Background
Optimal breastfeeding is essential for child survival and development because breast milk has all the necessary nutrients for healthy growth and provides significant protection from childhood diseases [
1]. According to World Health Organization (WHO) recommendations for new born health; all babies should exclusively breastfeed from birth up to 6 months of age and their mothers counseled and given support for exclusive breastfeeding at each postnatal visit [
2]. The child should be introduced to complementary foods at six months while continuing breastfeeding for up to 12 months if adequate complementary foods which are nutritious and safe can be sustained [
2]. Such well-meaning guidelines when viewed in the framework of Prevention of Mother To Child Transmission (PMTCT) of HIV are not exempted from challenges [
3,
4].
Considerable advances have been made in the effort towards preventing mother-to-child HIV transmission in sub-Saharan Africa, including clinical trials that have provided evidence on efficacy of antiretroviral regimes that can prevent HIV transmission during pregnancy, delivery and lactation period [
3,
5,
6]. In 2013, WHO released a new set of guidelines dubbed Option B+ in which, as soon as diagnosed, all pregnant women living with HIV are offered life-long antiretroviral treatment, regardless of their cluster of differentiation four (CD4) count while the HIV exposed infants receive daily Nevirapine (NVP) or Azidothymidine (AZT) from birth up to six weeks regardless of infant feeding method [
5,
7,
8]. Prior to the 2013 guidelines, there were the WHO 2010 PMTCT guidelines option A and option B for pregnant women living with HIV with CD4 greater than 350 cells/mm
3 which Zambia had already adopted and was implementing. Overall, under Option A, mothers receive antepartum and intrapartum ARV prophylaxis along with postpartum regimen whereas the infants receive postpartum ARV prophylaxis throughout the duration of breastfeeding [
7,
9]. Option B on the other hand entailed triple ARVs starting at 14 weeks of gestation and continued intrapartum and through childbirth if not breastfeeding or until 1 week after cessation of all breastfeeding whereas infants receive daily NVP or AZT from birth through age 4–6 weeks irrespective of infant feeding method utilized [
7,
8]. At the close of breastfeeding, women who do not yet require ART would discontinue the prophylaxis and continue to monitor their CD4 count in the long run re-starting ART when the CD4 falls below 350 cells/mm [
7].
In 2013, Zambia adopted the 2013 consolidated guidelines considered to be progressive from the 2010 recommendations [
7,
8,
10]. The transition from 2010 course of action and subsequent adjustments in Infant and Young Child Feeding (IYCF) in tune with PMTCT strategies to fit the 2013 guidelines led to the need for the government to progressively revise health care providers’ PMTCT training packages. This need attracted extra costs and contributed to the staggered and delayed implementation. It equally occasioned a lapse in revision and harmonization of the IYCF training package for health care providers and inclusion of the same into community training package. Majority of resource-constrained countries in sub-Saharan Africa face related challenges in making adjustments to meet and implement the WHO guidelines due to human resource capacity, limiting educational strategies targeting Infant and Young Child Feeding and PMTCT policies [
3,
4]. Several studies indicate that, changes in such or related critical guidelines have often contributed to low implementation rates. The low execution and efficiency is often attributed to staff adjustment constraints factoring already overburdened and limited human resource in the health sector, inconsistencies in information provided to mothers and therefore lack of adherence by mothers because of some level of confusion alongside adjustment lapse and unpredictable funds for ART 17,19 [
11,
12].
Choma district in Zambia is one of the model districts that was chosen to implement Option B+ as an advancement from the 2010 guidelines. The changes occurred too fast before an evaluation of the 2010 PMTCT guidelines could be done at the facilities. The aim of the study was thus to investigate challenges and opportunities of implementing IYCF and PMTCT guidelines among HIV positive mothers of children 0–24 months and health care providers as well as examine implications presented by implementing the 2013 consolidated guidelines in Maternal and Child Health (MCH) in Choma district in Zambia. Like other developing nations, Zambia has a high number of people living with HIV/AIDS who are within the reproductive age bracket of 15–49 years old and are mainly women [
13]. Global trends indicate that, mother to child transmission is estimated to account for over 90% of new HIV infection in children [
14]. In absence of treatment, the likelihood of HIV passing from mother-to-child is considered to be between 15%–45% [
6,
14] whereas, antiretroviral treatment and other effective PMTCT interventions can decrease this risk to below 5% as reported by WHO. Similarly, longitudinal surveys have emphasized progressive identification of pointers that predict PMTCT program performance thus gearing towards triggering timely identification of implementation problems and challenges that need corrective action for a more strengthened and progressive expansion of PMTCT services, particularly in sub-Saharan Africa [
3,
15]. This is in tune with the United Nations Programme on HIV/AIDS (UNAID) and President’s Emergency Plan for AIDS Relief (PEPFAR) among other partners quest towards Global PMTCT targets. It also resonates with the recently launched Start Free, Stay Free, AIDS Free – a framework calling for a worldwide sprint towards “super fast-track targets”, to end AIDS among children, adolescents and young women by 2020. Hence, the need for incremental appraisal of evidence on cues to enhancing PMTCT in tandem with evolving policies, guidelines and practice.
Discussion
From the presented findings, the overall children’s age ranged from 0 to 24 months and mean age was eight months. Of the 85 mothers who participated, 20% were single mothers and mostly school going adolescents. The mothers interviewed demonstrated high levels of knowledge (60%) on what they learnt during clinic visits. The consolidated guidelines for PMTCT proved effective despite the inherent health systems challenges alongside innovative approaches and commitments by both the health providers and the community (at family or volunteers level) to ensure the success of the intended aims of PMTCT programme. The Zambia government has put in place a system where adolescents who fall pregnant are allowed to attend school under special arrangement (i.e. afternoon school/evening school). Adolescent pregnancies in this study underpin the increasing double challenge trend in sub-Saharan Africa of early pregnancy and increased HIV among young adults and school going age teenagers. Thus, the increasing need for locally adaptable strategies [
13,
31]. The proportion of mothers who had attained secondary and primary level education emphasizes the need for simplified packaging of educational materials for increased impact of PMTCT and related programmes in resource limited settings [
32]. The indicators further demonstrate the importance of addressing individual-level factors (level of education, livelihood determinants and family support among others) through education and counseling in medical interventions for PMTCT for the mothers during their clinical visits. It is possible, context specific targeted efforts (such as health education mode of delivery through special clinic days and male partner involvement) to improve adherence to recommended PMTCT guidelines by health care providers to all eligible mothers played a key role [
33,
34] in the mothers level of knowledge observed. Enhanced levels of knowledge by mothers has been shown to be instrumental in aiding them understand health seeking behaviours and enable them to abide to counseling messages obtained from the clinic [
35].
As earlier pointed, mother to child transmission is estimated to account for over 90% of new HIV infection in children and in absence of treatment, the likelihood of HIV passing from mother-to-child is considered to be between 15%–45% [
6,
14,
36]. Use of antiretroviral treatment and other effective PMTCT interventions can decrease this risk to below 5% as reported by WHO. Earlier studies have also demonstrated the association between positivity rates among HIV-exposed infants with changes in prevention of mother-to-child transmission efforts. The association has been in the dimension of mother-child pairs neither receiving ARVs, mixed feeding practices or mothers not adhering to institutional ANC and postnatal care across the continuum of health care [
37]. Thus, the findings on proportion of HIV positive infants born from HIV positive mothers between 2011 and 2014 point to the long debated paradigm that; the success of ART in PMTCT and improving maternal treatment is constrained by knowledge gaps about optimal maternal regimens, duration of infant prophylaxis alongside the short-term and long-term effects on both the mother and children. With the evidence surrounding PMTCT regimens constantly evolving, the trend in MTCT in this study is in tune with most countries highly affected by HIV trying to ensure that their PMTCT programmes are effective. A 2012 snapshot of PMTCT regimens approved by ministries of health in twenty two countries experiencing a high burden of HIV infection revealed that almost a half of these countries had an Option A regimen policy in place although three of them had piloted Option B+ in selected settings; six had an Option B policy; and six had an Option B+ policy and reported varying decrease in MTCT rates from 26% to 17% in 2012 [
38,
39]. An anticipated further decline in MTCT with the introduction of Option B+ and its subsequent full implementation were observed 50 [
38]. The trend in challenges and opportunities of IYCF to PMTCT of HIV are in concomitant with earlier established observations [
40,
41].
Presenting early at ANC is crucial for PMTCT so that interventions are made early. The findings reveal that most of the information is received at antenatal clinics and immediately after delivery. The observations underpin the relevance of supporting the integration of PMTCT and pediatric HIV with Maternal, Neonatal, and Child Health (MNCH) services at the level of policy, program administration and service delivery. This will provide an opportunity for leveraging on other key programs in scenarios of constrained health systems in developing countries like Zambia and many more in sub-Saharan Africa [
5,
6]. The trend on sources of health information equally provides real world indication to the potential of community health volunteers/workers as a cornerstone workforce for the scaling up of community health delivery. The personnel would be core in ART with reporting lines, training, supervision, acceptability, expanded access to care and feedback in a bidirectional manner [
42‐
44].
Exclusive breast feeding practices of majority of mothers were in line with the WHO (2012) recommendation on exclusive breast feeding. WHO aims at supporting countries with implementation and monitoring of the "Comprehensive implementation plan on maternal, infant and young child nutrition" through increasing the rate of exclusive breastfeeding for the first six months up to at least 50% by 2025 [
2,
45]. For the first six months exclusive breast-feeding by HIV positive mothers in countries where replacement feeding is generally not affordable feasible, acceptable, sustainable or safe (AFASS) would be integral in the context of PMTCT [
15,
46] which is the case in Zambia. In Zambia, before introduction of Option B+, HIV+ mothers could choose to breast feed or not to breastfeed. Introduction of Option B+ accompanied by the nutrition education support, has made it possible for more HIV+ mothers to breastfeed their infants. Findings from Botswana have demonstrated that the risk of MTCT with exclusive breast feeding is low when breast milk has low viral load which comes with ART [
47].
Cultural norms, practices and attitudes that are enshrined within communities play an important role in child care practices, family support for HIV infected women and health promotion interventions [
48‐
50]. Male partner and male volunteer involvement in IYCF/PMTCT was evident. Focused group discussions with PMTCT/IYCF community volunteers’ counselors indicated that, there exist support systems within the community for mothers for infant feeding practices among family members, friends and volunteers. The observations concurs with what was captured from mothers interviews; which indicated that 62% of the mothers had received some form of support for infant feeding via community support channels predominantly from the community health volunteers but also empowered peer mother groups. It is therefore eminent, as ambitious strategies and policies are established by governments and unprecedented resources deployed towards the fight against mother-to-child transmission of HIV across the globe, there is clearly a need to develop effective family-oriented and culture-centered community-based PMTCT interventions that could in the long run achieve comprehensive four pronged strategy of: (a) primary prevention and control of HIV infection among women of reproductive age, (b) the prevention of unplanned pregnancies among HIV positive women, (c) the prevention of HIV transmission from HIV infected mothers to their infants, and (d) the provision of care, support and empowerment for HIV infected mothers, infants and family members. When there is family support, there exists a huge potential for improving the effectiveness of PMTCT among HIV positive mothers [
50]. The importance of male involvement cannot be underestimated in PMTCT programmes as they have important roles to play in care and maintenance of expectant mothers [
51]. Male involvement increases uptake of reproductive choices through improvement of communication by spouses through pathways of increased knowledge or decreased male opposition [
52].
When the infants are born, they also must adhere to antiretroviral prophylaxis regimens and undergo appropriately timed HIV testing and if they are found to be infected must initiate ART treatment timely. If there is attrition at any point in the chain, the system is seen as inefficient and limits program impact, reduces overall coverage, and leads to more infant HIV infection [
4]. According to nurses interviewed, the unique model of involving skilled volunteers and male partners emanating from the communities within which the facilities operate has contributed to enhanced community-facility counter referral support mechanism. PATHFINDER global PMTCT strategy emphasizes the need to create an enabling environment within communities where members can provide PMTCT services to affected women within their communities [
53,
54]. This is because social norms, stigma, gender-based inequities and socioeconomic factors influence the ability of women to practice what they learn at the clinic. In addition, poor infant feeding practices in the general population and increased rates of non-adherence to ART regimens are evidence of a poor enabling environment and the challenge associated with changing behaviours [
41]. A referral linkage between facility services and community care is also crucial to avoid gaps in support and follow-up of these mothers if the PMTCT programme is to prove effective. To protect and improve health, especially in poor communities, combining community and facility based activities is required, which should be supported also by the national level policy and strategies.
From the study findings, all the mothers interviewed were on appropriate ARVs regimen despite the challenge of unsteady supply. Unsteady supply and availability of essential PMTCT commodities are among gaps that desire streamlining by many African governments health authorities [
41,
47]. It is critical that, mothers take ARVs for their own health, all through the duration of breastfeeding to reduce viral load while their infants should receive ARVs for 4–6 weeks after birth in an effort to prevent postnatal vertical transmission of HIV [
41,
47]. PMTCT interventions can be effective and highly successful in reducing the risk of HIV transmission especially in sub-Saharan Africa [
40]. However, its efficiency is hampered by a lot of challenges including shortage of personnel, poor infrastructure and inadequate supply of PMTCT kits as well as other social cultural factors such as preference for home delivery. These factors as replicated in the present study, end up playing a key role in lack of effectiveness of PMTCT services. Even so, in order to provide services for more women in need of timely intervention, there is an increasing local and international support for integrating PMCT into MCH infrastructure [
55] without further expansion to infrastructure being considered thus, compromising quality of services provided. Therefore, caution needs to be taken in ensuring integration of PMTCT in the overall MCH conforms to capacity needs in terms of infrastructure and human resource with proper monitoring and evaluation [
55].
The conditions in Zambia are not unique, as other studies conducted in Tanzania and Uganda indicate that insufficient PMTCT information and counselling were provided by nurses due to time and human resource constraints [
56,
57]. In Ethiopia, an increase in health providers’ workload with the introduction of the PMTCT services was observed [
58]. Although community health volunteers/workers play an important role in the implementation of PMTCT, they can only play a complementary role. They cannot be key in overcoming the structural shortfalls in service provision in the regular health care systems as is the case in Zambia and prior findings in Uganda and Tanzania [
56‐
58]
. With close to a decade of rigorous PMCT program advocacy, implementation and well known benefits, the aforementioned shared and unwavering challenges especially in sub- Saharan Africa warrants the need for opening up comprehensive discussion. Open debate and consultations among enthusiasts and cautious critics of option B+ [
49] will potentially enable define better implementation approaches that are locally adaptable and pragmatic based on regional programmatic and economic concerns [
15]. In linkage to the multi-record data capture and storage systems, emphasize the need to leverage on Smart-Care in the context of Zambia health system by enhancing its functionalities for efficiency [
23]. Smart-care is the largest electronic medical record that was developed by the Ministry of Health in Zambia and Centre for Disease Control. It aimed at linking services for HIV patients while improving access to health information regardless of location, thereby mitigating delays in initiation of treatment, duplication of investigations, reduce risks and errors, expenses and improve HIV data standards, security and confidentiality [
23]. The smart-care platform contains electronic forms that health providers use to record patient information that include counselling and testing, initial history and physical examination, investigations, medication and long term follow up. After entry of all the information, the data is copied to a smart card that has a unique pin number. In the two clinics where the study was conducted, there is duplication of effort, where both the paper based and electronic systems are used. Frequent electricity outages, breakdown of computers and inadequate IT support were reasons given for the need for a back-up manual paper system.
Despite the challenges integration of ART in MCH remains critical to the success in implementing options B+ in pre-natal and post-natal care. Especially through the breastfeeding period as opposed to referral of pregnant women and their babies to a separate ART clinic as was the case in Zambia previously. Due to integration, fewer mothers are lost to follow-up [
6,
55]. Operational considerations indicate that incorporation of ART in MCH department ensures improved outcomes for HIV infected pregnant mothers and HIV-exposed children [
6]. Experience from a Malawi programme indicated that ART initiation within MCH sites improved retention compared to referral to ART sites. However, the presented findings point to the fact that for the progressive success of merging PMTCT and MCH programs, such efforts should fit into good planning and allocation of human resources for health. In resource-poor settings, shortages of PMTCT staff, interruptions in treatment and supplies of medical equipment, as well as a shortfall in counseling services, all act as barriers to PMTCT services [
32,
59]. These factors often mean long waiting times for post-test counseling.
In order to better understand the downstream impact of the Option B+ approach, more such “real world” program data are needed in sub-Saharan Africa and must be carefully evaluated. This means that the aggregate tallies made routinely in the HIMS, longitudinal patient-level data should be collected at representative sites, ideally linked between programs i.e. PMTCT, ART and between mother, child and community model partnerships to inform enhanced and well integrated health services delivery. Moreover, future insights in PMTCT counselling should also target women’s broader living conditions, that is economic factors and community-level factors (particularly stigma, fear of disclosure and partner support) [
32]. Only through a combination of individual, community and structural interventions will we achieve an AIDS-free generation, which requires the elimination of vertical transmission of HIV in sub-Saharan Africa [
32,
60]. The presented findings had some limitations. The research only looked at breastfeeding practices among HIV positive mothers and did not include complementary feeding part of the IYCF guidelines.