Does livestock ownership predict animal-source food consumption frequency among children aged 6-24 months and their mothers in the rural Dale district, southern Ethiopia?

Background: Animal-source foods are food items that come from animals. Animal-source foods provide a variety of micronutrients that plant-source foods cannot provide to the same extent and without extra precaution. Milk, eggs, poultry, flesh meat and fish are animal-source foods mainly used in Ethiopia. Low animal-source food consumption among children and mothers is a great concern in many low-income settings. This study aimed to describe animal-source food consumption frequencies among children aged 6-24 months and their mothers in rural southern Ethiopia where livestock farming is very common. We also analysed the association between livestock ownership and animal-source food consumption among children and mothers. Methods: A community-based cross-sectional study was conducted among 851 randomly selected households with child-mother pairs from August to November 2018. The study was conducted in the rural Dale District, southern Ethiopia. Structured and pre-tested questionnaires were used to collect data on mother and child information, livestock ownership, and animal-source foods consumption frequencies. Ordinal logistic regression analysis was used to describe associations between animal-source foods consumption and livestock ownership. Result: Nearly, three-quarters (74.1%) of the households owned cows, and a quarter (25%) had goats or sheep. Dairy, egg and meat consumption among children during the past month was 91.8%, 83.0% and 26.2%, respectively. Likewise, the consumption of dairy, eggs and meat among mothers was 96.0%, 49.5% and 34.0%, respectively. The percentage of children who had not consumed any animal-source foods during the month prior to our survey was 6.6%, and the figure was 2.2% for the mothers. Dairy consumption was 1.8 times higher among children (aOR = 1.8, 95% CI [1.3-2.5]) and 3.0 times higher among mothers (aOR = 3.0, 95% CI [2.2-4.2]) in households that kept cows than in households without cows. The egg consumption frequency was positively associated with hen and goat/sheep ownership for both children and mothers. Meat consumption frequency among children was negatively associated with cow ownership (aOR = 0.66, 95% CI [0.45-0.95]); however, cow ownership was not associated with meat consumption among mothers. Conclusion: Dairy products were common animal-source foods consumed by young children and mothers in the study area. However, meat consumption was low among children and mothers. Strategies like promoting the keeping of goats/sheep and hens to improve complementary feeding and mothers' nutrition are warranted in the study area.

"She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda.

BACKGROUND: There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda. METHODS: This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis. RESULTS: Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom. CONCLUSIONS: Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.

Predicting adherence to postdischarge malaria chemoprevention in Malawian pre-school children: A prognostic multivariable analysis.

Chemoprevention with antimalarials is a key strategy for malaria control in sub-Saharan Africa. Three months of postdischarge malaria chemoprevention (PDMC) reduces malaria-related mortality and morbidity in pre-school children recently discharged from hospital following recovery from severe anemia. Research on adherence to preventive antimalarials in children is scarce. We aimed to investigate the predictors for caregivers' adherence to three courses of monthly PDMC in Malawi. We used data from a cluster randomized implementation trial of PDMC in Malawi (n = 357). Modified Poisson regression for clustered data was used to obtain relative risks of predictors for full adherence to PDMC. We did not find a conclusive set of predictors for PDMC adherence. The distribution of households across a socio-economic index and caregivers' education showed mixed associations with poor adherence. Caregivers of children with four or more malaria infections in the past year were associated with reduced adherence. With these results, we cannot confirm the associations established in the literature for caregiver adherence to artemisinin-based combination therapies (ACTs). PDMC combines multiple factors that complicate adherence. Our results may indicate that prevention interventions introduce a distinct complexity to ACT adherence behavior. Until we better understand this relationship, PDMC programs should ensure high program fidelity to sustain adherence by caregivers during implementation.

Heavy metals in children's blood from the rural region of Popokabaka, Democratic Republic of Congo: a cross-sectional study and spatial analysis.

Exposure to heavy metals can affect cell differentiation, neurocognitive development, and growth during early life, even in low doses. Little is known about heavy metal exposure and its relationship with nutrition outcomes in non-mining rural environments. We carried out a community-based cross-sectional study to describe the distribution of four heavy metal concentrations [arsenic (As), cadmium (Cd), lead (Pb), and mercury (Hg)] in the serum of a representative population of children aged 12 to 59 months old from the rural region of Popokabaka, Democratic Republic of Congo. The four metals were measured in 412 samples using inductively coupled plasma-mass spectrometry (ICP-MS). Limits of detection (LoD) and quantification (LoQ) were set. Percentiles were reported. Statistical and geospatial bivariate analyses were performed to identify relationships with other nutrition outcomes. Arsenic was quantified in 59.7%, while Cd, Hg, and Pb were quantified in less than 10%, all without toxicities. The arsenic level was negatively associated with the zinc level, while the Hg level was positively associated with the selenium level. This common detection of As in children of Popokabaka requires attention, and urgent drinking water exploration and intervention for the profit of the Popokabaka community should be considered.

Distribution and Determinants of Serum Zinc, Copper, and Selenium Levels among Children under Five Years from Popokabaka, Democratic Republic of Congo: A Cross-Sectional Study.

Information about essential trace elements among children in many African countries, including the Democratic Republic of Congo (DRC), is limited. We aimed to measure the distribution and determinants of serum zinc (Zn), copper (Cu), and selenium (Se) concentrations in a representative sample of children under five years old. We conducted a community-based cross-sectional study in Popokabaka, DRC. Blood samples were drawn from 412 children. The serum concentrations of minerals were measured using inductively coupled plasma−mass spectrometry. The median concentrations (P25−P75) of Zn, Cu, and Se were 61.9 µg/dL (52.8−70.2), 145.5 (120.0−167.0) µg/dL and 5.3 (4.3−6.3) µg/dL. The CRP-adjusted prevalence of serum Se deficiency was 84.1% (95% confidence interval [CI] 81.4−87.0) and of Zn deficiency was 64.6% (95% CI 59.8−69.1%). Only a few children were Cu deficient [1.5% (0.6−3.2)]. Evidence of inflammation (C-reactive protein, >5 mg/L) was associated with a lower Se concentration and higher Cu concentration. Furthermore, serum Se concentration was positively associated with linear growth. The average Cu/Zn molar ratio (2:1) was twice that recommended. Children in western Popokabaka had higher Zn and Se levels than their eastern neighbors. Zinc and selenium deficiencies are common among children in Popokabaka and require attention and prioritization.

Diet and nutritional status among hospitalised children in Hawassa, Southern Ethiopia.

BACKGROUND: Undernutrition constitutes a major problem among children in Hawassa, Ethiopia, and the literature on nutritional status in hospitalised children is scarce. The aim of this study was to investigate dietary diversity, nutritional practices, and the frequencies of undernutrition and the factors associated with severe acute malnutrition (SAM) in a hospitalised paediatric population in Hawassa, Southern Ethiopia. METHODS: A hospital-based cross-sectional study was carried out among hospitalised children in Hawassa, Southern Ethiopia. Children aged 6 to 59 months and their caregivers admitted for >24 hours from two public hospitals in Hawassa between November 2019 and January 2020 were included. Dietary diversity was assessed using World Health Organization (WHO) guidelines. Weight and height/length of the children were measured, and z-scores were calculated using the WHO growth standards. The definition of SAM was a weight-for-height z-score (WHZ) less than -3 or a clinically confirmed SAM diagnosis with higher WHZ. RESULTS: A total of 188 caregiver-child pairs were assessed in the two public hospitals. The majority of the patients were admitted with SAM (N = 70/188, 37%) or respiratory tract infections (N = 44/188, 23%). There was a similar number of boys and girls with SAM. Of all the children, 59% reported to have consumed foods from fewer than four food groups, while 40% reported eating foods from four or more food groups. The rate of malnutrition was high, and 35.8% of the children were classified as wasted (WHZ < -2) and 41% were stunted (height-for-age z-score < -2). Nearly 30% of the SAM patients were also stunted. CONCLUSION: This study revealed that hospitalised children in this setting had poor dietary diversity and nutritional status, a high degree of morbidity, and extreme poverty. There is thus a need to focus on nutrition patterns in clinical settings.

'I am not only beneficial to the community but to the entire country, I am trained as a researcher now': Developing health research skills in low-income countries.

ABSTRACTPartnerships between Higher Education Institutions in the global South and North have potential for building capacity in public health research in low-resource countries. We present experiences of partners involved in a North-South-South partnership between universities in Norway, the Democratic Republic of Congo (DRC) and South Africa. The partnership aimed to establish a postgraduate programme in nutritional epidemiology at the University of Kinshasa, DRC, and develop a cadre of researchers and academic leaders to provide locally generated health research to inform policy. In-depth interviews were conducted with 31 purposively selected stakeholders, facilitators, and students from partner institutions. All participants expressed positive experiences, indicating that the partnership provided excellent opportunities to network, enriched participants' learning and enhanced academic growth, with benefits at individual, institutional, and country levels. Participants suggested that maintaining a common vision was important for success, facilitated by joint planning of project activities, focussing strongly on building research and academic capacity at Kinshasa School of Public Health and addressing local nutrition problems. Important challenges highlighted for future partnerships included failures of co-facilitation and co-supervision, poor research dissemination and policy impact, and concerns about sustainability. Notwithstanding, North-South-South partnerships can address skills shortages in public health research with significant benefits to all partner institutions.

Infant feeding, growth monitoring and the double burden of malnutrition among children aged 6 months and their mothers in KwaZulu-Natal, South Africa.

South Africa has a documented high prevalence of stunting and increasing obesity in children as well as obesity in adults. The double burden of malnutrition, which can be on an individual-, household- or population level, has implications for both health and the economic development of a community and country. This paper describes a large-scale survey (N = 774) of infant feeding, growth monitoring and anthropometry among mother and child pairs aged 6 months of age in KwaZulu-Natal (KZN), South Africa, conducted between January and August 2017. Among children, a large increase in the prevalence of stunting and obesity was seen between birth and 6 months of age increasing from 9.3% to 21.7% and 4.0% to 21.0%, respectively. 32.1% of the mothers were overweight [body mass index (BMI): 25.0-29.9] and 28.4% had obesity grade 1 (BMI: 30-<40). Although most mothers (93%; 563/605) initiated breastfeeding, the introduction of other foods started early with 17.6% (56/319) of the mothers having started giving other fluids or food to their child within the first month. At 6 months 70.6% (427/605) children were still breastfed and 23.5% were exclusively breastfed. In addition, we found that length measurements were done less frequently than weight measurements between birth and 6 months, on average 2.2 (SD: 1.3) versus 5.8 (SD: 1.5) times. Moreover, there is a need for improvement of health worker training and understanding regarding anthropometric measurements when assessing malnutrition in children in the clinics. Early detection and improved infant feeding practices are key in preventing both stunting and obesity in children.

A North-South-South partnership in higher education to develop health research capacity in the Democratic Republic of the Congo: the challenge of finding a common language.

BACKGROUND: Globally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North-South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI. METHODS: In-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants' language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach. RESULTS: Most participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students' research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI. CONCLUSION: Partnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Establishing a postgraduate programme in nutritional epidemiology to strengthen resource capacity, academic leadership and research in the democratic republic of Congo.

BACKGROUND: Low- and Middle-income countries (LMIC) face considerable health and nutrition challenges, many of which can be addressed through strong academic leadership and robust research translated into evidence-based practice. A North-South-South partnership between three universities was established to implement a master's programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), Democratic Republic of Congo (DRC). The partnership aimed to develop academic leadership and research capacity in the field of nutrition in the DRC. In this article we describe the educational approach and processes used, and discuss successes, challenges, and lessons learned. METHODS: Self-administered questionnaires, which included both open and closed questions, were sent to all graduates and students on the master's programme to explore students' experiences and perceptions of all aspects of the educational programme. Quantitative data was analysed using frequencies, and a thematic approach was used to analyse responses to open-ended questions. RESULTS: A two-year master's programme in Nutritional Epidemiology was established in 2014, and 40 students had graduated by 2020. Key elements included using principles of authentic learning, deployment of students for an internship at a rural residential research site, and support of selected students with bursaries. Academic staff from all partner universities participated in teaching and research supervision. The curriculum and teaching approach were well received by most students, although a number of challenges were identified. Most students reported benefits from the rural internship experience but were challenged by the isolation of the rural site, and felt unsupported by their supervisors, undermining students' experiences and potentially the quality of the research. Financial barriers were also reported as challenges by students, even among those who received bursaries. CONCLUSION: The partnership was successful in establishing a Master Programme in Nutritional Epidemiology increasing the number of nutrition researchers in the DRC. This approach could be used in other LMIC settings to address health and nutrition challenges.

Growth, clinical and neurodevelopmental outcomes at school age are similar for children who received 1-year lamivudine or lopinavir/ritonavir HIV prophylaxis in early life.

In the ANRS 12174 trial, HIV-exposed uninfected African neonates who received lopinavir-ritonavir (LPV/r) prophylaxis for 1 year exhibited slower growth from birth to week 50 compared with those receiving lamivudine (3TC). We assessed whether this difference in growth persisted over time, and was accompanied by differences in neuropsychological and clinical outcomes. Between February 2017 and February 2018, we conducted a cross-sectional clinical evaluation among former trial participants who completed the 50-week follow-up and who were not HIV-infected. In addition to clinical examination, neuropsychological outcomes were assessed using the tests Kaufman-ABCII, Test of Variables of Attention, Movement Assessment Battery for Children and the Strengths and Difficulties questionnaire, parent version. Of 1101 eligible children, aged 5-7 years, 553 could be traced and analysed (274 in the LPV/r and 279 in the 3TC groups). Growth, clinical and neuropsychological outcomes did not differ between treatment groups. At school age, children exposed to LPV/r and 3TC at birth for 1 year had comparable growth and neuropsychological outcomes without evidence of long-term side-effects of LPV/r. It provides reassuring data on clinical outcomes for all HIV-infected children treated with this antiretroviral drug in early life.

Translating new evidence into clinical practice: a quasi-experimental controlled before-after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa.

OBJECTIVES: We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding. DESIGN: Quasi-experimental controlled before-after study. SETTING: Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa. PARTICIPANTS: All HWs providing infant feeding counselling in selected facilities were invited. INTERVENTIONS: Three 1-2 hours, on-site workshops over 3-6 weeks. PRIMARY OUTCOME MEASURES: Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level. RESULTS: In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups. CONCLUSION: A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

Antiretroviral treatment and its impact on oral health outcomes in 5 to 7 year old Ugandan children: A 6 year follow-up visit from the ANRS 12174 randomized trial.

BACKGROUND: Antiretroviral therapy for HIV in sub-Saharan Africa has transformed the highly infectious virus to a stable chronic condition, with the advent of Highly active antiretroviral therapy (HAART). The longterm effects of HAART on the oral health of children are understudied. OBJECTIVE: To compare the effect of lopinavir-ritonavir and lamivudine on oral health indicators (dental caries, gingivitis, tooth eruption, and oral health related quality of life) in 5 to 7 year old HIV-1 exposed uninfected children from the ANRS 12174 trial. METHODS: This study used data collected in 2017 among children aged 5 to 7 years from the Ugandan site of the ANRS 12174 randomized trial (ClinicalTrials.gov no: NCT00640263) implemented between 2009 and 2012 in Mbale district, Eastern Uganda. The intervention was lopinavir-ritonavir or lamuvudine treatment to prevent vertical HIV-1 transmission. One hundred thirty-seven and 139 children were randomized to receive lopinavir-ritonavir or lamivudine treatment at day 7 postpartum to compare efficacy of prevention of vertical HIV-1 transmission. At follow up, the children underwent oral examination using the World Health Organization methods for field conditions. The oral health related quality of life was assessed using the early childhood oral health impact scale. Negative binomial and logistic regression were used for the analysis of data. MAIN OUTCOME MEASURES: Dental caries, gingivitis, tooth eruption, and oral health related quality of life) in 5 to 7 year old HIV-1 exposed uninfected children. RESULTS: The prevalence of dental caries was 48% in the study sample: 49% in the lopinavir-ritonavir arm and 48% in the lamivudine treatment group. The corresponding mean decayed missing filled teeth and standard deviation was 1.7 (2.4) and 2.3 (3.7) The mean number (standard deviation) of erupted permanent teeth was 3.8 (3.7) and 4.6 (3.9) teeth in the lopinavir- and lamivudine group, respectively. The prevalence of reported impacts on oral health was 7% in the lopinavir-ritonavir and 18% in the lamivudine group. Gingivitis had a prevalence of 7% in the lopinavir-ritonavir and 14% lamivudine treatment group. The regression analysis revealed 70% less reported impacts on oral health in lopinavir-ritonavir group than the lamivudine treatment group with an incidence rate ratio of 0.3 (95% confidence interval: 0.1-0.9). CONCLUSIONS: HIV exposed uninfected infants in the lopinavir-ritonavir group reported less impacts on oral health than the lamivudine treatment group. Dental caries, gingivitis, and tooth eruption were not significantly affected by the treatment lopinavir-ritonavir or lamivudine. TRIAL REGISTRATION CLINICALTRIALS. GOV IDENTIFIER: NCT00640263.

"If I have money, I cannot allow my baby to breastfeed only " barriers and facilitators to scale-up of peer counselling for exclusive breastfeeding in Uganda.

BACKGROUND: Early initiation and exclusive breastfeeding for 6 months reduces infant morbidity and mortality and can positively impact on cognitive function. In Uganda, exclusive breastfeeding for 6 months is recommended but many women introduce alternative feeds early. Interventions to scale-up peer support provision for exclusive breastfeeding are limited. We explored the barriers, facilitators and solutions to scaling-up of peer counselling support for exclusive breastfeeding in Uganda. METHODS: A qualitative study was conducted in Mbale District and Kampala City between April and July 2014. Data were collected through 15 key informant interviews with health workers and managers of organizations involved in child and maternal health as well as seven focus group discussions with peer counsellors who took part in the PROMISE EBF Trial (2006-2008), VHT members, mothers and fathers of children aged 1 year and below. Data were analysed using the content thematic approach. RESULTS: The need for peer support for exclusive breastfeeding, especially for young and first-time mothers, was highlighted by most study participants. While mothers, mothers-in-law, friends and husbands were mentioned as major stakeholders regarding infant feeding, they were perceived to lack adequate information on breastfeeding. Health workers were mentioned as a key source of support, but their constraints of heavy workloads and lack of education materials on breastfeeding were highlighted. High community expectations of peer counsellors, the perceived inadequacy of breast milk, general acceptability of complimentary feeding, household food insecurity, heavy workload for women and unsupportive 'work-places' were key barriers to scaling-up of peer counselling support for breastfeeding. The peer counsellors who were part of the PROMISE EBF trial in Mbale, the village health team programme, health facilities, community groups, the media and professional associations emerged as potential facilitators that can aid the scaling-up of peer counselling support for breastfeeding. CONCLUSIONS: Peer support for breastfeeding is highly valued in this setting. The health system and health workers are regarded as the main facilitators to scaling-up of peer support for exclusive breastfeeding. Partnerships with village health teams (VHTs), community groups, role models, professional associations and the media are other potential facilitators to this scaling-up.

Caries experience and oral health related quality of life in a cohort of Ugandan HIV-1 exposed uninfected children compared with a matched cohort of HIV unexposed uninfected children.

BACKGROUND: Very few studies consider the oral health status and quality of life in HIV-1 exposed uninfected (HEU) children. The aim of this study was to estimate the prevalence of caries in primary teeth and its oral health related quality of life impacts in HEU children compared to HIV-unexposed-uninfected (HUU) children, whilst adjusting for confounding covariates. METHODS: This study uses data from the Ugandan site of the ANRS 121741 PROMISE- PEP trial (ClinicalTrials.gov, number NCT00640263) conducted in 2009-2013 that recruited mothers with HIV-1 and their uninfected children. Of 244 HEU-children-caretaker pairs available at the end of the one-year trial, 166 were re-enrolled in the ANRS 12341 PROMISE-PEP M&S study at 5-7 years and 164 were included in this study. These were age and sex-matched with 181 HUU children-caretaker comparators. Caries experience was recorded using World Health Organization's Decayed, Missed and Filled teeth (dmft/DMFT) indices. The Early Childhood Oral health Impact Scale (ECOHIS) was used for assessment of oral health related quality of life. Mixed effects logistic regression was conducted with dmft and ECOHIS scores as outcomes and HIV-1 exposure status as the main exposure. RESULTS: Forty-eight percent of HEU children and 60% of HUU had dmft> 0. Corresponding figures for ECOHIS> 0 were 12% of HEU and 22% of HUU. The crude analysis showed differences related to HIV-1 exposure in caries experience and oral health related quality of life. Mixed effect logistic regression analyses were not significant when adjusted for use of dental care and toothache. If caregivers' DMFT> 0, the adjusted odds ratio for caries experience (dmft> 0) was 1.6 (95% CI: 1.0-2.8) while if dmft> 0 the adjusted odds ratio for quality of life impacts (ECOHIS> 0) was 4.6 (95% CI: 2.0-10.6). CONCLUSION: The prevalence of untreated caries in primary teeth and quality of life impacts was high in this study population. HIV-1 exposed uninfected children were not more likely than HUU children to experience dental caries or have impaired oral health related quality of life. Given the global expansion of the HEU child population, the present findings indicating no adverse effect of pre- and post-natal HIV-1 exposure on caries in deciduous teeth are reassuring.

An educational intervention to update health workers about HIV and infant feeding.

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.

Breastfeeding advice for reality: Women's perspectives on primary care support in South Africa.

Breastfeeding education and support are critical health worker skills. Confusion surrounding infant feeding advice linked to the HIV epidemic has reduced the confidence of health workers to support breastfeeding. High antiretroviral therapy coverage of breastfeeding women living with HIV, and an Infant Feeding policy supportive of breastfeeding, now provides an opportunity to improve breastfeeding practices. Challenges remain in restoring health worker confidence to support breastfeeding. This qualitative study presents findings from focus group discussions with mothers of young infants, exploring their experiences of health worker breastfeeding counselling and support. Analysis followed the thematic framework approach. Six researchers reviewed the transcripts, coded them independently, then jointly reviewed the codes, and agreed on a working analytical framework. Although mothers received antenatal breastfeeding messages, these appeared to focus rigidly on the importance of exclusivity. Mothers described receiving some practical support with initiation of breastfeeding after delivery, but support and advice for post-natal breastfeeding challenges were often incorrect or absent. The support also ignored the context in which women make infant feeding decisions, including returning to work and pressures from family members. Despite improved breastfeeding policies, restoring confidence in health workers to support breastfeeding remains a challenge. The post-natal period, when mothers experience breastfeeding difficulties, is particularly critical, and our findings reinforce the importance of continuity of care between communities and health facilities. This research has implications for how health workers are trained to support breastfeeding. Greater attention is needed on developing skills and confidence in identifying, assessing, and supporting women experiencing breastfeeding challenges.

[Development and challenges to breastfeeding in sub-Saharan Africa]. / Entwicklungen und Herausforderungen der Stillpraxis in den Ländern des südlichen Afrikas.

Since there is no doubt concerning the superiority of breastfeeding compared to other forms of infant feeding, the promotion of exclusive breastfeeding up to six months and continued breastfeeding up to two years and beyond are again embraced at the highest global nutrition agenda. The latest is the United Nations decade of action on nutrition 2016-2025, building on research results and the work by the World Health Organization (WHO) over the last two decades, and extensive societal, clinical, and academic discussions in the field of breastfeeding.While the discussion was about the optimal duration of exclusive breastfeeding around the millennium shift, the focus is on the most effective measures for the promotion and protection of breastfeeding. Contemporary breastfeeding rates are well behind the goals. In sub-Saharan Africa, almost all infants are breastfed, while exclusive breastfeeding is more seldom and not sufficient. Africa, being a vast and diverse continent with a myriad of cultural practices, has had some shared attitudes ranging from the west to east regarding views on motherhood, body fluids, including milk, infant feeding, and responsible others.The region still faces high maternal HIV infection rates and high infant and child mortality rates. However, due to effective antiretroviral therapies, it is now possible and safe for women living with HIV to breastfeed their infants and to ensure them HIV-free survival. However, there is need for improvement regarding availability, compliance, and adherence to these drugs. Research gaps include the long-term effects of antiretroviral therapy on the growth, health, and development of the exposed children.

HIV-1 disease progression in immune-competent HIV-1-infected and breastfeeding mothers participating in the ANRS 12174 clinical trial in Burkina Faso, South Africa, Uganda and Zambia: a cohort study.

OBJECTIVE: We have assessed HIV-1 disease progression among HIV-1-positive mothers in relation to duration of any or exclusive breast feeding in the context of ANRS 12174 trial. METHODS: The analysis was completed on 203, 212, 272 and 529 HIV-1-positive and lactating mothers with CD4 count >350 cells/µL from Burkina Faso, South Africa, Uganda and Zambia, respectively. The trial compared lamivudine and lopinavir/ritonavir as a peri-exposure prophylaxis during a 50-week follow-up time. A multiple logistic regression model was run with the mothers' weight, CD4 count and HIV-1 viral load as separate dependent variables, then combined into a dependent composite endpoint called HIV-1 disease progression where HIV-1 viral load was replaced by the HIV-1 clinical stage. Exclusive or predominant breast feeding (EPBF) and any breastfeeding duration were the key explanatory variables. RESULTS: In the adjusted model, the associations between EPBF duration and weight change, CD4 cell count and the HIV-1 viral load were consistently insignificant. The CD4 cell count was associated with a significantly higher mothers' body mass index (BMI; a mean increase of 4.9 (95% CI 2.1 to 7.7) CD4 cells/µL per each additional kilogram per square metre of BMI) and haemoglobin concentration (19.4 (95% CI 11.4 to 27.4) CD4 cells/µL per each additional gram per decilitre of haemoglobin concentration). There was no significant association between EPBF duration and HIV-1 disease progression. A higher education level was a factor associated with a slower HIV-1 disease progression. CONCLUSION: Breast feeding was not a risk factor for a faster progression of HIV-1 disease in mothers of this cohort with a baseline CD4 cell count >350 cells/µL. TRIAL REGISTRATION NUMBER: NCT0064026; Post-results.

Correction to: Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children.

[This corrects the article DOI: 10.1186/s13006-015-0041-x.].