In high HIV burden countries, the dilemma of how best to feed infants of HIV-infected mothers remains complex. The debate has always been between exclusive breastfeeding and exclusive formula feeding. Exclusive breastfeeding carries a higher risk of HIV transmission over the first six months of life, but is infrequently practiced by mothers or not effectively supported by health systems [1]. Replacement feeding avoids all postnatal HIV transmission but carries the risk of death [1][2] when given in household circumstances that are not ideal. Early data suggest that highly active antiretroviral treatment given to HIV-infected mothers during the period of breastfeeding can reduce transmission risks, even if she is already immunodeficient [1][2][3].

In Nigeria, the recommendation on infant feeding in the context of HIV infection changed a number of times over the years and mirrors the various recommendations of the World Health Organization [4] [5][6][7][8][9]. One common theme of the various guidelines is the emphasis on the strict adherence to the appropriate infant feeding method chosen by the mother. Also, that health workers should support the mother’s chosen infant feeding method. Mothers should be discouraged from adopting inappropriate feeding, not only because of its associated malnutrition, respiratory tract infections and diarrhea, but with the increased risk of mother to child transmission (MTCT) [1][2][3] . Health care workers at facility levels are expected to counsel mothers on strict adherence to their chosen infant feeding option among the three appropriate infant feeding choices (exclusive breastfeeding, exclusive formula feeding and replacement feeding) in the context of HIV infection [4][5][6].

Optimal adherence to infant feeding method of choice is not only context specific but requires deep understanding of facilitators and barriers to appropriate infant feeding [9]. Unfortunately, limited data exists on these facilitators and barriers to effective adherence to appropriate infant feeding in the context of HIV infection in our environment. Availability of this information will be useful in designing an effective counseling strategy that is context specific and has the potential to ensuring adherence to appropriate infant feeding.

The HIV treatment centre, since 2004 has been providing PMTCT services including infant feeding counseling to over 5,000 HIV positive mothers. The counseling strategy has changed a number of times based on the recommendation of the prevailing national guidelines and is well positioned to provide answers to some of this critical knowledge deficit. In this study we determined the risk factors for inappropriate infant feeding in the context of HIV infection.

Postpartum, mother and baby are followed-up at the PMTCT clinic until 18 months when the child is either discharged from the clinic if negative or transferred to the pediatric clinic if positive. On each of the visits mothers are given health talk on infant feeding methods based on the prevailing guidelines. Information is collected on the mother’s infant feeding choice at each postpartum visit.

Study relevant data were extracted from the PMTCT data base which was collected prospectively. For each mother-infant pair we extracted information on the maternal age and parity, marital status, religion, educational status, husband’s occupation, gestational age at PMTCT enrolment and delivery, birth weight and sex of the baby. Information on CD4 count, viral load, HIV status before pregnancy, and duration of ARV drugs, HIV disclosure status, partners HIV status, and year of delivery were also extracted. Data analysis was with SPSS version 20.

Frequency distributions were generated and univariate analysis using relevant statistics was performed to identify factors associated with infant feeding method practiced by the mothers. Multivariate logistic regression was used to identify independent risk factors for infant feeding practice while controlling for potential confounders. For this analysis infant feeding practices in the context of HIV were dichotomized into adequate (exclusive breastfeeding, exclusive formula feeding and replacement feeding) and inadequate (mixed breast feeding) infant feeding practice. Variables were entered into the model if their p-value on univariate analysis was 0.10 or less. The variable with the strongest association in the univariate model was estimated first, followed by others in descending order. The p < 0.05 was considered to be statistically significant odds ratios (OR) and 95% confidence intervals (CI) for the OR were also calculated.

Ethical approval for the study was obtained from the Institutional Review Board, Nigerian Institute of Medical Research, Lagos Nigeria (IRB-04–03). Written informed consents were obtained from all women for the use of their data for the study. However, women who declined consent to participate in the study were provided care but excluded from research.

Mixed breastfeeding: Giving the infant breast milk and other fluids and solids. Mixed breastfeeding may be further classified into predominant breastfeeding and partial breastfeeding: Predominant breastfeeding means giving the infant breast milk and non-nutritive liquids. Partial breastfeeding means feeding breast milk and non-nutritive and nutritive liquids and solids.

Exclusive formula feeding: Giving the infant only commercial infant formula milk for the first six months of life.

Replacement feeding: Refers to the process of feeding a child who is not receiving any breast milk a diet that provides all the nutrients the child needs until the child is fully fed on family foods. During the first six months a suitable breast milk substitute should be used and subsequently complementary foods made from appropriately prepared and nutrient-enriched family foods should be added.

Appropriate infant feeding in the context of HIV infection: Refers to any of the alternative infant feeding in the context of HIV infection recommended by the prevailing policy and guidelines. These include any of exclusive breastfeeding, exclusive formula feeding and replacement feeding.

Inappropriate infant feeding in the context of HIV infection: Refers to any other infant feeding practices not recommended by the prevailing policy and guideline. For example, mixed breastfeeding.

A total of 5888 mothers registered for prevention of mother to child transmission (PMTCT) services during the study period; of which 5034 mother-infant pairs fulfilled the eligibility criteria for inclusion into the study.

The socio-demographic characteristics of mothers in the study are given in Table 1. The majority of the women were married (80.3%), completed at least a secondary education (73.1%), practiced christian religion (60.7%), of low socioeconomic class (60.4%), gainfully employed (75.4%) and had at least two previous deliveries (74.6%) .

The obstetric and infant characteristics in the study are given in Table 2. Majority of mothers registered for PMTCT services after the first trimester (81.3%) delivered at term (78.5%) and in an orthodox health facility (91.1%). Vaginal delivery was the more common mode of delivery (59.7%). Over 90% of the babies weighed at least 2500 g and male babies were in the majority (50.5%).

The HIV related characteristics of the mothers at or near delivery is given in Table 3. The majority of mothers had CD4 count above 200 cells/mm³ (77.9%), viral load of less than 1000 copies (44.6%) and on care before pregnancy (63.8%). While majority of the mothers had disclosed their HIV status (83.9%), only one-third of the mothers had a spouse with HIV positive status (33.9%).

Of the 5034 mothers in the study, majority practiced exclusive formula infant feeding (86.4%; 4349), while others practiced exclusive breastfeeding (9.0%; 453), replacement feeding (1.8%; 91) or mixed feeding (2.8%; 141). The inappropriate feeding rate during the study period was thus 2.8%.

To determine the factors associated with the practice of inappropriate infant feeding in the context of HIV infection, comparison were made between the demographic, obstetric and HIV related characteristics of those that practiced appropriate infant feeding and those who practiced inappropriate infant feeding. The differences in proportion of mothers who practiced infant feeding appropriately and inappropriately were found for various variables, first at univariate analysis and then at multivariate analysis. At univariate analysis (Table 4 and Table 5), a higher proportion of mothers who practiced inappropriate infant feeding were of low socioeconomic class (cOR: 2.7; CI: 1.2–4.6), had less than secondary education (cOR: 3.9; CI: 2.7–5.7), resides in a rural community (cOR: 2.8; CI: 1.7–4.6), unemployed (cOR: 4.5; CI: 3.1–6.5), not on care before PMTCT enrolment (cOR: 2.0; CI: 1.4–2.9) and in a HIV serodiscordant relationship (cOR: 1.5; CI: 1.03–2.3 compared to those who practiced appropriate infant feeding. Mothers who have not disclosed their HIV status (cOR: 6.8; CI: 4.7–9.9), registered for PMTCT services after the first trimester (cOR: 1.8; CI: 1.01–3.1), delivered outside orthodox health care facility (cOR: 9.7; CI: 6.6–14.3) and had twin delivery (cOR: 2.5; CI: 1.0–6.3) were also more likely to practice inappropriate infant feeding than their counterparts. No statistically significant differences were found between mothers who practiced inappropriate infant feeding and those who practiced appropriate infant feeding in terms of their age, religion, marital status, ethnicity, duration of HIV disease, sex of baby mode of delivery. Of the ten variables initially found to be independently associated with inappropriate infant feeding in the context of HIV infection at univariate analysis, six variables of low educational status (aOR: 3.6; CI:2.4–5.1), low socioeconomic status (aOR: 2.3; CI: 1.3–4.1), unemployed status (aOR: 3.9; CI: 2.5–5.5), not being on care before PMTCT enrolment (aOR: 1.9; CI: 1.5–2.7), non-disclosure of HIV status (aOR: 6.3; CI: 4.9–8.3) and delivery outside an orthodox health facility (aOR: 8.1; CI: 7.4–11.7) retained their independent association with inappropriate infant feeding (Table 4 and Table 5). HIV serodiscordant relationship, late booking for PMTCT, twin delivery and place of residence lost their independent association with inappropriate infant feeding after controlling for possible confounders (Table 4 and Table 5).

The majority of mothers in this study practiced appropriate infant feeding (97.2%). The finding is similar to the findings of previous studies in our environment and elsewhere [7][10][11][12][13][14][15]. This high rate may be a reflection of the quality of PMTCT program in the country. Although Nigeria presently contributes over 30% of global PMTCT gap, the few centers available are mainly in the tertiary and secondary facilities, hence the quality of services offered. For PMTCT program to achieve its potential, quality have to be matched with coverage, as most pregnant Nigerian women receive care at primary health care facilities [16].

Worrisome, however, is the inappropriate feeding rate of 2.8% in the study. With this high inappropriate infant feeding obtained in a tertiary facility with well-resourced and motivated staff, one could only imagine what the situation would be in the lower levels. Issues contributing to the inappropriate feeding practice should urgently be addressed to avert the negative consequences of the practice. All pregnant and lactating HIV positive mothers should be counseled on the dangers of inappropriate infant feeding during and after pregnancy until the child is weaned successfully.

Mothers who practiced inappropriate infant feeding in the context of HIV infection were found to be of low socioeconomic and educational status, unemployed, not on care before PMTCT enrolment, have not disclosed their HIV status and delivered outside an orthodox health facility. This finding is in support of previous studies in our environment which showed that maternal education and socioeconomic status are important predictors of infant feeding practices [17][18]. According to these studies, mothers who are of low socioeconomic and education status are more likely to practice mix feeding, which is inappropriate in the context of HIV infection. With good education and economic empowerment mothers are likely to stick to their choice of infant feeding because they are both independent minded and economically empowered. On the other hand, mothers of low educational and economic status are more likely to be influenced by culture and peers. She may occasionally feed her child with formula feed if she is predominantly breastfeeding to show that she knows the modern trend and not so poor after all.

This study like that of Maru et al. [14] found that mothers who have not disclosed their HIV status are more likely to practce inappropriate feeding method. The reasons are obvious as she is not likely to insist on practicing one feeding method exclusively and also lacks partners support. Nigeria is a predominantly breastfeeding but not exclusive breastfeeding nation, which translates to mixed feeding if practiced in the context of HIV infection. Any mother who practices otherwise is likely to raise some eye brows and because of fear of exposing her HIV status, the lowly economic and poorly educational mothers are more likely to stick to mixed feeding which is the norm in our setting but dangerous in HIV exposed infant.

The finding of mothers who delivered outside orthodox health care settings been associated with inappropriate infant feeding choice may be a proxy for low socioeconomic status and non-adherence to positive health choices. In our setting, women who deliver outside orthodox health care system are often of low socioeconomic and educational status [19]. It is therefore not surprising that they will make wrong choice of infant feeding method. These category of women should be offered regular counseling session to ensure no child get infected during delivery and through breastfeeding.

This study is challenged by some limitations that may make generalization difficult. The study was conducted in a dedicated stand-alone tertiary HIV treatment centre and may not reflect the true situation at population level. However, the large number of clients and the diversity among the cohort in this study which is similar to the distribution in general population will make generalization possible.

A very small proportion of mothers in this study practiced inappropriate infant feeding in the context of HIV infection (2.8%). Inappropriate infant feeding in context of HIV infection was found to be associated with low educational, socioeconomic and unemployed status, not on care before PMTCT enrolment, non-disclosure of HIV status and delivery outside an orthodox health facility. Mothers who were found to be at risk of practicing inappropriate infant feeding should be identified and specially counseled on the risk of mixed feeding.

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