Unlike women in Canada and Nigeria, African, Black and Caribbean women living with HIV in Miami were less likely to divulge exactly how they were feeding their infants, or what their partners wanted for infant breastfeeding, according to a paper published in BMC Public Health.

The finding comes as women with HIV begin to open up to providers about their desire for and practice of breastfeeding, and as experts and activists continue to press providers to be more open about what’s known about the impact of an undetectable viral load on the safety of breastfeeding for women and their infants.

Josephine Etowa, RN, PhD, of the University of Ottawa School of Nursing, and colleagues gathered responses from 690 African, Black and Caribbean mothers living with HIV in Ottawa, Miami and Port Harcourt, Nigeria by soliciting participation at AIDS service organizations, clinics and community centers. Interestingly, women in Miami were the least likely to return their responses to the survey, with a response rate of just 67%, compared to 89% in Ottawa and 100% in Port Harcourt. All participants had babies since the World Health Organization established its first infant feeding guidelines in 2010.

The mothers were most likely to be in their 30s or 40s. Most were married (ranging from 33% in Ottawa to 85% in Nigeria), and 93% of the women, overall, had had three children or fewer since their HIV diagnosis. Almost all (98%) were on antiretroviral treatment. Two thirds were employed, with women in the United States the most likely to have jobs. Half made their money from their own businesses.

When it came to breastfeeding, nearly half of the women (47%) reported exclusive formula feeding, especially in Ottawa, where 91% did so. Understandably, based on country guidance, women in Port Harcourt were least likely to use formula (18%) and most likely to exclusively breastfeed (67%). Three out of four women in Miami reported exclusive formula feeding, 5% reported exclusive breastfeeding and 7% did a little of each. Notably, it was only women in the U.S. who declined to answer the question, while women in Canada and Nigeria were more willing to disclose.

Meanwhile, women were receiving input from their partners, their communities, and family members about their infant feeding habits. While women in Port Harcourt reported concordance between their own breastfeeding behaviors and the desires of their partners, the results were more varied for women in North America. While 75% of women in Miami said they were exclusively formula feeding, only about half (53%) reported that their partners supported that approach. Likewise, in Canada, partners were less likely to think women should exclusively breastfeed; 12% of women in Ottawa and 10% of women in Miami reported that their partners wanted them to exclusively breastfeed. Again, a full 32% of women in the U.S. declined to answer the question.

And then there was the issue of cultural beliefs about breastfeeding: nearly one in four women in Ottawa said they came from a culture that prohibited formula feeding, compared to 14% of women in Miami. Interestingly, again, U.S.-based respondents were more likely to go without answering the question—a full 49%.

American women were also least likely to report receiving prenatal care (91%, compared to 99% in Nigeria). This is notable because the more likely women were to have received prenatal care, the more likely they were to practice exclusive formula feeding. What’s more, the researchers found that women who reported higher levels of stress were more likely to practice a variety of feeding options rather than exclusive breast or formula feeding. Meanwhile, women were more likely to exclusively breastfeed (a 20-fold increased likelihood) if they received prenatal care from a nurse or midwife rather than a clinic staff member or doctor.

“These results point to the importance of health care providers providing evidence-based HIV prevention and care,” wrote the study authors. “In addition, health care providers need to be practiced in culturally safe and responsive manner to mee the needs of Black women living with HIV. Global and national guidelines also need to take into consideration the unique needs of those that are impacted by such policies.”

Click here to read the full survey.

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