CERTIFICATION

The Research proposal entitled “ASSESSING THE KNOWLEDGE OF NURSING

MOTHERS IN THE PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV
AT MIFI DISTRICT HOSPITAL”. Done and submitted to the Department of Nursing, at the
faculty of Health Science ,of HIGHER INSTITUDE OF SCIENCE, TECHNOLOGY,
BUSINESS AND AGRICULTURE. Under the supervission of Mr. ASONG . This work is free
from plargiaism and all forms of acedemic malpractices
NJASOWELLE PRECIOUS LUCY AYUK
SUPERVISOR
SIGN: ______________________. DATE___________________

i
 DECLARATION
I, NJASOWELLE PRECIOUS LUCY AYUCK, declare that this research project entitle

ASSESING THE KNOWLEDGE OF NURSING MOTHERS IN THE PREVENTION OF

MOTHER TO CHILD TRANSMISSION OF HIV AT MIFI DISTRICT HOSPITAL ” is

the product of research conducted entirely by me under the guide-line laid down by HISTBA

UNIVERSITY BAFOUSSAM, in Partial Fulfillment of the Requirements, of the Award of

Higher National Diploma in Nursing Science. This is my original work writting after several

months of hard work and to the best of my knowledge no material contained herein had been

presented for the award of higher national diploma in HISTBA or any other institute of learning .

All references used in the study have been duly acknowledged. I am solely responsible for the

views expressed and any errors viewed in style or otherwise.

NJASOWELLE PRECIOUS LUCY AYUCK

SIGN :……………………………………………………………

DATE :………………………….................. …………………….

ii
 DEDICATION

This study is dedicated to HIV positive mothers

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 ACKNOWLEDEMENTS

I express my sincere gratitude and thanks to my supervisor Mr. ASONG who kindly sacrifice his
time to read through and amend this work till success.
Special thanks to the HIGHER INSTITUTION OF SCIENCE, TECHNOLOGY, BUSSINESS
AND AGRICULTURE for producing an excellent nurse in me. Also a big thanks to my
respondents at MIFI DISTRICT HOSPITAL for taking out time to mark my questionnaires.
My gratitude to my fellow classmate for their moral support throughout.
My outmost thanks to my loving mom EPEY DIANA BATE, relatives and friends for their
physical, financial and spiritual support. My infinite gratitude to God Almighty for his grace,
mercies, love, protection, and spiritual support

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 ABSTRACT

BACKGROUND: the majority of people living with HIV in the world are women and an
estimated 880 children are infected with HIV daily through vertical transmission. A woman
infected with HIV can transmit the virus to her child during pregnancy, labour or through
breastfeeding. HIV positive mothers have to decide on the best feeding practice of their infants.
The choice lies with them although there are various external factors which may influence the
decision on whether to exclusively breastfeeding or use formula feeding. This study assesses
Knowledge and Factors Influencing the Choice of Infant Feeding Among HIV Positive Mothers
at Mifi District Hospital
Methods: This hospital - based, cross- sectional descriptive study design was carried out 2025.A
structured Questionnaire was used to collect data from 66 HIV - positive mothers who are
selected using the purpose sampling technique. The data will be analyzed using SPSS version
25.0.
Results: more than half of the participants were age 24-- 35years (48.0%) and Married (50.
0%).The sample was fairly educated with more than a third (46.0%) of the participant attended
primary school education. majority (30.0%) of the HIV positive mothers practice exclusive
formula feeding to prevent MTCT. Half (20.0%) of the participants reported that infant should be
breastfeed on the demand and majority (30.0%) reported that exclusive breastfeeding should be
done till the baby is feed to eat normal food. The choice of breastfeeding was significantly
associated with the mothers' level of education

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 Table of Contents

CERTIFICATION .................................................................................................................................... i
DECLARATION ..................................................................................................................................... ii
DEDICATION ....................................................................................................................................... iii
ACKNOWLEDEMENTS ....................................................................................................................... iv
ABSTRACT ............................................................................................................................................ v
Table of Contents .................................................................................................................................... vi
LIST OF FIGURES .............................................................................................................................. viii
LIST OF TABLES .................................................................................................................................. ix
LIST OF ABBREVIATIONS .................................................................................................................. x
CHAPTER ONE ...................................................................................................................................... 1
Introduction ......................................................................................................................................... 1
Background of the Study ...................................................................................................................... 1
1.2 statement of the problem ................................................................................................................ 3
1.3 Rationale ........................................................................................................................................ 3
1.4 Research Questions ........................................................................................................................ 4
1.5 Research Objective......................................................................................................................... 4
1.5.1 General objectives ....................................................................................................................... 4
1.6 Significance of Study ..................................................................................................................... 4
1.7 Definition of Terms ........................................................................................................................ 4
CHAPTER TWO ..................................................................................................................................... 6
LITERATUR REVIEW ........................................................................................................................... 6
2.1 conceptual overview on Mother -to-Child-Transmission (MTCT) ................................................... 6
2.1.1 Overview of Mother-to-child-transmission (MTCT) .................................................................... 6
2.1.2 Maternal knowledge ON PMTCT of HIV .................................................................................... 6
2.2 HIV/AIDS and infant feeding practices .......................................................................................... 7
2.2.1 Breastfeeding .............................................................................................................................. 8
2.2.3 Mixed feeding ........................................................................................................................... 10
2.3Factors influencing the maternal choice of infant feeding practice ................................................. 10
2.3.1. Level of maternal knowledge .................................................................................................... 10
2.3.2 Family influence. ....................................................................................................................... 10
2.3.3 Social stigma and discrimination ............................................................................................... 11
2.3.4 Beliefs ....................................................................................................................................... 11
2.3.5 Economic factors ....................................................................................................................... 12
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 2.4 Empirical Review ......................................................................................................................... 12
CHAPTER THREE ............................................................................................................................... 17
METHODOLOGY ............................................................................................................................ 17
3.1 study design ................................................................................................................................. 17
3.2 Study Area ................................................................................................................................... 17
3.3 Study Population .......................................................................................................................... 17
3.4 Sample size .................................................................................................................................. 17
3.5 Sampling technique ...................................................................................................................... 18
3.5.1 Inclusion criteria........................................................................................................................ 18
3.5.2 Exclusion criteria ...................................................................................................................... 18
3.6 Data collection Tools ................................................................................................................. 18
3.6.1 Validity and Reliability ............................................................................................................. 18
3.6.3 Data Analysis ............................................................................................................................ 18
3.7 Ethical Consideration ................................................................................................................... 19
CHAPTER FOUR ................................................................................................................................. 20
RESULTS.......................................................................................................................................... 20
4.1 Socio-demographic characteristics of participants ......................................................................... 20
4.2 Knowledge of HIV positive mothers on infant feeding options ..................................................... 21
CHAPTER FIVE ................................................................................................................................... 24
DISCUSSION, CONCLUSION AND RECOMMENDATIONS ........................................................ 24
5.1 Discussion.................................................................................................................................... 24
5.1.1 Knowledge of HIV positive mothers on infant feeding options .................................................. 24
5.1.2 Infant feeding options for HIV exposed children ........................................................................ 24
5.1.3 Factors influencing the choice of infant feeding options among HIV positive mothers ............... 25
CONCLUSION ..................................................................................................................................... 27
5.3 Recommandations ........................................................................................................................ 27

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 LIST OF FIGURES

Figure 1Figure 1: Overall knowledge of mothers on infant feeding options for HIV infants ....... 22
Figure 2Infant feeding options for HIV positive mothers ......................................................... 233
Figure 3Figure 1: Overall knowledge of mothers on infant feeding options for HIV infants ..... 233

viii
 LIST OF TABLES

Table 1: Socio-demographic characteristics of participants ........................................................ 21

Table 2Knowledge of HIV positive mothers on infant feeding options....................................... 22

ix
 LIST OF ABBREVIATIONS
ARV Antiretroviral
ART. Anti- Retroviral Treatment
ANC. Antenetal care
HISTBA. Higher Institute Of Science Technology Bussiness and Agriculture
EBF. Exclusive Breastfeeding
IRF. Infant Replacement Feeding
MF. Mixed feeding
MTCT. Mother -to-child-Transmission
UN. United Nations
PMTCT Prevention of Mother-to-child-Transmission
UNAIDS Joint United Nations Programme on HIV and AIDS
VTC. Voluntary counseling and Testing
UNICEF. United Nation International Children Emergency Fund
WHO. World health organization

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 CHAPTER ONE
Introduction
Background of the Study

HIV/AIDS is possibly the biggest challenge facing the global health care system today. Globally,
of the 38million of people living with HIV, an estimated 2.8 are children, with about 880 new
daily infections and an estimated 310 deaths among children (UNICEF,2019). The majority of
people living with HIV are women _women aged 15 years and older making up 58%of people
living with HIV/AIDS and over 90%of these women live in developing world (UNAIDS 2016).
Annually, more than 5.1 million become infected with HIV, most of which were cause by vertical
transmission of HIV virus or mother - to - child - transmission (MTCT) during pregnancy,
delivery, or breastfeeding (Andare et al., 2019; WHO,2016);40% of transmission of HIV in
children occur during breastfeeding (WHO,2016).70% of all new HIV infections in children
occurs in sub -sahara African countries (Glenda,2018).
One of the global strategies for controlling and preventing the spread of HIV/ AIDS is the
prevention of mother - to - child transmission of HIV/ AIDS (PMTC) program UNAIDS,2016)
PMTC provide ART to HIV - positive pregnant women, recognized globally to prevent MTCT
during pregnancy. Labour and breast feeding (oladokun et al.,2010). The change of MTCT during
pregnancy is 25 to 45% without treatment (Andare et al.,2019; UNAIDS,2016). However, ART
and other effective PMTCT interventions can reduce the risk of HIV transmission to below
5%(WHO,2016) but it deos not solve the problem of infant feeding which is responsible for as
much as 5-20%of infections (Lema and Bayisa, 2019). The implementation of PMTCT services
prevented around 1.4million HIV infections among children between 2019 and
2018(UNAIDS,2018).

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In addition to providing ART, other strategies are also proposed to minimize the vertical
transmission and reduce the incidence of HIV in children. One recommendation involves infant
feeding practices -the two safe infant practices recommended for HIV positive mothers are
exclusive breastfeeding or exclusive /formula feeding (Amare et al., 2019; UNAIDS,2016). The
WHO updated guidelines on infant feeding for HIV positive mothers indicate that mothers living
with HIV who are on ART should receive full support to breastfeed their infant exclusively for
the first 6 months of life , followed by introduction of appropriate complementary food while
continuing to breastfeed for at least 12 months and up to 24 months or longer (Amare et al.,
2019;WHO,2016). Breastfeeding is regarded as the best option to feed infants, as breast milk is a
rich source of nutrients for infants. Breast milk is also highly recommended for infant feeding
because it contains agents which increase resistance against disease ensuring good health (WHO,
2016; UNAIDS,2018). Exclusive breastfeeding can prevent an estimated 5-8% of child deaths
and countries were advised to choose and promote one method to HIV - infected mothers in their
country based on local condition (WHO, 2016). This does not necessarily apply to HIV positive
mothers who are faced with the challenge to choose the best feeding practice for their infants to
best suit their situation.
Exclusive breastfeeding is the recommended infant feeding option for HIV - infected mothers
(Chisenge et al., 2011). The alternative to breastfeeding, which is formula feeding, is very costly
and difficult to maintain especially among the very poor (WHO, 2016). Data shows that the
number of mothers living with HIV who opt for formula feeding is considerably higher than the
number of mothers who choose to breastfeed their infants (Ndubuka, 2013) and approximately
90% of HIV infected mothers reported feeding their babies with infant formula (Paulson and
Nadege,2013). Formula Feeding could eliminate the risk of HIV transmission, but could also
enhance the risk of diseases like malnutrition, diarrhea and respiratory tract infection among the
infant (Bentley et al., 2015). It also requires certain home conditions like assurance of safe water
supply and sanitation at household and community levels, reliable supply of sufficient infant
formula to support normal growth and development of the infant, ability of mother or caregiver to
prepare the formula cleanly and frequently enough so that it carries low risk of diarrhea and
malnutrition, ability of the mother or caregiver to give formula exclusively in the first 6 months,
the family support of the practice, and ability of mother or caregiver to access healthcare facility
that offers comprehensive child health services (WHO,2010).

2
1.2 statement of the problem
A woman infected with HIV can transmit the virus to her child during pregnancy, labour or
breastfeeding (WHO,2016). The majority of people living with HIV in the world are women and
an estimated 880 children are infected with HIV daily through vertical transmission
(UNICEF,2019). . According to UNAIDS (2018), MTCT through breastmilk contribute 15% and
the risk increases (25_45%) with the age of the infant and maternal practice of mixed infant
feeding before 6 months. WHO recommends exclusive breastfeeding for the first 6 months of
life, with the introduction of appropriate complimentary under ART cover (WHO 2016). HIV
positive mothers have to decide on the best feeding practice for their infants. The choice
ultimately lies with them although there are various external factors, which may influence the
decision on whether to exclusively breastfeed or use formula Feeding. The method primarily
intended by HIV positive mothers to feed their babies is often not what they end up doing. The
influence of the education gained during counseling in the prevention - of- mother - to - child
transmission of HIV (PMTCT)program often remolds the infection of the mothers. Some other
personal and environmental factors may also hinder the mothers from carrying out practices of
their choice and occasionally force them to practice mixed feeding While breastfeeding is the
best for the baby, most HIV - positive mothers would prefer formula feeding in order to protect
their babies from HIV infections through breast milk. The risk associated with formula feeding
depends on the environment and the individual circumstances of the women including their
education and economic status, it would therefore be critical to address the factors that influence
the choice of infant feeding among HIV positive mothers at Mifi District Hospital
1.3 Rationale
Based on accumulated evidence on the effectiveness of ART in reducing HIV transmission
through breastmilk, the WHO recommends exclusive breastfeeding for the first 6 months of life
, with the introduction of appropriate complementary foods under ART cover ( lema and
Bayisa,2019; UNAIDS,2018;WHO,2016).in view of the current WHO guidelines, which
recognizes that breastfeeding is safe , critical for improving child survival and preventing the
hazards posed by unsafe formula milk preparation practices, useful information from this study
can be employed in counseling HIV positive mothers from different backgrounds on infant
feeding options and help in reducing the incidence of HIV in children.

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1.4 Research Questions
1 what are the factors influencing the choice of infant feeding among HIV positive mothers?
2 what is the level of knowledge on appropriate infant feeding options among HIV positive
mothers?
1.5 Research Objective
1.5.1 General objectives
The general objective of the study is to determine knowledge and factor influencing the choice of
infant feeding among HIV positive mothers at Hopital district de Mifi District Hospital
Bafoussam
TO determine the various feeding metod used by nursing mothers to ensure PMTCT.

1.5.2 Specific objectives

 To assess the level of knowledge on infant feeding among HIV positive mothers at Mifi
District Hospital
 To identify the factors influencing the choice of infant feeding among HIV positive
mothers at Mifi District Hospital
1.6 Significance of Study
 To the researcher, the findings contributed to the new knowledge in the field of learning
and professional development
 To the government, churches and NGO’s, may also use the information obtained from the
study to design educational system materials and programs for MTCT prevention
 The study provides the key to a vital body of knowledge that guides the HIV positive
mothers to make continue exclusive breast feeding practices of their children to prevent
morbidity and mortality of their infant
1.7 Definition of Terms
 Prevention of mother-child transmission (PMTCT). Transmission of HIV from an HIV
positive woman to her child during pregnancy, delivery or breast feeding. The phrase is
used because the immediate source of the virus is the mother and does not entail fault on
the mother.
 Human Immune-deficiency Virus (HIV), Acquired Immune Deficiency Syndrome
(AIDS). This is a disease that is as a result of Human Immuno-Deficiency Virus.
 Infant: a baby/child anywhere from birth to 1-year-old (CDC,2021)

4
 Infant feeding options: infant Feeding refers to the prefer choice of feeding children under
1year of age. WHO infant feeding options are presented as a package in the prevention of
HIV transmission from mother to child. This infant feeding options are exclusive
breastfeeding, replacement or formula Feeding and mixed feeding (WHO,2010). In this
study feeding options refer to either exclusive breast feeding or exclusive formula
feeding.
 Mother: Refers to the biological female parents of a child in the age group of 0-1 year and
who are residing in the study area.
 Knowledge: familiarity with facts, information, description, skills acquired through
experience or education. In this context, knowledge refers to response given by weaning
mothers for awareness and understanding of weaning.

5
 CHAPTER TWO

LITERATUR REVIEW
2.1 conceptual overview on Mother -to-Child-Transmission (MTCT)
2.1.1 Overview of Mother-to-child-transmission (MTCT)

When HIV is transmitted from a mother to a child during pregnancy, labour, or breastfeeding,
this is referred to as Mother-to-Child Transmission (MTCT). The risk of MTCT is 25-45%
without intervention. There is a 5-10% risk of being infected during the pregnancy, 10-15% risk
of being infected during labour and delivery, and 5-20% risk of being infected during
breastfeeding (Ministry of Health and Social Welfare, 2007). A majority of infants and young
children infected by HIV are infected through MTCT. In 2009, 370 000 children were newly
infected with HIV (UNAIDS, 2010). Several factors increase the risk of MTCT. These include
low CD4 count of the mother and high maternal viral load, which is often a reality in newly
infected people and people with advanced stages of HIV; placental infection, such as malaria;
ruptures of membranes before delivery; increased contact with the mother’s blood or body fluids
during delivery; complicated deliveries; how long the mother breastfeeds; mixed feeding before
the baby is six months; oral diseases such as mouth sores or thrush of the infant; breast abscesses,
nipple fissures, and mastitis of the mother (UNAIDS,2016; Oladokun et al.,2010). In the absence
of interventions to prevent transmission during pregnancy , delivery or breastfeeding for HIV -
infected pregnant women, it is estimated that 35%of births will result in mother -to - child
transmission ( MTCT) of HIV (WHO,2010)- if effective intensions are implemented to prevent
MTCT (PMTCT), the rate can be reduced to less than 5%(WHO,2016)

2.1.2 Maternal knowledge ON PMTCT of HIV

Goat milk expressed breast milk and powdered milk is rarely used. The ideal of expressed milk
sounded strange to them since it was not normal, expressing breasts cannot produce enough milk
to satisfy the baby and may make breasts painful.

Findings of a study conducted in Nairobi to determine the relationship between feeding practices
and nutritional status of an infant born to HIV positive women indicate that 31% of counselled
respondents practiced mixed feeding six weeks after delivery (Kiarie et al., 2004). In another
6
study done by Chopra et al. (2005) in South Africa, level knowledge on infant feeding among
mothers was low. This was attributed to a lack of consistent access to accurate, appropriate and
simple information. This hindered effective adoption and adherence to recommended optimal
infant feeding practices. In normal situations, mothers are supposed to receive information from
health workers during health care services delivery. A study by Koniz (2004), points out that
counsellors and health workers are also inadequately informed and not aware of the existence of
updated guidelines. This is associated with inadequate refresher pieces of training in the context
of HIV, counselling, support facilities and essential resources (Swartzendruber et al., 2002). Staff
shortage and inadequate time to properly counsel mothers posed more barriers to inform infant
feeding choices. (Ehrnst et al., 2005).

According to Sebalda et al., (2006) lack of knowledge and confidence in the recommended
feeding options made it difficult for respondents to cope. Mothers did not have accurate
information on infant feeding practice and were unable to understand the disadvantages of
exclusive breastfeeding compared to mixed feeding. In this dilemma, Mothers preferred mixed
feeding. They believed that exclusive breastfeeding was customarily not feasible beyond three
months. The belief was that breast milk was insufficient for a fast-growing child. Some
caregiver’s belief that babies need water in the first month because they ‘feel thirsty’. Many
reportedly gave babies water before initiating breastfeeding. Boiled water and gripe water were
often used for relief of abdominal colic. Apart from water, other complementary foods were
reportedly introduced to infants before three months.

2.2 HIV/AIDS and infant feeding practices

Infant and young child feeding in the context of HIV pose significant challenges due to the risk of
transmission of the virus via breastfeeding. Before WHO (2010) guidelines on HIV and infant
feeding, avoidance or early cessation of breastfeeding seemed logical or appropriate. However,
the repercussions for the health and survival of the infants were serious, with studies showing
much higher mortality rates due to diarrhea, malnutrition and other diseases in non-breastfed
children. The 2010 recommendations are based on evidence of positive outcomes for HIV-free
survival through the provision of ARVs to breastfed HIV-exposed infants. Thus the focus is now
firmly on ensuring HIV-free survival, not just on preventing transmission. The 2010 UN
guidelines provide a much clearer pathway towards this goal.

7
Infant feeding practices vary with individuals in different communities. The comparative
preferences depends on social, cultural and economic factors. These include the maternal
willingness and freedom to choose a preferred method, level of maternal knowledge on infant
feeding, physical & social support provided during pregnancy, childbirth and postpartum
experiences. These factors are, in turn, influenced by familial, medical, cultural attitudes &
norms, demographic, economic conditions, commercial pressures, and national policies. Thus, to
promote optimal breastfeeding and complementary feeding practices, interventions should target
individual mothers and the context in which they live.

Infant feeding is categorized into breastfeeding and replacement feeding. Replacement feeding
involves feeding infants on commercial infant formula feeding, home-prepared infant formula,
modified breastfeeding (expressed heat-treated breast milk and wet nursing) and use of unsuitable
breast milk substitutes (Oguta et al., 2001).

2.2.1 Breastfeeding
Breastfeeding is the normal way and breast milk is all the baby needs for the first six months of
life (Burgess et al., 2009). It is a universally accepted infant feeding practice. Optimal
breastfeeding carries significant health benefits for infants and young children (Oguta et al.,
2001). It reduces infant morbidity and mortality and contributes to good health status, survival
and development. Breast milk has essential nutrients, antibodies and enzymes that protect
against infections and strengthens the infant’s immune system (DeKock et al., 2000). Without
intervention, about 35% of HIV-positive pregnant women will pass on the infection to their
babies during pregnancy, delivery and post-natally through breastfeeding. Without preventive
interventions, about 10-20 percent of infants born to infected mothers will contract the virus
through breast milk if breastfed for two years (WHO, 2010).

WHO (2010) recommends mothers to safely breastfeed exclusively for 6 months and continue
breastfeeding until 12 months alongside complementary feeding after 6 months provided that
they or their infants receive ARV drugs during the breastfeeding period. Exclusive breastfeeding
is where an infant receives only breast milk and no other liquids or solids, not even water, except
drops or syrups consisting of vitamins, mineral supplements or medicines (Burgess et al., 2009).
This has been shown to give infants the best chance to be protected from HIV transmission in
settings where breastfeeding is the best option.

8
Studies show that complementary foods introduced to an infant less than 6 months of age damage
the already delicate and permeable gut wall of the infant and allows the virus to penetrate easily
(UNICEF, 2010). As a result, UNICEF, WHO and many health providers recommended
exclusive breastfeeding for about 6 months.

HIV negative women and those with unknown status should be encouraged to continue
breastfeeding. Confidentiality, informed choice, protection, respect and fulfilment of human
rights are key issues in HIV situation. Key rights of clients need to be observed, for example,
right to health, survival, information and informed consent (Campbell and MacPhail, 2002).

Types of breast feeding

Natural or traditional breastfeeding

This refers to mothers directly being in contact with an infant to breastfeed. The infant suckles
breast an hour after birth. This method is most preferred since it enhances rooting and attachment
of infant to the mother. This feeding requires the physical presence of the mother and the child
(Oguta et al., 2001).

Modified breastfeeding

Commercial infant formula feeding

Commercial infant formula is manufactured for sale. It is branded by an individual manufacturer

and is available for purchase in local markets. It is bio-chemically the most suitable replacement
feed for the newborn. Its formulation is based on modified cow's milk. Soy protein is closest in
nutrient composition to breast milk (Sebalda et al., 2006). It is usually adequately fortified with
micronutrients including iron. It is a good option if the family has reliable access to sufficient
formula, clean water, fuel, clean utensils, adequate skill and time to prepare it accurately and
hygienically.

It is important that women are counselled about the different possible infant feeding alternatives
and that maternal choice is respected. Ideally, all babies should be fed on milk only for the first 6
months after which a balanced complementary food is added to the diet.

Generic infant formula

9
This is unbranded infant formula and is not available on the open market, thus requiring a
separate supply chain. After six months the suitable breast milk substitute should be
complemented with other foods (WHO, 2006).

2.2.3 Mixed feeding

This infant feeding involving a combination of breastfeeding with feeding other fluids, solid
foods and/or non-human milk, such as infant formula or animal bowls of milk. Predominant
breastfeeding is where breastfeeding is combined with small amounts of water or water-based
drinks only. Partial breastfeeding is a type of mixed feeding where breastfeeding is combined
with non-human milk or food-based fluid or solid food. An infant who is either predominantly or
partially breastfed is considered to be receiving mixed feeding (WHO, 2006).

Mixed feeding before 6 months is not recommended because studies suggest it carries a higher
risk than exclusive breastfeeding (WHO, 2010). Before this period the baby’s stomach and the
intestinal lining is not fully developed and cannot withstand solid food. Mixed feeding may
damage the lining of the baby's stomach and intestines and thus makes it easier for HIV in breast
milk to infect the baby (UNICEF, 2010).

2.3Factors influencing the maternal choice of infant feeding practice

2.3.1. Level of maternal knowledge

HIV positive women face difficult choices about how to feed their infants (Latham and Preble,
2000). They face challenges of inadequate information related to HIV and safe infant feeding. A
lot of risks are associated with replacement feeding especially in poor resource settings
characterized by poor sanitation and economic constraints. The basic principle of ‘informed
choice’ requires that HIV positive women are provided with adequate information before
deciding on appropriate infant feeding option (United Nations, 1990).

2.3.2 Family influence.

This social bias may leave the women with no other option but to breastfeed the infant thus
increasing the risk of HIV through MTCT via breast milk (FANTA, 2004). According to Thairu
et al., (2000), elderly mothers readily disclose their HIV status. Young is in denial of their status
and more likely for a longer period compared to older adults (Campbell & MacPhail, 2002; Eaton
et al., 2003).

10
It is difficult to practice exclusive breastfeeding in situations where family members do not
understand its value. This is likely to be acute in young women. Adolescent mothers frequently
receive advice from their families to practice mixed feeding which conflicts with advice from
health care providers. As described by Bentley et al., (1999), adolescents may also be
inexperienced and insecure about their own beliefs and logically turn to their families,
particularly their mothers and grandmothers, for parenting help. In the event where adolescent
mothers’ express disagreement, families may insist on their own decisions or, less frequently,
implement their preferred feeding practices without the mother’s consent.

2.3.3 Social stigma and discrimination

Social stigma is strongly associated with HIV and the relationship of choice of infant feeding
mode (Oguta et al., 2001). In a community where breastfeeding is normative in the strongest
sense of the word, choosing replacement feeding would seem abnormal, even before the advent
of the HIV pandemic. Now there has been sufficient public discussion about the transmission of
the virus through breast milk that choosing to bottle feed is tantamount to announcing that one is
HIV positive. As a consequence of negative community attitudes, women face a very difficult
decision about whether to disclose their HIV status, when they learn they are infected.

2.3.4 Beliefs
Statements that relate to the transmission of HIV through breast milk are given by mothers with
explicitly associated fear of infecting the infant. On the other hand, the potential for transmission
is sometimes discussed without an explicit statement of fear. This influences the mother’s choice
of infant feeding option (Thairu, 2000).

Mothers know that breastfeeding protects the infant against diseases. Often the value of
breastfeeding is just exposed to formula as in the following statement: ‘the baby who is formula
fed always gets sick’. The strength of the belief in the superiority of breast milk over formula is
so great and therefore may influence maternal choice on infant feeding option.

The importance of hospital breastfeeding policy as recommended by WHO (2010) and attitudes
of health personnel towards breastfeeding practices has been repeatedly documented (Weng et
al., 2003). The effect of pro-breastfeeding policies in situations of endemic HIV infection and a
high level of social stigma associated with the disease has not been adequately appreciated. In
reality, the ‘baby Friendly hospital initiative’ does not preclude the use of replacement feeding in
11
medically indicative situations (UNICEF, 1998). However, mothers need privacy and support for
replacement feeding, on one hand, to allow them to keep their HIV status confidential and on the
other to prevent erosion of breastfeeding policy by the hospital.

2.3.5 Economic factors

Infant feeding has cost implications and greatly influences maternal choice. This is particularly
evident among mothers in low resource settings. According to FANTA (2004), the choice of
infant feeding should be based on the AFASS principle. That is, the practice chosen should be
affordable, feasible, accessible, safe and sustainable. Mothers in low resource settings rarely opt
for commercial formula because it is expensive and therefore not feasible and sustainable (WHO,
2006). HIV mothers who wish to opt to practice replacement feeding but do not have adequate
resource to meet the cost of buying infant commercial food may find themselves in dilemma. In
some instances, these may result in dilution of food fed to an infant or unconsciously practice
mixed feeding. Sebalda (2006) points out, mothers are generally uncertain about the use of infant
formula. Those who have used it experienced problems in calculating the right amounts of
formula powder and water.

2.4 Empirical Review

Muzondo (2010) examine factors influencing the infant feeding practices of HIV positive
mothers in a low resource community in Khayelitsha at Michael Mapongwana clinic. The study
aimed to establish the mother’s current feeding practices, to determine the various factors
influencing their practices and to establish the relationship between these factors and their
practices. Questionnaires were used to sampled 20 HIV positive mothers who had children up to
2 years and attended the ARV clinic or the PMTCT clinic. Further, 2 healthcare workers who
directly work with these mothers were also surveyed. Findings show that the majority, (95%) of
the mothers were practicing the replacement feeding method with a minority of (5%) practicing
mixed feeding. Most mothers chose replacement feeding because it was free of charge, to avoid
MTCT of HIV and also the healthcare workers recommended the mothers to use infant formula.
The safety of exclusive breastfeeding was questioned by (90%) of the mothers making it very
unpopular. Several factors influencing against exclusive replacement feeding were stigma,
discrimination, pressure from the family and lack of support from a partner or significant family
member.

12
Suuk and Veloshnee (2011) assessed the perspectives of HIV-positive mothers and family
members (grandmothers and fathers) of the infant feeding options recommended for
HIV-infected mothers in Ghana. They interviewed 40 HIV positive mothers with infants aged 0
to 12 months and 6 focus group discussions with HIV-positive mothers, fathers and grandmothers
of unknown status in two urban districts. Findings revealed that all infants born to HIV-positive
mothers in both districts had been breastfed. Breastfeeding was initiated between three hours and
three days following birth. While some of the infants had been exclusively breastfed, none had
been exclusively formula-fed. Early mixed feeding patterns were deeply entrenched. Barriers to
exclusive replacement feeding by HIV-positive mothers included cultural and familial influences,
socio-economic factors including cost of infant formula, lack of access to fridges, clean water and
fuel. Interventions designed to promote safer infant feeding among HIV infected mothers in these
settings need to be mindful of these barriers (socio-economic, cultural and familial) that these
women face. Failure by policymakers to incorporate these issues will continue to lead to a gap
between well-intended policies and programmes, and actual practices of HIV-positive mothers.

Godfrey (2013) assess infant feeding practices and viable breast milk alternatives for infants born
to HIV positive mothers and the socio-cultural and economic conditions surrounding the choice
of such practices in a rural community in Western Kenya. Descriptive cross-sectional study
design employing both quantitative and qualitative methodologies were used. Multistage
sampling technique was used using a semi-structured questionnaire to 111 HIV positive mothers.
Also, focus group discussion (FGD) guide was used to collect information from elderly women,
women in the age bracket 15-49 years and men whose spouses were within 15-49 years’ age
bracket. Key informant guide (KII) was used to collect data from health facility in-charges. The
study results show a high (66.7%) Maternal knowledge on MTCT of HIV in the study area.
However, this had no association with maternal choice of infant feeding practice (P=0.09). On the
other hand, maternal knowledge indicated some association with the level of formal education
attained and exposure to other information received through health talks and or counselling from
health workers or media. The study concluded that despite a high level of maternal knowledge,
majority of respondents practiced mixed infant feeding before 6 months, which increases the
MTCT of HIV. The choice of alternative infant feeding practice was influenced by several factors
among them; cultural attitudes, level of income and availability and affordability of food. A
strong association was noted; income, cultural attitudes, pressure from family members, stigma

13
and discrimination, belief about HIV transmission from mother to child and HIV has no cure and
household food availability.

Abebe et al., (2014) assess the EBF practices of HIV positive mothers and its determinants in a
selected health institution of West Oromia (Ethiopia). Using quantitative and qualitative methods,
they employed a descriptive cross-section survey design to sample 119 HIV positive mothers
using a structured questionnaire in selected health institutions with ART and PMTCT facilities in
west Oromia. This study results show that the practices of EBF, mixed feeding and replacement
feeding were at 72%, 24.6%, and 3.4% respectively. Regarding determinant factors, the only
workplace was found to be the only predictor of the practices of EBF among HIV positive
mothers that is HIV positive mothers who work far from their home were found to be 0.348 times
less likely to practice EBF than those mothers who work near their home.

Usman et al., (2015) examine factors influencing infant feeding choices of HIV positive mothers
in Southwestern, Nigeria. They employed a semi-structural question to sampled 600 HIV positive
mothers using a cross-sectional survey design to assess practices regarding infant feeding choices
and factors influencing these choice(s) by mothers enrolled in Prevention of Mother-to-Child
Transmission (PMTCT) of HIV clinics in Oyo State. Bivariate analyses were done to measure the
association between independent variables and infant feeding options using Crude odd’s
ratio(COR). The logistic regression model was fitted to identify factors influencing the choice of
infant feeding practice by HIV positive mothers. Findings of the study revealed that Infant
feeding choices among the mothers were Exclusive Breast Feeding (EBF) (61.0%), Exclusive
Replacement Feeding (ERF) (26.0%) and Mixed Feeding (MF) (13.0%). The choice of EBF,
ERF and MF were influenced by fear of stigmatization (55.0%), disclosure of HIV status to the
spouse (67.0%) and neighbours’ advice (66.0%) respectively. Predictors of EBF were; monthly
income, infant feeding counselling and fear of stigmatization. Predictors of ERF were; being a
civil servant, desire to reduce the risk of transmission of HIV and disclosure of HIV status to
spouses [Predictors of MF were; parity, receiving neighbours’ advice and infant illness. Although
a high proportion of mothers practiced exclusive breastfeeding for fear of stigmatization, mixed
feeding is still being practiced due to neighbours’ advice. Family members’ education on safer
infant feeding practices and behavioral change programmes in the context of HIV are advocated.

Igbokwe et al., (2016) compared factors that Influence Infant Feeding Options of HIV-Positive

14
Mothers in Urban and Rural Communities in South-East, Nigeria. They employed a comparative
cross-sectional study involving 550 HIV-positive mothers whose babies were HIV-negative, and
below 24 months using a systematic sampling method. Questionnaires and Focused Group
Discussion (FGD) guide were used. The study findings revealed that Infant feeding practices
differed significantly between the communities. Majority of the rural mothers practiced exclusive
breastfeeding, while the urban counterparts mainly practiced exclusive formula feeding. The
major reason for choosing breastfeeding as an option was that the women felt that breast milk
was the best for their babies. Those that opted for formula feeding did so mainly to protect their
babies from being infected with HIV. It was however discovered that the family income
significantly influenced the infant feeding choices of the respondents such that majority of the
richer ones preferred to use a formula in both communities. The researchers recommended that
Information on the current National Policy and Guidelines on infant feeding for HIV positive
mothers should be disseminated to all relevant authorities especially health facilities for onward
communications to mothers through programmes like organized seminars for mothers, Health
talks in women’s gatherings, workshops etc.

Wakwoya et al., (2106) examine infant feeding practice and its associated factors among HIV
positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia.
They employed a cross-sectional design to sampled 260 HIV positive mothers utilizing a
structured questionnaire. Bivariate and multivariate analysis was performed to check association
and to control confounders. Findings revealed that 85.8% of HIV mothers were feeding their
children based on the recommended feeding way of infant feeding practice with the remaining
percentage 14.2% were practising mixed feeding. In multivariate analysis mothers attending high
school and above, having antenatal care follow up, being on antiretroviral therapy and disclosure
of HIV status were found to be independently associated with infant feeding practice. The
researchers suggested that continuous education of mothers, increasing ANC utilization,
counselling mothers to start ART, encouraging and supporting mothers to disclose their HIV
status should be implemented.

Armelia et al., (2017) explored factors influencing the infant feeding choice of HIV-positive
mothers at a peri-urban hospital in Tembisa, South Africa. The study was qualitative and was
conducted among 30 purposefully selected postnatal HIV-positive mothers at Tembisa hospital,

15
Gauteng, from May to June 2017. In-depth interviews were conducted mainly in isiZulu and
Sepedi which were then transcribed into English. An open coding system of analysis was used for
thematic analysis. Findings revealed that nurses significantly influenced the feeding choices of
new mothers-sometimes with inconsistent information. The grandmothers of infants also
influenced the new mothers’ feeding options, in some cases with the new mother coming under
duress. Other relatives like the sisters and aunts of mothers appeared to significantly affect
feeding choices. The time frames expressed for the initiation of a supplementary diet were as
follows: before 1 month, at 1 month and 4 months. The main reason was the belief that infants
required more than breast milk as sustenance during this period.

16
 CHAPTER THREE
METHODOLOGY
3.1 study design

This study will adopt a cross-sectional survey research design. This is because the cross-sectional
survey research design is mostly use to gather data from a sample population at a particular time,
and it will enable the researcher to observe two or more variables at the point in time, and it will
be useful for describing a relationship between two or more variables (Breakwell et al.,
1995).This design is preferred because it is relatively cheap and can collect diverse data within a
short period required to analyze cause-effect relationships in a representative subset of a
population.

3.2 Study Area

This was carried out at Mifi District [Link] mifi division of cameroon has an estimated
population of about 347,517 people and a surface area of about 1,173 kilometers [Link]
District Hospital is the main referral hospital in the Mifi division

3.3 Study Population

This study consisted of HIV positive mothers who receive treatment from Mifi District Hospital.

3.4 Sample size

An estimated sample size of 66 members were selected for this study. this sample size was
determined using Slovin's formula ( Pasgoso et al.,1992) as follows

n=N/(1+Ne2),

Where

- n = sample size

-N =Pre-estimate of targeted population (sample frame). For this study,N=80

- e2 = margin of error preferred (5%)

Therefore,n=80/(1+80×0.0025)=66

17
3.5 Sampling technique
The non-probability sampling technique called convenience simple random sampling was used to
select mothers for the study. Based on this sampling technique only HIV positive mothers with
0-12Months were selected based on the participant availability and willingness to participate in
the study.

3.5.1 Inclusion criteria

The respondents will be eligible to participate in the study included mothers of reproductive age
(15-49 years) aware of their HIV serostatus, have a child aged 0-12 months and are residents of
Bafoussam for a period, were selected to participate in this study.

3.5.2 Exclusion criteria

Mothers with children who were sick of opportunistic infections and unable to participate in the
study were excluded. Eligible mothers who were not present at the time of data collection where
also excluded.

3.6 Data collection Tools

Data was collected through a semi-structured questionnaire. The choice of questionnaire as a tool
was due to administer, relatively low cost and its versatility to collect both quantitative and
qualitative data. The questionnaire was designed to get information on the following:
Demographics- age, marital status, household size, level of education, occupation and area of
residence, the physical and social support during pregnancy, childbirth and postpartum, Familial,
medical, cultural attitudes and norms relating to infant feeding, Reproductive history of the
woman, Maternal knowledge on HIV, modes of transmission, MTCT through breastfeeding,
infant feeding options in the context of HIV, Existing methods of prevention of transmission and
Socio-economic factors that influenced the choice of infant feeding.

3.6.1 Validity and Reliability

The supervisor for this study checked and validated the content of the questionnaire after
ensuring that the questions were in line with the objectives of this study. For reliability, the
questionnaire wad pre-testing

3.6.3 Data Analysis

The data was checked for completeness, and entered into MS EXCEL [Link] statistical
package for social sciences (SPSS), Version 25.0(IBM Corp, Chicago, Illinois, USA) was used to

18
analyse the data. The results were summarized and presented on frequency distribution tables and
charts.

3.7 Ethical Consideration

Administrative authorization to carry out this study was obtained from HISTBA Institude and
taken to the delegation of public health Bafoussam along side a copy of research proposal. The
authorisation form was gotten from the delegation of public health and presented to Hopital
District de la Mifi and the hospital gave an aproved authorization form to carry out this research.
the HIV mothers were informed of the purpose of the study and administered the questionaires
only after obtaining verbal inform consent.

19
 CHAPTER FOUR
RESULTS
4.1 Socio-demographic characteristics of participants

In this study, 55 HIV positive mothers were enrolled and 50 (90.9%) completed the
questionnaire. The mean age of the respondents was 30.51 years (standard deviation ± 14.6).
Majority 24 (48.0%) of the respondents were aged 25 – 34 years old. Half 25 (50.0%) of the
participants were married. Twenty percent 10 (20.0%) of the HIV positive mothers were
unemployed. The majority of the respondents 44 (88%), were Orthodox Christians. Regarding
educational level, 23 (46.0%) had attended primary education (Table 1)
Table 1: Socio-demographic characteristics of participants
Variable Frequency Percentage (%)
Age (Years)
15 – 24 10 20.0
25 – 34 24 48.0
35+ 16 32.0
Religion
Christian 44 88.0
Muslim 04 8.0
Atheist 04 4.0
Level of education
No formal 12 24.0
Primary 23 46.0
Secondary 10 20.0
Tertiary 05 10.0
Marital status
Married 25 50.0
Divorced 08 16.0
Widow 07 14.0
Single 10 20.0
Occupation

20
 Employed 19 38.0
Unemployed 10 20.0
Housewife 08 16.0
Student 13 26.0

4.2 Knowledge of HIV positive mothers on infant feeding options

Of the 100 HIV mothers sampled, 48 (96.0%) of them knew HIV can be transmitted from mother
to child. Sore in the baby’s mouths (60.0%) and cracked nipples (52.0%) were the main ways of
transmission of the virus from the mother to the child during breastfeeding. Sixteen percent of the

Mothers did not know the recommended feeding options for HIV exposed infants. The main
sources of information on infants feeding options for HIV positive mothers were health facility
33 (66.0%) and family/friends 07 (14.0%). Only 20 (40.0%) of the participants knew that
exclusive breastfeeding was recommended for HIV exposed infants.

Table 2:
Knowledge of HIV positive mothers on infant feeding options
Knowledge Frequency Percent
Can HIV be transmitted from mother to child?
Yes 48 96.0
No 02 4.0
Ways of transmiting HIV from MTC through breastfeeding*
Breast milk contaminated with HIV 15 30.0
Broken skin on the breast 23 46.0
Cracked nipples 26 52.0
Sores in the baby’s mouth 30 60.0
Diarrhoea 06 12.0
Are there feeding options for infants born of HIV positive
mothers?
Yes 42 84.0
No 08 16.0

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 If yes, what is your source of information on these feeding
options?
Hospital 33 66.0
School/Book 04 8.0
Social media 06 12.0
Friends/family 07 14.0
Which feeding options less risky for HIV exposed infants?
Complementary breastfeeding before six months 08 16.0
Exclusive breastfeeding 20 40.0
Exclusive formula feeding 17 34.0
Mixed feeding 05 10.0
*multiple response questions
Of the 100 HIV mothers sampled, 54 (54.0%) had good knowledge on the infant feeding options
among HIV exposed infants (Figure 1).

Figure 1: Overall knowledge of mothers on infant feeding options for HIV infants

22
Figure 2: Infant feeding options for HIV positive mothers
Figure 1Infant feeding options for HIV positive mothers

Figure 2Figure 1: Overall knowledge of mothers on infant feeding options for HIV infants

Figure 3: Factors influencing the choice of infant feeding option among HIV positive mothers

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 CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.1 Discussion
5.1.1 Knowledge of HIV positive mothers on infant feeding options

This study found that 54.0% of the HIV positive mothers had good knowledge on the infant
feeding options. This finding is in line with that of Leroy et al. (2017) in a related study in South
Africa reported that HIV positive women with good knowledge levels on HIV transmission
through breastfeeding practiced appropriate infant feeding options reducing the risk of
transmitting HIV to

their infants and increasing child survival. A higher number of HIV positive mothers with poor
knowledge levels on risk factors associated with HIV transmission through breastfeeding; they
had a poor understanding of HIV transmission through contaminated breast milk, broken breast
skin, cracked nipples, sores in the baby's mouth which showed a poor association of conditions in
a breast-feeding mother and baby with damage to gastro-intestinal lining. Majority of the
women with poor knowledge on the risks of HIV transmission through breastfeeding got
information from their friends.

This study found that there was an adequate flow of information from various sources, including
hospital and friends, pamphlets, radio, television, the internet, PMTCT and Newsletter. The fact
that hospital and friends were the main source of information meant that there was a need to
ensure the community; especially women of child-bearing age had accurate information on
MTCT of HIV so that correct information can be passed among the community members. De
Cock et al. (2015) in a related study in South Africa found that information on HIV/AIDS was
mainly acquired through the radio and television possibly because the study was done in the city
where more people had access to television.

5.1.2 Infant feeding options for HIV exposed children

Infant-feeling options for HIV-infected women have largely been governed by guidelines by
WHO, the United Nations Children’s Fund (UNICEF) and the Joint United Nations Program on
HIV/AIDS (WHO, UNICEF, UNAIDS, 2009). In Cameroon these guidelines have been adopted

24
by the Ministry of Public Health. These guidelines offered women a reasonable framework in
which to make choices on infant feeding appropriate to their socio-economic conditions.
However, the task of weighing risks and benefits created considerable difficulties for
policy-makers and for health-care workers in the field. Among the 50 HIV positive women
interviewed in this study only 26.0% made appropriate infant feeding choices (exclusive
breastfeeding) the recommended safer infant feeding options for HIV infected mothers while
74.0% made inappropriate infant feeding choices (mixed feeding, complimentary formula
feeding , complimentary breastfeeding, animal milk feeding ) despite the fact that they had the
potential of exposing the infants to the HIV virus thereby suggesting the difficulty of
implementing this type of intervention. This was consistent with a previous study in Nairobi
where 25.5% of the mothers practiced appropriate infant feeding options while 74.5% practiced
inappropriate infant feeding options (Nduati et al., 2015). However, a similar study in South
Africa Kwa zulu Natal found that 60.8% of HIV positive mothers practiced appropriate infant
feeding options, probably because formula milk was issued free in all government public health
facilities (Coutsoudis et al., 2015). Choice of infant feeding option for HIV infected women in
resource constrained setting has thus become a great challenge due to the cultural, economic and
social issues surrounding infant feeding (Ngacha et al., 2015).

5.1.3 Factors influencing the choice of infant feeding options among HIV positive mothers

The current study revealed that the main factors influencing the choice of infant feeding option
among HIV positive mothers were less risk of transmission, lack of knowledge on PMTCT of
HIV, nutritious content of the option and stigmatization. This is in line with studies in
Sub-Saharan Africa which document high rates of mixed feeding among HIV positive mothers
who have not disclosed their HIV status to their partners or relatives (Leroy et al., 2017; Chopra
et al., 2015). Lack of social support from the family members who are not aware of the HIV
status makes them practice mixed feeding which is a more acceptable and normative pattern of
infant feeding but one which has the highest risk of transmitting HIV to their infants. Formula
milk feeding may be interpreted as a sign of HIV positive status, especially if no good and
legitimate explanation for formula milk feeding, such as caesarean section, can be produced. As
knowledge of HIV transmission through breast feeding is disseminated into local communities, a
woman who opts for formula milk feeding will be carefully watched. The costs involved,
25
combined with the scorn and suspicion that it is perceived to foster, thus make formula milk
feeding an option only for women who have disclosed their HIV status to their partner, or who
are not married, or who are not living in close proximity to another family member (Thairu et al.,
2015). Disclosure of HIV status to the partner is usually a major condition for successful infant
feeding adherence. However, disclosure of HIV-positive status to a partner was, in this study as
in many other studies, greatly feared by the study participants, and this had a bearing on and was
an obstacle to adherence to appropriate infant feeding option.

26
 CONCLUSION

The knowledge of HIV positive mothers on infant feeding choices was average. Only 26.0% of
HIV positive mothers in the MIFI District Hospital practiced the recommended exclusive
breastfeeding. The main factors influencing the infant feeding choices among HIV positive
mothers were less risk of transmission, lack of knowledge on PMTCT of HIV, nutritious content
of the option and stigmatization.

5.3 Recommandations

1. Strengthen MTCT support systems beyond care at health facility level to enhance maternal
knowledge and practice.

2. Mixed feeding to infants before six months’ increases risk of MTCT of HIV. Therefore, there
is need to intervene through health education, counseling and sensitization to health workers and
mothers on the importance of adherence to WHO recommended guidelines.

3. Intensify sensitization on vertical transmission of HIV and associated risks to mothers

attending MCH services in the health facilities. Health care providers need to intensify health and
nutrition education, voluntary and confidential counseling and testing.

4. Target community with behavior change programs to address negative social factors that the
research has revealed contributes MTCT of HIV among HIV positive mothers.

5. This study recommends further research on assessment of maternal adherence to WHO infant
feeding guidelines in context of HIV.

27