Exclusive Breastfeeding Practice Among Lactating Mothers Infected with HIV in Southern Highlands of Tanzania, Assessing the Prevalence and Factors Associated with the Practice; An Analytical Cross-Sectional Study

Background: There is no other better way proven to safeguard an infant's health in the rst six months of life than Exclusive Breast Feeding (EBF). Mother's breast milk is valuable in all aspects of an infant's physical and mental growth as well as immune development. The study aimed at assessing the prevalence and factors associated with EBF practice among lactating HIV-infected mothers in the Southern Highlands of Tanzania. Method: A hospital-based analytical cross-sectional study was conducted among lactating HIV-infected mothers. A random sampling procedure was used to obtain 372 HIV-infected mothers of infants of 6 to 12 months who were still breastfeeding at the time of data collection. An interviewer-administered structured questionnaire was used for data collection. Bivariate and multivariate logistic regression was used to assess factors associated with EBF practice. Statistical package for social science (SPSS v.20) software was used for data entry and analysis. Results: The prevalence of EBF practice was 58.1% at 95% Condence Interval of 52.9% to 63.1%. More than half of the respondents 199(53.5%) had adequate knowledge while 173(46.5%) had inadequate knowledge on EBF. After adjusted for confounders, factors associated with EBF practice were knowledge on EBF [Adequate knowledge (AOR=5.114 at 95% CI= 3.2-8.172, p<0.001)], ANC visit [ Adequate (AOR=1.756 at 95% CI=1.094-2.817, p=0.002)], Income per day [1 0r more USD (AOR=1.828 at 95% CI=1.136-2.943, p=0.013)], perception towards EBF [ positive perception (AOR=3.506 at 95% CI=2.248-5.468, p<0.001) and ever experienced breast problem AOR=3.908 at 95% CI=1.891-8.075, p<0.001 Conclusion: More than half of interviewed mothers practiced EBF. The EBF practice among HIV lactating mothers was signicant inuenced by adequate knowledge on EBF,


Background
Human immunode ciency virus (HIV) is a virus that abates the body immune of a person and exposing the body to several opportunistic infections [1]. Albeit the major means of virus transmission is via unprotected sex, a signi cant majority of transmission occurs from mother to child. Mother-to-child transmission happens when HIV is transmitted from the mother to the child in the uterus, during birth, or while breastfeeding [1]. Exclusive breastfeeding (EBF) is the process in which the infant gets only breast milk and nothing else, except for ORS, minerals, vitamins, and medicines [2].
HIV and EBF have become important parameters today. It is estimated that about 37.9 million people were HIV positive by the end of 2018. Similarly, 1.7 million people became newly infected with HIV in 2018 globally [3]. For African Region, WHO observed that in the same year, there was an acute problem whereby there were about 25.7 million people affected with HIV infection [3].
Breastfeeding is one of the factors cited in the literature to contribute to the transmission of HIV to breastfeeding babies. However, exclusive breastfeeding for six months after birth has been found to lower the risk. Globally, it is estimated that 34.8% of infants were fully breastfed in the rst 6 months of life [4]. In sub-Saharan Africa, the prevalence of EBF to both HIV-positive mothers and negative is low as to 36% [4]. In Tanzania, EBF up to the rst six months at the national level has shown to raise from 49% in 2010 to 59% in 2015 [5]. While the study was conducted in Ilala municipal, Tanzania the prevalence of exposed infants who were EBF was 46% [6].
Breastfeeding has a signi cant function in the nutrition, health, and cognitive growth of infants because human milk is the perfect nutrition for infants' survival, development, and growth [6. If infants get well breastfed in the rst six months of life, their immune system becomes strengthened. A strengthened immune system protects them from diseases that cause infant mortality [7,8]. With exclusive breast-breastfeeding (i.e. not mixing it with other feeds), the risk of HIV transmission is lowered [9].
The rst breast milk (colostrum) gives the newborn natural protection from the mother to avert infections. This is to say that infants need exclusive breastfeeding for the rst six months of life to achieve optimal growth and development (10). Research shows that EBF, when applied for the rst 6 months of a baby's life, lowers the risk of MTCT by 3-4times when compared to mixed breastfeeding [9]. HIV transmissions have been revealed to in uence family choices on infant breastfeeding methods despite government policy such as maternal age, HIV stigma, education of the mother, economic factors, and cultural beliefs on breast milk [9,11].
According to WHO guidelines, the baby must be exclusively breastfed for the rst six months. Moreover, WHO emphasized EBF even if ARV medications are not accessible unless the environment and social circumstances do not allow or it allows for safe and supportive replacement breastfeeding [2]. Concerning Tanzania guidelines, HIV-positive mothers should exclusively breastfeed for the rst six months of life then introduce complementary foods while continuing to breastfeed up to 12 months and after six weeks these infants should be checked for their serological status even if the results were negative. A rapid test should be done at 18 months to con rm their serological status as at this time maternal HIV antibodies would have diminished [12].
EBF among HIV-infected mothers can be hindered by several factors. Studies documented such factors as primiparity, maternal systemic illness, stigma, women's employment [14]. Some women living with HIV infection lacked adequate counseling on EBF. Similarly, a culture of mixed breastfeeding norms has been reported as a barrier [14,15]. Having inadequate knowledge and a negative attitude on EBF have also been found to impede EBF practice among HIVinfected nursing [4]. Some studies in Tanzania identi ed different factors; advanced maternal age and insu cient milk [15]. Two studies conducted in Tanzania, further noted fear of transmitting HIV to the baby, fear of disclosure, and maternal underweight contributed to inadequate EBF practice [6,16].
Studies have further revealed the negative attitude of mothers to EBF to have been connected to some myths. For example, HIV lactating mothers believed EBF as very di cult to the mother's body, and that EBF has the potential of weakening their health, lowering their blood quantity, fear of spreading HIV to their infants, and fear of getting infants who are often sick than if they did not exclusively breastfeed. some women also believed that practicing EBF could lower their immunity [17].
Efforts did by the government to encourage baby-friendly hospital initiative breastfeeding campaigns and breastfeeding commemoration day every August yearly, and provision of three months maternity leave to employed women, still, EBF is a problem of concern in Tanzania. This necessitated the need to conduct a study on prevalence and factors associated with EBF practice lactating HIV-infected mothers in the Southern Highlands of Tanzania.

Study Setting
The study was conducted in the Southern Highland Zone (Iringa and Njombe) regions. Iringa Region is served by a total of 36 health facilities, of which 13 are hospitals and 23 health centers. All these health facilities provide CTC and PMCTC services. The Iringa Region borders the dry belt of central Tanzania

Study Design
A hospital-based analytical cross-sectional study employed a quantitative approach was used. The study population comprised of HIV-positive lactating mothers attending the PMCT program at Iringa and Njombe Regions.

Inclusion Criteria
All HIV-positive lactating mothers with an infant aged 6 to 12 months who were attending the PMCT program during data collection were included.

Exclusion Criteria
All HIV-positive lactating mothers with very seriously ill children who were not able to concentrate on answering the questions were excluded from the study.
Mothers diagnosed with cognitive or psychiatric conditions were also excluded as their level of comprehension would be limited. HIV-positive lactating mothers who were very seriously sick at the time of data collection were excluded as body weakness would result in the inability to not being able to go through all questions comprehensively.

Sample Size
The sample size was estimated by using the Kish Leslie formula (1965). Therefore, the actual sample size for this study was 372 HIV lactating mothers.

Sampling Technique
The Census method was used to include regional hospitals that are Iringa and Njombe Regional hospital. In other health facilities simple random procedure was employed whereby in Iringa there are six districts out of these only 3 were selected by lottery replacement method after that one hospital was selected from each district using the lottery replacement method, and two health centers from each district. The same procedure of simple random method by lottery replacement was used in Njombe Region whereby three districts out of six were selected; one hospital was selected from each district using the lottery replacement method, and two health centers from each district. Then, systematic random sampling was employed in which the rst round of HIV-positive lactating mothers was identi ed from the clinic registration. In the second round, calculation of the K th interval was done using the K th formula to select mothers who were invited to participate in the study. In this study, the total population of HIV lactating mothers was 963 and the sample size was 372 963/372=2.5 therefore the sampling interval included every second HIV lactating mother.

Data Collection Technique and Tool
The data for this study was gathered through face-to-face interviewer-administered structured questionnaires adapted and modi ed from [6, 19,20]. Data were collected by two trained research assistants and the principal investigator. Standard structured questionnaires were then translated by the language teacher to Kiswahili which the language is spoken by study participants. The Kiswahili version questionnaire was used. Since data collection was done during COVID-19 precaution against protection was ensured all researcher assistants, principal investigator, and the study participants used sanitizer and masks, as well as one meter between the study participants was observed.

Variables and its Measurements Dependent Variables
Exclusive Breastfeeding status was measured by nominal scale as exclusive breastfeeding practices and non-exclusive breastfeeding practices as continuous breastfeeding since birth such as starting to provide the baby with breast milk within the rst hour after delivery, breastfeeding on demand day and night, and continuous breastfeeding alone up to 6 months.

Independent variables
Socio-demographic Characteristic: comprised 19 questions and were measured by nominal scale i.e. residence, education, marital status, occupation, a model of delivery, place of delivery, counseling on EBF whereby age, and income, were measured by an ordinal scale.
Knowledge on exclusive breastfeeding was measured by a nominal scale involving 12 questions, with yes/no answers which were then converted into correct and incorrect. The total score was obtained and computed for mean to categorize it into adequate and inadequate knowledge. The mean score of knowledge on EBF among lactating mothers was 7.66 the maximum score being 12 points while the minimum score was 1 point. A score below the mean was considered inadequate knowledge and above the mean adequate knowledge.
Perceived Bene ts of exclusive breastfeeding Perception towards EBF was measured using 5 points Likert scale. 13 questions were used to determine the perception of mothers. The order of scoring for positive statements was strongly agree = 5, agree = 4, undecided = 3, strongly disagree = 2, disagree = 1 and vice versa for negative statement. The total score was obtained and computed for mean and then categorized into positive and negative perceptions.
The mean score of perception on EBF among lactating mothers was 41.38 the maximum score being 60 points while the minimum score was 22 points. A score above the mean was regarded as a positive perception, while a score below the mean was considered as a negative perception.

Data Analysis
The descriptive statistics used were frequency and percentages in categorized variables like gender, infant HIV serostatus, areas of residence, education level, income level, marital status, and occupation. Also, frequency and percentages were used in determining the prevalence of outcome variables. The mean or median, standard deviations, and range were used to summarize continuous/discrete random variables such as age, Likert scale items. In analyzing Likert scale items on perception and knowledge the mean score was generated. The hypothesis was tested using chi-square to test the proportion of outcomes (EBF practices) across different exposures.
In building the logistic regression model, the process started from simple to complex analysis that led to parsimonious models. The independent variables were added one after another and those with signi cant results in the univariate were adjusted in the nal model. The measure of effects was estimated by the Odds ratio and was tested at a 95% con dence interval and a 5% signi cance level

Social-demographic characteristics
This study included 372 breastfeeding women who had been diagnosed with HIV infection before or during pregnancy. Their mean age was 30.66 ± 5.72 (range 18-49) and that of their children at the time of data collection was 9.74 ± 2.08 (range 6-12 months). Socioeconomically, most of the women were married 337(90.6%) lived at or less than one USD per day 207(55.6%), and had primary level of education 199(53.5%) ( Table 1)  Knowledge of Breastfeeding Practice The ndings showed that 348(96.2%) of respondents knew that breast milk was cheap and available and that the baby should be breastfed in demand 290(78.0%) and 352(94.6%) breast milk increases bonding between the mother and the baby. However, between 51% and 68% of the respondents could de ne EBF and knew that colostrum is nutritious to the infant, milk alone is su cient to the infant in the rst six months of life, EBF time is six months, breast milk protects the child from diseases and that EBF maintains mothers' body weight. The majority did not know that EBF acts as a contraceptive and that it reduces the risk of maternal breast cancer ( Table 2).

Knowledge of exclusive breastfeeding practice
The mean score of knowledge on EBF among HIV lactating mothers was 7.66, the maximum score being 12 points while the minimum score being 1 point.
More than half of the respondents 199(53.5%) had adequate knowledge while 173(46.5%) had inadequate knowledge on EBF.

Perception of EBF among Lactating Mothers Infected with Human Immunode ciency Virus
The mean score for the perception of EBF among HIV lactating mothers was 41.38. The maximum score was 60 points while the minimum score was 22 points out of all respondents (N = 372), positive perceptions were 194(52.2%), and negative perception 178(47.8%).

Prevalence of EBF practice among lactating HIV infected mothers
The prevalence of EBF practice was 58.1% at a 95% Con dence Interval of 52.9-63.1%. More than half of the respondents 216 (58.1%) had exclusively breastfed their infants for the rst six months while 156(41.9%) did not breastfeed their infants exclusively in the rst six months The relationship Lactating mothers' characteristics and EBF practice By cross-tabulation, there was a signi cant relationship between knowledge on EBF and the practice of EBF (p < 0.001) in which those who had adequate knowledge were most likely practicing EBF. Other variables that showed a signi cant relationship were the income of a mother (p = 0.002), level of education of a mother (p = 0.007), and antenatal visits (p < 0.001), perception towards EBF (p < 0.001), and ever experienced breast problem (p < 0.001) refer to Table 3.  (Table 4).

Discussion
The prevalence of exclusive breastfeeding among exposed infants was found to be higher compared to a previous study in Ilala municipal council in Dar es Salaam, Tanzania [6] which is lower compared to the study done in Kilimanjaro only 0.2% of mothers practice exclusive breastfeeding [21]. However, the current study prevalence is lower than 63.4% reported in Ethiopia [22] and is lower than the 90% target recommended by the world health organization [2]. These differences could be attributed to the high HIV prevalence in the current study and design used in the previous studies. The time-lapse between the previous Tanzanian studies and the current one is ve to eight years in which health promotion education might have improved the status quo of EBF.
The current results revealed that more than half of the respondents had adequate knowledge of exclusive breastfeeding but this is lower than what was found in one study conducted in Ethiopia whereby more than three-quarters of the respondents were knowledgeable on EBF [23]. This calls for an effort to improve this knowledge and these regions could bene t from strategies used in more successful settings such as Ethiopia. The fact that the Ethiopian study shows such a success and yet an African setting, is an encouragement that this is still possible in Tanzania.
The study further indicated that respondents with adequate knowledge of EBF practice were nearly two times more likely to practice EBF than their counterparts with inadequate knowledge. The results of the current study were consistent with studies done in Ethiopia and South Africa which reported that knowledgeable respondents were ve times more likely to practice EBF [4,24]. The current and studies we refer to are evidence on the need to impart lactating mothers with knowledge for them to practice EBF. It also follows that adequate ANC attendance increased the odds of EBF practice by more than one time, especially among pregnant women who attended ANC services more than 4 times. Most women rely on ANC for necessary information on maternal and child health. It is therefore most likely that the level of knowledge on maternal and child health is dependent on ANC visits. This association between attendance to ANC, level of knowledge, and the practice of EBF have also been reported by Alebel et al. [25] in Ethiopia.
In this current study more than half of the respondents had a positive perception toward exclusive breasting feeding which has similarities and yet less than a report from another study in Ethiopia which reported that more than three-quarters of the respondents had a positive perception toward EBF [23]. The difference in perception could be attributed to the difference in the level of knowledge of EBF between the two settings. There are also sociocultural and belief differences that may affect how EBF is perceived from one setting to another. Sociocultural factors are also reported as the most predominant determinants of EBF in a study in South Africa [24]. It is important to create a positive belief/perception as shown in the health belief model that this is what ignites the process of change of behavior [26].
This is also evident in the current study where it is found that respondents with positive perceptions were four times more likely to practice EBF than those who had a negative perception. The nding of the present study was consistent with the study conducted in Ethiopia by Gebeyehu et al. [4] which noted that respondents who had positive perceptions were seven times more likely to practice EBF. Positive perception could be encouraged through counseling on infant feeding practice during ANC but also showing with example the consequences of not breastfeeding exclusively [4]. Again, following the Health Belief Model, pregnant and lactating women will most likely choose EBF if they are convinced that this is possible even within limited time and resources.
The present results revealed that the majority of respondents identi ed insu cient breast milk as a barrier to practicing EBF. The nding was similar to the study done by Maonga et al. [15] in Muheza Tanzania which reported that insu cient breast milk was one of the hindrances to practice EBF. However, the nding from these two Tanzanian studies is different from a report from South Africa showing that the most prominent barriers to EBF were cultural factors and in uence from elders in the family [24]. Variation in predominating challenges to EBF is further seen as a study in Kenya (unlike Tanzania and South Africa) shows that stigma is the commonest barrier to EBF among HIV-infected lactating mothers [27].
The study further indicated that respondents who did not experience breast problems were three times more likely to practice EBF than their counterparts with breast problems. Breast problems were also identi ed as a barrier to EBF in another study in Nigeria [13]. Screening for breast conditions during pregnancy and lactation is therefore of paramount importance so that treatable conditions can be identi ed and given due management. This will likely increase the prevalence of EBF and improve infants' health.
In another study by Muhammed & Seid [11], it was found that HIV -infected mothers who were employed were ten times more likely to be none exclusive breastfeeding than the unemployed. The current study did not nd this as a signi cant barrier. These differences could be due to educational status with the current study majority had a primary level of education which means the study subjects did not differ so much in employment status. However, with the growing pace of women's education and the acquisition of full-time jobs, the means through which EBF can be promoted in this population ought to be considered.
Generally, it can be seen that barriers to EBF among HIV-positive lactating mothers are diverse and it would be so that they are also different even within the same country. It suggests that addressing these barriers should be setting speci c and no intervention can t all. There are also methodological differences between the studies such as varying sample sizes, tools for data collection, and design which could account for these differences.

Conclusion
More than half of interviewed mothers practiced EBF. The EBF practice among HIV lactating mothers was signi cant in uenced by adequate knowledge on EBF, positive perception toward EBF, adequate ANC visits, and having never experienced breast problems. Strengthening adherence to ANC routine visits, counseling on breastfeeding, and improving mother's knowledge of exclusive breastfeeding would contribute to the enhancement of EBF practice in this region. An innovative interventional study is recommended to come up with an effective strategy to improve EBF knowledge among HIV-infected mothers. Approval to conduct the study was given by the University of Dodoma Research and Publication Committee. Government authorities at regional and council levels at Njombe and Iringa were contacted for Permission to conduct the study in both study regions. A written permit was obtained to conduct the study.

Consent for publication
Not applicable

Competing interests
The authors declare that had no con ict of interest Availability of data and materials The data and material used in the current study are available from the corresponding authors upon request.

Funding
This study was not funded.