Background: Breastfeeding amongst HIV-infected and HIV-exposed mother-infant dyads is a wide-ranging and persistent field in which more investigation is needed. The literature widely recognizes the multifactorial and syndemic nature of HIV and infant feeding, specifically pertaining to maternal and other breastfeeding-associated risks. Findings differed regarding breastfeeding and general developmental outcomes amongst HIV-exposed and HIV-infected infants when compared with HIV-unexposed infants. Evidence, however, suggests slight neurodevelopmental differences in HIV-exposed infants when compared with HIV-unexposed infants, suggesting possible feeding differences. Recent literature also indicated a lack of knowledge among allied health care staff regarding evidence-based counselling content to be provided to mothers concerning single option feeding, breastfeeding outcomes and risks in HIV-affected mother-infant dyads in South Africa. Owing to these varied findings related to HIV-affected mother-infant dyads, synthesising of knowledge regarding HIV, infant breastfeeding outcomes and associated risk factors is warranted. Objective: To critically appraise recent literature regarding breastfeeding outcomes and associated risks in HIV-infected and HIV-exposed infants using the PRISMA-P statement guidelines. Method: Five electronic databases were systematically searched to obtain English publications from the last ten years pertaining to breastfeeding outcomes and associated risks of HIV-infected and HIV-exposed infants and children. Grey literature sources were also included. Data were extracted according to various data items and were synthesised using thematic synthesis. Results: Of the initial 7151 sources identified, 42 articles were deemed eligible for final inclusion. The final selection included 19 cohort studies and two expert committee reports, classified as grey literature. The remaining 21 studies compromised of case-control, cross-sectional, and randomized controlled trial studies. The following themes were identified from the review objectives: breastfeeding outcomes, breastfeeding risk factors, infant growth and developmental outcomes and barriers and facilitators to feeding decisions. Most studies focused on HIV-exposed infants’ growth and developmental outcomes. Exclusive breastfeeding was confirmed to have the best outcomes for all infants, regardless of their HIV status, which in turn supports national and international policies. The most prevalent factors that made it difficult for mothers to breastfeeding were maternal factors affecting decision-making for breastfeeding, followed by biological risk factors. Conclusion: Knowledge regarding breastfeeding outcomes in HIV-exposed and HIV-infected infants remains lacking and further research is necessary. This review emphasised that the majority of HIV-affected mother-infant dyads reside in sub-Saharan Africa, illustrating that health professionals, especially those in sub-Saharan Africa (SSA), have to look beyond their traditional assessment and management focuses to include the factors that can impact successful exclusive breastfeeding. Addressing both infants’ needs and maternal HIV-related needs and risks on macro, meso, and microsystem levels is necessary. / Dissertation (MA (Speech-Language Pathology))--University of Pretoria, 2021. / Speech-Language Pathology and Audiology / MA (Speech-Language Pathology) / Unrestricted

Magister Artium - MA / Introduction A high burden of Human Immunodeficiency Virus (HIV) constitutes a key global public health concern. In South Africa, it is estimated that 260 000 children aged 0-14 years had HIV infection and only 63% of them were reported to have received HIV treatment in 2018. Without antiretroviral therapy (ART), HIV infection during infancy is associated with rapid disease progression where more than half of all infected children are expected to die before two years of age. Early infant diagnosis (EID) of HIV is therefore essential for accessing timely HIV treatment. However, preanalytical errors within the EID diagnostic cascade prevent optimal access to HIV polymerase chain reaction (PCR) results. The aim of this study was to describe the prevalence and contributing factors of preanalytical errors resulting in missed diagnostic opportunities for HIV among children below 18 months of age in Thabo Mofutsanyana (TM) district. Methodology The study was conducted using a descriptive cross-sectional study design and data was collected in two phases. Phase 1 involved obtaining the routine HIV PCR testing data set from the National Health Laboratory Services (NHLS) for all samples collected at TM public health facilities in 2018 and registered by NHLS. Phase 2 included a facility assessment checklist and semi structured questionnaire administered to 36 health care workers (HCWs) from 10 purposively selected health facilities. Data collected in phase 2 was analyzed to describe health facilities and HCW factors that might be contributing to the HIV PCR preanalytical errors. Results Phase 1. Of the 9318 samples included in the analysis, 49.6% were birth HIV PCRs whilst 42.1% and 8.3% were from 10 weeks and above 12 weeks age categories, respectively. A total of 745 (8%) samples were rejected because of the following preanalytical errors: insufficient specimen (84.3%), unsuitable sample (9.9%) and clerical error (5.8%).By age, the preanalytical errors were: birth (534), 10 weeks (170) and the above 12 weeks age category (41). Hospitals had the highest proportion of total preanalytical errors (58.1%). For PHCs the errors were: insufficient specimen (90%), unsuitable sample (5.5%) and clerical (4.8%).

Globally, ~17 million women and ~2.1 million children are living with HIV. Sub-Saharan Africa accounts for 70% of HIV-infected (HIV+) persons. Mother-To-Child Transmission of HIV (MTCT) during pregnancy, delivery and breastfeeding, is the main route of HIV infection in children. The World Health Organisation recommends lifelong antiretroviral therapy (ART) for all HIV+ pregnant and breastfeeding mothers to prevent MTCT, and breastfeeding for ≥24 months for optimal child health in resource limited settings (Option B+ strategy). Initiation of ART in HIV+ adults is associated with a 2-6% decrease in areal bone mineral density (aBMD) regardless of ART regimen, but data are limited in pregnant and lactating women. Tenofovir, a preferred first-line drug in Option B+ ART regimen, is associated with 1-2% greater decreases in aBMD. Pregnancy and lactation are associated with physiological changes in maternal bone mineral density, but most evidence shows that this is recovered after cessation of breastfeeding. The hypothesis of this thesis is that ART may accentuate the normal process of bone mobilisation during pregnancy and lactation, leading to bone loss that is not recovered in the mother and/or compromised infant growth and bone mineral accretion. The primary objective of this research was to investigate if HIV+ women experience greater reductions in bone mineral compared to HIV-uninfected (HIV-) counterparts. Two groups of pregnant women, 95 HIV+ on ART (Tenofovir-Lamivudine-Efavirenz, previously ART naïve) and 96 HIV- were followed prospectively in Kampala, Uganda. Data were collected at 36 wks gestation (PG36), 2 (PP2) and 14 wks postpartum (PP14). Dual-energy x-ray absorptiometry was used to measure bone phenotype (aBMD, bone mineral content (BMC), bone area (BA), and size-adjusted BMC (SA-BMC, adjusted for height or length, weight and BA) of the whole body (WB) and lumbar spine (LS) in mother-baby pairs, and total hip (TH) in mothers. The primary outcome was the difference between groups in % change (± SE) in maternal LS aBMD between PP2 and PP14. Secondary outcomes included changes in maternal markers of bone formation (P1NP and BAP) and resorption (CTX), serum 25-hydroxy vitamin D (25(OH)D), parathyroid hormone (PTH), plasma and urine concentrations of creatinine (Cr), calcium (Ca), phosphate (PO4) and magnesium (Mg), urine mineral:creatinine ratios, TmCa/GFR and TMP/GFR, respectively), breastmilk mineral composition (Ca, P, Na, K and Na/K ratio); and infant growth Z-scores and bone mineral. Statistical models were adjusted for potential confounders. Median maternal age was 24.5 (IQR 21.1, 26.9) yrs. Mean gestation was 40.9±1.8 wks and not significantly different between groups. All women were breastfeeding at PP2 and PP14. More HIV+ women reported exclusive breastfeeding (PP2: 82.9% v 58.7%, p=0.0008; PP14: 86.7% v 66.2%, p=0.002). Body weight was 4-5% lower in HIV+ women. By PP14, mean duration of ART was 29.3±5.1 wks, adherence was > 95%, and the median CD4 count was 403 (IQR 290-528) cells/mm3. Maternal aBMD decreased between PP2 and PP14 at all skeletal sites in both groups as expected in lactation. Reductions in LS aBMD were not significantly different between groups (-1.8±0.4% vs -2.5±0.4%, p=0.3). However, HIV+ women had a significantly greater reduction in TH aBMD which persisted after adjustment for body size (-3.7±0.3% vs -2.7±0.3%, p=0.04). Median serum 25(OH)D was 67.4 nmol/L (IQR 54.8, 83.7) at PG36 and 57.6 nmol/L (48.7, 70.1) at PP14 with no significant difference between groups. Changes in 25(OH)D and PTH from PG36 to PP14 were not significantly different between groups (25(OH)D: -13.9±4.1% vs -11.1±3.1%; PTH: +60.0±6.4% vs +57.6±6.4%; both p > 0.05). However, HIV+ women had 33-35% greater plasma PTH concentrations at both PG36 and PP14. Bone formation and resorption markers increased in both groups between PG36 and PP14. HIV+ women had greater increases (CTX: +74.6±5.9% vs +56.2±5.9%; P1NP: +100.3±5.0% vs +72.6±5.0%; BAP: +67.2±3.6% vs +57.1±3.6%, all p < 0.05). They also had a greater decrease in plasma Ca (-6.6±0.5% vs-3.8±0.5%, p≤0.0001) and greater increase in plasma phosphate (+14.4±2.0% vs +7.7±2.0%, p=0.02). Changes in plasma Cr and Mg, TmP/GFR and urine mineral:creatinine ratios were not significantly different between the groups. However, at both PG36 and PP14, HIV+ had significantly lower mean plasma Ca (PG36: -1.0±0.5%; PP14: -4.1±0.6%) and TmP/GFR (PG36: -11.4±3.1%; PP14: -7.2±3.0%) but higher PTH (PG36: +33.0±7.0%; PP14: +35.3±7.6%) compared to HIV- women (all p < 0.05). Mean breastmilk Ca decreased between PP2 and PP14, and the changes were not different between the groups (-19.9±3.0% vs -24.2±3.1%, p=0.3). There were no significant changes in breastmilk phosphorus (P) in both groups, but HIV+ women had significantly higher concentrations (PP2: +9.7±3.8%, p=0.01; PP14:+9.6±3.5 %, p=0.007). Breastmilk P was significantly correlated with maternal plasma [CTX] in a separate ANCOVA model (β = +0.13±0.04% per 1% increase in CTX, p=0.0003). Mean breastmilk Na, K concentrations and Na/K decreased between PP2 and PP14 in both groups. However, HIV+ women had a smaller decrease in breastmilk Na (-44.3±8.9% vs -72.6±9.0%, p=0.03). They also had a trend towards smaller reduction in Na/K ratio (-22.2±9.3% vs -46.6.6±9.5%, p=0.07). Babies born to HIV+ mothers (HIV-exposed infants, HEI) had significantly lower gains in weight +53.0±1.4% vs +57.5±1.4%, p=0.02) compared to HIV-unexposed infants (HUI), and also lower weight-for-age (-0.47±0.16, p=0.003) and length-for-age (-0.53±0.18, p=0.005) Z-scores at PP14. HEI had a slower gain in WB BMC (+51.2±1.9% vs +57.3±1.9%, p=0.02), but the difference was not significant after adjustment for body size (-6.0±3.5% vs -7.6±3.8%, p=0.2); showing that the bone mineral accretion was appropriate for achieved infant size. In contrast, HEI had a greater increase in LS BMC (+29.5±1.7% vs +24.4±1.7%, p=0.03), a difference which remained after size-adjustment (+9.4±5.8% vs +4.3±6.2%, p=0.02). This is the first study to compare changes in maternal aBMD and bone metabolism between HIV+ mothers on Option B+ ART and HIV- counterparts. The results show a greater reduction in TH aBMD in Ugandan HIV+ women on Option-B+ ART compared to HIV- in the first three months of lactation, consistent with their greater increases in bone turnover markers, lower TmP/GFR and plasma phosphate, and higher breastmilk phosphorus concentration. Also, HEI have slower growth and whole body bone mineral accretion compared to HUI. It is important to determine if these changes are temporary or have long-term consequences for the bone health of the mother and child.

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Text in English / The aim of the study was to describe the competencies of midwives during the provision of immediate postnatal care (PNC) with the intention of adapting and linking international best practice guidelines as well as a conceptual framework for the implementation of PNC in Swaziland. A quantitative cross-sectional design study was conducted to investigate the competencies of midwives during the provision of immediate postnatal care services to mothers and their infants. A systematic random sampling technique was used to select eighty-eight (88) midwives and six (6) senior midwives to participate in the study. Data collection was done using structured questionnaires. Quantitative data was complemented by data that was generated from open-ended questions at the end of the questionnaires. Data analysis was conducted using IBM SPSS Statistics version 22.0 software. The study highlighted that all the midwives who participated in this study had the relevant qualification. Of the respondents, 70.5% were state-certified midwives with a second registered certificate, 27.3% had bachelor’s degrees, while 2.3% had an advanced midwifery certificate. The study found no difference between the type of qualification of midwives and the knowledge of PNC interventions to be offered to mothers immediately post-delivery across different qualifications held by the midwives (Kruskal-Wallis test: x2=5.498, df=2, p=0.064). Gaps were identified in their knowledge and practices. There were discrepancies in the level of knowledge and practices regarding maternal vital sign assessment immediately after delivery (within 30 minutes). It was noted that these vital signs, i.e. blood pressure (12.5%), temperature (50.0%), pulse (54.5%), respiration (63.6%) were not taken after delivery. It was also noted that 15.0%, 58.0%, 64.8% of the respondents were not aware of the importance of assessing newborns for APGAR, skin-to-skin contact and drying the neonate. The study found that there were no postnatal care guidelines in Swaziland. The findings of the study led to the adaption and linkage of the latest international evidence-based guidelines and a conceptual framework for the implementation of immediate PNC to mothers and their infants in Swaziland. / Health Studies / D. Litt. et Phil. (Health Studies)