Department of Community Health Systems, School of Nursing University of California, San Francisco, CA, USA.
Department of Anthropology, Durham University, Durham, UK.
J Int AIDS Soc. 2019 Jan;22(1):e25224. doi: 10.1002/jia2.25224.
Currently, the United States (U.S.) recommends that infants born to women living with HIV (WLHIV) be fed formula, whereas many low-resource settings follow the World Health Organization's recommendation to exclusively breastfeed with ongoing antiretroviral therapy. Evidence on infant feeding among WLHIV in high-resource countries suggest that these contrasting recommendations create challenges for providers and patients. Our study used multiple methods to understand providers' infant feeding perspectives on caring for their pregnant and post-partum WLHIV in the U.S.
We sent a survey (n = 93) to providers across the U.S. who have cared for WLHIV. A subset of survey participants opted into a follow-up qualitative interview (n = 21). These methods allowed us to capture a broad understanding of provider attitudes via the survey and more nuanced qualitative interviews. The study was completed prior to an updated breastfeeding section of the U.S. Perinatal Guidelines.
The majority of providers (66.7%) discussed infant feeding intent with their patients using open-ended questions. Many also discussed alternative feeding methods (37.6%) and disclosure avoidance strategies (34.4%). Over 75% (95% confidence interval (CI): 65.1 to 84.2) of participants reported that a WLHIV asked if she could breastfeed her child, and 29% (95% CI 20 to 40.3) reported caring for a patient who breastfed despite recommendations against breastfeeding. Providers reported that their patients' primary concern was stigma associated with not breastfeeding (58%), while providers were primarily concerned about medication adherence during breastfeeding (70%). Through qualitative analysis, four overarching categories emerged that reflect providers' sentiments, including (1) U.S. guidelines inadequately addressing WLHIV's desire to breastfeed; (2) negotiating patient autonomy amidst complex feeding situations; (3) harm reduction approaches to supporting WLHIV in breastfeeding; and (4) providers anticipating multilayered patient stigmatization.
The majority of provider respondents cared for a WLHIV who desired to breastfeed, and a third had WLHIV who breastfed despite recommendations against it. Providers found that the status of U.S. guidelines and their incongruity with WHO guidelines left them without adequate resources to support WLHIV's infant feeding decisions. Our findings provide important insight to inform professional associations' discussions about public health policy as they consider future directions for infant feeding guidelines among WLHIV.
目前，美国（U.S.）建议感染艾滋病毒的妇女（WLHIV）所生婴儿应食用配方奶，而许多资源匮乏的地区则遵循世界卫生组织（World Health Organization）的建议，即只要妇女持续接受抗逆转录病毒治疗，就应进行纯母乳喂养。在资源丰富的国家，有关 WLHIV 婴儿喂养的证据表明，这些相互矛盾的建议给提供者和患者带来了挑战。我们的研究使用多种方法来了解提供者在照顾感染艾滋病毒的孕妇和产后妇女方面对婴儿喂养的看法。
我们向全美范围内曾照顾过 WLHIV 的医护人员发送了一份调查问卷（n=93）。调查的一部分参与者选择参加后续的定性访谈（n=21）。这些方法使我们能够通过调查和更细致的定性访谈来全面了解提供者的态度。该研究是在美国围产期指南更新母乳喂养部分之前完成的。
大多数提供者（66.7%）使用开放式问题与患者讨论婴儿喂养意图。许多人还讨论了替代喂养方法（37.6%）和避免披露的策略（34.4%）。超过 75%（95%置信区间（CI）：65.1 至 84.2）的参与者报告称，有 WLHIV 询问过她是否可以母乳喂养她的孩子，而 29%（95% CI 20 至 40.3）的参与者报告称，他们照顾过一名尽管不建议母乳喂养但仍进行母乳喂养的患者。提供者报告说，他们的患者最关心的是与不母乳喂养相关的耻辱感（58%），而提供者最关心的是母乳喂养期间药物的依从性（70%）。通过定性分析，出现了四个总体类别，反映了提供者的情绪，包括（1）美国指南未能充分满足 WLHIV 对母乳喂养的愿望；（2）在复杂的喂养情况下协商患者自主权；（3）减少危害的方法来支持 WLHIV 进行母乳喂养；以及（4）提供者预计会出现多层次的患者耻辱化。
大多数提供者受访者都照顾过希望母乳喂养的 WLHIV，有三分之一的人照顾过尽管不建议母乳喂养但仍进行母乳喂养的 WLHIV。提供者发现，美国指南的现状及其与世界卫生组织指南的不一致性，使他们缺乏足够的资源来支持 WLHIV 的婴儿喂养决策。我们的研究结果为专业协会在考虑未来 WLHIV 婴儿喂养指南的方向时，就公共卫生政策展开讨论提供了重要的信息。
