected mothers )

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 signifcant 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.

Page 7/14 “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 fnding.(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 fnding is surprising because one would not expect differences in breastfeeding duration between male and female HEIs. Our fnding 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 fnd 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 draining and exhausting effect on mothers hence the early breastfeeding cessation. Despite the differences, our fnding seem to emphasis that routine provision of health education on benefts 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 sufcient knowledge and experience compared to nulliparous mothers. Our fnding 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 signifcantly longer breastfeeding duration as compared to primiparous mothers.

Another study in Ethiopia shows that mothers who are defcient 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 beneft from targeted health education messages compared to multiparous mothers.

Page 8/14 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 fndings are consistent with this result, several reasons could explain the non-initiation of breastfeeding on same-day as birth namely, insufciency 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 frst hour of birth. Consequently, in providing EMTCT interventions, healthcare providers should emphasize the importance of early initiation of breastfeeding within the frst hour of birth.

Study Strengths And Limitations

This study has several strengths. First, it is among the frst 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 fndings 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 frst day of birth. We recommend the strengthening of health education messages on infant feeding in the context of HIV among every HIV infected postpartum mother and expectant women. Further robust studies are needed to underscore reasons for preferential breastfeeding of male HEIs relative to females.

Abbreviations

Page 9/14 aRR Adjusted Risk Ratio. EID Early infant diagnosis of HIV. EMTCT Elimination of mother to child transmission of HIV. HEI HIV exposed infant. HIV Human Immunodefciency Virus. uRR Unadjusted Risk Ratio. WHO World Health Organization.

Declarations

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.

Competing interests

The authors declare that they have no competing interest.

Funding

None.

Author contributions

Page 10/14 JGP, JI and SO: Study conception and design. JGP: Acquisition of data. JI: Analysis and interpretation of data. JI and SO: Drafting of manuscript. JI and SO. Critical revision. All authors read and approved the fnal manuscript.

Acknowledgements

We thank the Institute of Public Health and Management, Clarke International University, all the Research Assistants, and Friends who supported the primary author in one way or another.

References

1. World Health Organization (WHO). Guideline: updates on HIV and infant feeding: duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. WHO Publications. 2016:1–59. 2. UNAIDS. Country factsheets Uganda 2018: UNAIDS; 2018 [cited 2020 March 10]. Available from: https://www.unaids.org/en/regionscountries/countries/uganda. 3. Kuhn L, Kasonde P, Sinkala M, Kankasa C, Semrau K, Vwalika C, et al. Prolonged breast-feeding and mortality up to two years post-partum among HIV-positive women in Zambia. AIDS (London, England). 2005;19(15):1677. 4. Duber HC, Dansereau E, Masters SH, Achan J, Burstein R, DeCenso B, et al. Uptake of WHO recommendations for frst-line antiretroviral therapy in Kenya, Uganda, and Zambia. PloS one. 2015;10(3). 5. Ladner J, Besson M-H, Rodrigues M, Saba J, Audureau E. Performance of HIV prevention of mother- to-child transmission programs in sub-Saharan Africa: longitudinal assessment of 64 Nevirapine- based programs implemented in 25 countries, 2000-2011. PloS one. 2015;10(6). 6. AVERT. Prevention of mother to child transmission (PMTCT) of HIV Global Information and education on HIV and AIDS; 2019 [updated March 8, 2019; cited 2020 March 10]. Available from: https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child. 7. Republic of Uganda. Consolidated guidelines for prevention and treatment of HIV in Uganda. Kampala: Minsitry of Health, December 2016. 8. Izudi J, Akot A, Kisitu GP, Amuge P, Kekitiinwa A. Quality Improvement Interventions for Early HIV Infant Diagnosis in Northeastern Uganda. BioMed Research International. 2016;2016:8. 9. Izudi J, Auma S, Alege JB. Early Diagnosis of HIV among Infants Born to HIV-Positive Mothers on Option-B Plus in Kampala, Uganda. AIDS Research and Treatment. 2017;2017:8. 10. Mason M, editor Sample size and saturation in PhD studies using qualitative interviews. Forum qualitative Sozialforschung/Forum: qualitative social research; 2010. 11. Lauritsen J, Bruus M. EpiData (version 3). A comprehensive tool for validated entry and documentation of data Odense: EpiData Association. 2003. 12. Stata Statistical Software: Release 15 [press release]. College Station, TX: StataCorp LLC2017.

Page 11/14 13. Schmidt OC, Kohlmann T. When to use the odds ratio or the relative risk? Int J Public Health. 2008;53:165-7. 14. Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162(3):199-200. 15. Haile D, Belachew T, Birhanu G, Setegn T, Biadgilign S. Predictors of breastfeeding cessation among HIV infected mothers in southern Ethiopia: a survival analysis. PloS one. 2014;9(3). 16. Hackman NM, Schaefer EW, Beiler JS, Rose CM, Paul IM. Breastfeeding outcome comparison by parity. Breastfeeding Medicine. 2015;10(3):156-62. 17. Rahman A, Hafeez A, Bilal R, Sikander S, Malik A, Minhas F, et al. The impact of perinatal depression on exclusive breastfeeding: a cohort study. Maternal & child nutrition. 2016;12(3):452-62. 18. Alemu YM, Habtewold TD, Alemu SM. Mother’s knowledge on prevention of mother-to-child transmission of HIV, Ethiopia: A cross sectional study. PloS one. 2018;13(9). 19. Ogwu A, Moyo S, Powis K, Asmelash A, Lockman S, Moffat C, et al. Predictors of early breastfeeding cessation among HIV‐infected women in Botswana. Tropical Medicine & International Health. 2016;21(8):1013-8.

Tables

Table 1: Socio-demographic characteristics of HIV infected mothers and HEIs

Page 12/14 Ceased breastfeeding at one year

Characteristics No (n=85) Yes(n= 150) All (n= 235) p value

Maternal age category n (%) n (%) n (%) 0.051

16-25 57 (67.1) 81(54.0) 138 (58.7)

25 and more 28 (32.9) 69 (46.0) 97 (41.3)

Maternal parity 0.116

1 38 (44.7) 57 (38.0) 95 (40.4)

2 29 (34.1) 42 (28.0) 71 (30.2)

≥3 18 (21.1) 51 (34.0) 69 (29.4)

Breastfeeding started on same-day as birth <0.01

No 60 (70.6) 148 (98.7) 208 (88.5)

Yes 25 (29.4) 2 (1.3) 27 (11.5)

Ever attended ANC visits 0.020

Yes 34 (40.0) 62 (41.3) 96 (40.8)

No 38 (44.7) 81 (54.0) 119 (50.6)

Missing data 13 (15.3) 7 (4.7) 20 (8.5)

Place of delivery 0.690

Home 2 (2.5) 5 (3.4) 7 (3.1)

Health facility 79 (97.5) 141 (96.6) 220 (96.9)

Time of Cotrimoxazole prophylaxis initiation 0.040

<6 weeks 28 (32.9) 79 (52.7) 107 (45.5)

≥6 weeks 57 (67.1) 71 (47.3) 128 (54.5)

Infant sex 0.002

Male 53 (62.3) 61 (40.7) 114 (48.5)

Female 32 (37.6) 84 (56.0) 116 (49.4)

Missing data 0 (0.0) 5 (3.3) 5 (2.1)

Mothers ART regimen 0.08

AZT based regimen 7 (8.2) 3 (2.0) 10 (4.3)

TDF based regimen 69 (81.2) 136 (90.7) 205 (87.2)

Other regimens 6 (7.1) 6 (4.0) 12 (5.1)

Missing 3 (3.5) 5 (3.3) 8 (3.4)

Table 2: Bivariate and multi variate factors associated with HIV exposed infant’s cessation of breastfeeding at one year

Page 13/14 Characteristics Level Modified Poisson regression analysis

uRR 95% CI aRR 95% CI

Infant sex$ Male Ref Ref

Female 1.35** (1.10,1.66) 1.25* (1.04,1.50)

Maternal age group ≤24 Ref Ref

≥25 1.21* (1.00,1.46) 1.08 (0.91,1.28)

Maternal parity 1 Ref Ref

2 0.99 (0.76,1.27) 1.02 (0.81,1.30)

≥3 1.23 (0.99,1.53) 1.26* (1.04,1.53)

Ever attended ANC visits No Ref

Yes 1.05 (0.87,1.28)

Breastfeeding initiated on same day as birth No Ref Ref

Yes 0.10*** (0.03,0.40) 0.06** (0.01,0.41)

Time of Cotrimoxazole prophylaxis initiation <6 weeks Ref Ref

≥6 weeks 0.87** (0.79,0.95) 0.93 (0.86,1.02)

Note: 1) 95% confidence intervals for risk ratios (RR) are in brackets; 2) * p < 0.05, ** p < 0.01, *** p < 0.001 at 5% level of significance; 3) Adjusted analysis included all statistically significant variable at unadjusted analysis; 4) Ref: Reference category; 5) uRR Unadjusted RR; 6) aRR: Adjusted RR. $The variable infant sex has five missing observations which were not imputed at adjusted analysis.

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