Setting

The study was conducted in Kilifi County Hospital (KCH), a government facility located on the Kenyan coast that serves a rural population of about 270,000. Over 80% of the population in Kilifi County live below the poverty line and rely on rain-fed subsistence farming. It is an area that suffers frequent food insecurity requiring emergency relief operations [40].

In 2014, the overall adult prevalence of HIV in the county was 4.4%, with higher prevalence among women (6.3%) than men (2.3%) [41]. In 2011, the antenatal clinic prevalence of HIV in KCH was approximately 6%, and about 24% of children admitted to the hospital with severe acute malnutrition were HIV infected.

Since 2003, KCH has been providing HIV services including the prevention of vertical transmission interventions and early infant diagnosis (EID). All nurses in the antenatal, postnatal and family planning clinics are trained in prevention of vertical transmission and almost all mothers attending KCH clinics are tested for HIV (> 90%). Women living with HIV are advised to give birth at a health facility and to register their infants for care soon after delivery at the KCH HIV clinic or the nearest health facility providing prevention of vertical transmission and EID services. In the KCH HIV clinic, 65% of the infants do not complete the 18 month follow-up period, with 43% of drop outs occurring within 2 months of enrolment [42].

At the time of this study, the national HIV infant feeding guidance was changing in line with the 2010 WHO guidance [13]. The prior recommendation had been exclusive breastfeeding in the first 6 months or replacement feeding only if it was acceptable, feasible, affordable, sustainable and safe (AFASS), and continuation of breastfeeding until the age of 12 months with the introduction of complementary feeds, if conditions of replacement of breast milk were still not met [43]. In addition, women living with HIV who were already on combined antiretroviral treatment (ART) were to continue with this, but for those who were not, it was recommended that they start zidovudine at 28 weeks’ gestation then, combine ART (zidovudine, lamivudine and nevirapine at the onset of labour with the continuation of zidovudine and lamivudine only up to 7 days [43]. For the infant nevirapine was to be administered within 72 h of birth plus lamivudine and zidovudine for 6 weeks [43]. This was subsequently revised in line with the WHO recommendations for the continuation of combined ART in the mother and nevirapine in the infant for the duration of breastfeeding [13].