Volume 85, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



In low-income settings, human immunodeficiency virus (HIV)-positive mothers must choose between breastfeeding their infants and risking transmission of HIV or replacement feeding their infants and risking diarrheal disease from contaminated water. We conducted a cross-sectional study of children < 2 years of age of 254 HIV-positive mothers in peri-urban Zambia to assess their exposure to waterborne fecal contamination. Fecal indicators were found in 70% of household drinking water samples. In a multivariable analysis, factors associated with diarrhea prevalence in children < 2 years were mother having diarrhea (adjusted odds ratio [aOR] = 5.18, 95% confidence interval [CI] = 1.65–16.28), child given water in the past 2 days (aOR = 4.08, 95% CI = 1.07–15.52), child never being breastfed (aOR = 2.67, 95% CI = 1.06–6.72), and rainy (versus dry) season (aOR = 4.60, 95% CI = 1.29–16.42). Children born to HIV-positive mothers were exposed to contaminated water through direct intake of drinking water, indicating the need for interventions to ensure microbiological water quality.


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  1. Kosek M, Bern C, Guerrant RL, , 2003. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 81: 197204. [Google Scholar]
  2. World Health Organization and UNICEF, 2010. Progress on Sanitation and Drinking-Water: 2010 Update. WHO Press, Geneva, Switzerland. [Google Scholar]
  3. UNAIDS, 2010. UNAIDS Report on the Global AIDS Epidemic, Joint United Nations Programme on HIV/AIDS. Geneva, Switzerland. [Google Scholar]
  4. Mermin J, Lule J, Ekwaru JP, Malamba S, Downing R, Ransom R, Kaharuza F, Culver D, Kizito F, Bunnell R, Kigozi A, Nakanjako D, Wafula W, Quick R, , 2004. Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV infection in rural Uganda. Lancet 364: 14281434.[Crossref] [Google Scholar]
  5. Bushen OY, Davenport JA, Lima AB, Piscitelli SC, Uzgiris AJ, Silva TM, Leite R, Kosek M, Dillingham RA, Girao A, Lima AA, Guerrant RL, , 2004. Diarrhea and reduced levels of antiretroviral drugs: improvement with glutamine or alanyl-glutamine in a randomized controlled trial in northeast Brazil. Clin Infect Dis 38: 17641770.[Crossref] [Google Scholar]
  6. Becquet R, Bequet L, Ekouevi DK, Viho I, Sakarovitch C, Fassinou P, Bedikou G, Timite-Konan M, Dabis F, Leroy V, , Group ADPS, 2007. Two-year morbidity-mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Cote d'Ivoire. PLoS Med 4: e17.[Crossref] [Google Scholar]
  7. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J, , 2000. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 283: 11671174.[Crossref] [Google Scholar]
  8. World Health Organization, 2007. Briefing Note—HIV and Infant Feeding. Conference on Retroviruses and Opportunistic Infections. Los Angeles, CA: World Health Organization. [Google Scholar]
  9. World Health Organization, 2009. HIV and Infant Feeding: Revised Principles and Recommendations RAPID ADVICE. Geneva, Switzerland: World Health Organization. [Google Scholar]
  10. Ministry of Health Republic of Zambia, 2010. 2010 National Protocol Guidelines: Integrated Prevention of Mother-to-Child Transmission of HIV. Lusaka, Zambia: Ministry of Health. [Google Scholar]
  11. Binagwaho A, Fawzi MCS, Drobac P, Franke M, Ivers L, Kim JY, Mukherjee J, Noguchi J, Rich M, Stulac S, Farmer P, , 2009. HIV, infant feeding and implementation failure: advancing policies for women with HIV infection and attaining the Milennium Development Goals. Bull World Health Organ 87: AB.[Crossref] [Google Scholar]
  12. Coutsoudis A, Coovadia HM, Wilfert CM, , 2009. Formula-feeding is not a sustainable solution. Bull World Health Organ 87: BC.[Crossref] [Google Scholar]
  13. Chiller TM, Mendoza CE, Lopez MB, Alvarez M, Hoekstra RM, Keswick BH, Luby SP, , 2006. Reducing diarrhoea in Guatemalan children: randomized controlled trial of flocculant-disinfectant for drinking-water. Bull World Health Organ 84: 2835.[Crossref] [Google Scholar]
  14. World Health Organization, 2009. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva, Switzerland: World Health Organization. [Google Scholar]
  15. UNICEF, 2007. Progress for Children: a World Fit for Children. Statistical Review, Number 6. New York, NY: UNICEF. [Google Scholar]
  16. Fadnes LT, Engebretsen IM, Wamani H, Wangisi J, Tumwine JK, Tylleskar T, , 2009. Need to optimise infant feeding counselling: a cross-sectional survey among HIV-positive mothers in Eastern Uganda. BMC Pediatr 9: 2.[Crossref] [Google Scholar]
  17. Fjeld E, Siziya S, Katepa-Bwalya M, Kankasa C, Moland KM, Tylleskar T, , 2008. ‘No sister, the breast alone is not enough for my baby’ a qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. Int Breastfeed J 3: 26.[Crossref] [Google Scholar]
  18. Vanderslice J, Popkin B, Briscoe J, , 1994. Drinking-water quality, sanitation, and breast-feeding—their interactive effects on infant health. Bull World Health Organ 72: 589601. [Google Scholar]
  19. Brown KH, Black RE, Lopez de Romana G, Creed de Kanashiro H, , 1989. Infant-feeding practices and their relationship with diarrheal and other diseases in Huascar (Lima), Peru. Pediatrics 83: 3140. [Google Scholar]
  20. Popkin BM, Adair L, Akin JS, Black R, Briscoe J, Flieger W, , 1990. Breast-feeding and diarrheal morbidity. Pediatrics 86: 874882. [Google Scholar]
  21. Dunne EF, Angoran-Benie H, Kamelan-Tano A, Sibailly TS, Monga BB, Kouadio L, Roels TH, Wiktor SZ, Lackritz EM, Mintz ED, Luby S, , 2001. Is drinking water in Abidjan, Cote d'Ivoire, safe for infant formula? J Acquir Immune Defic Syndr 28: 393398.[Crossref] [Google Scholar]
  22. Imong SM, Rungruengthanakit K, Ruangyuttikarn C, Wongsawasdii L, Jackson DA, Drewett RF, , 1989. The bacterial content of infant weaning foods and water in rural northern Thailand. J Trop Pediatr 35: 1418.[Crossref] [Google Scholar]
  23. Rosa G, Clasen T, , 2010. Estimating the scope of household water treatment in low- and medium-income countries. Am J Trop Med Hyg 82: 289300.[Crossref] [Google Scholar]
  24. World Health Organization/UNICEF, 2010. Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Available at: http://www.wssinfo.org/definitions-methods/watsan-categories/. Accessed January 17, 2011. [Google Scholar]
  25. World Health Organization, 2006. Core Questions on Drinking-Water and Sanitation for Household Surveys. Geneva, Switzerland: World Health Organization and UNICEF. [Google Scholar]
  26. World Health Organization, 2008. Indicators for assessing infant and young child feeding practices. Proceedings of a Consensus Meeting, November 6–8, 2007; Washington, DC. [Google Scholar]
  27. World Health Organization, 2005. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers, 4th rev. Geneva, Switzerland: Department of Child and Adolescent Health Development, World Health Organization. [Google Scholar]
  28. Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A, Bank TW, , 2002. , ed. Socio-Economic Difference in Health, Nutrition, and Population: Zambia 1996. Washington, DC: The World Bank. [Google Scholar]
  29. World Health Organization, 2004. Guidelines for Drinking-Water Quality, 3rd ed. Geneva, Switzerland: World Health Organization. [Google Scholar]
  30. Amadi B, Kelly P, Mwiya M, Mulwazi E, Sianongo S, Changwe F, Thomson M, Hachungula J, Watuka A, Walker-Smith J, Chintu C, , 2001. Intestinal and systemic infection, HIV, and mortality in Zambian children with persistent diarrhea and malnutrition. J Pediatr Gastroenterol Nutr 32: 550554.[Crossref] [Google Scholar]
  31. Chintu C, Luo C, Baboo S, Khumalo-Ngwenya B, Mathewson J, DuPont HL, Zumla A, , 1995. Intestinal parasites in HIV-seropositive Zambian children with diarrhoea. J Trop Pediatr 41: 149152.[Crossref] [Google Scholar]
  32. Korich DG, Mead JR, Madore MS, Sinclair NA, Sterling CR, , 1990. Effects of ozone, chlorine dioxide, chlorine, and monochloramine on Cryptosporidium parvum oocyst viability. Appl Environ Microbiol 56: 14231428. [Google Scholar]
  33. US EPA, 2005. Method 1622: Cryptosporidium in Water by Filtration/IMS/FA. Cincinnati, OH: US Environmental Protection Agency Office of Water. [Google Scholar]
  34. Vyas S, Kumaranayake L, , 2006. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 21: 459468.[Crossref] [Google Scholar]
  35. Victora CG, Huttly SR, Fuchs SC, Olinto MT, , 1997. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 26: 224227.[Crossref] [Google Scholar]
  36. Bland RM, Rollins NC, Coovadia HM, Coutsoudis A, Newell ML, , 2007. Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ 85: 289296.[Crossref] [Google Scholar]
  37. World Health Organization, 2008. Guidelines for Drinking-Water Quality: Second Addendum to Third Edition. Geneva, Switzerland: World Health Organization. [Google Scholar]
  38. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality, 2000. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 355: 451455.[Crossref] [Google Scholar]
  39. Xue J, Mhango Z, Hoffman IF, Mofolo I, Kamanga E, Campbell J, Allgood G, Cohen MS, Martinson FE, Miller WC, Hosseinipour MC, , 2010. Use of nutritional and water hygiene packages for diarrhoeal prevention among HIV-exposed infants in Lilongwe, Malawi: an evaluation of a pilot prevention of mother-to-child transmission post-natal care service. Trop Med Int Health 15: 11561162.[Crossref] [Google Scholar]
  40. Gundry S, Wright J, Conroy R, , 2004. A systematic review of the health outcomes related to household water quality in developing countries. J Water Health 2: 113. [Google Scholar]
  41. Central Statistical Office (CSO)MoHM, Tropical Diseases Research Centre (TDRC), University of Zambia aMII, 2009. Zambia Demographic and Health Survey 2007. Calverton, MD: CSO and Macro International Inc. [Google Scholar]
  42. Lule JR, Mermin J, Ekwaru JP, Malamba S, Downing R, Ransom R, Nakanjako D, Wafula W, Hughes P, Bunnell R, Kaharuza F, Coutinho A, Kigozi A, Quick R, , 2005. Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. Am J Trop Med Hyg 73: 926933. [Google Scholar]
  43. Harris JR, Greene SK, Thomas TK, Ndivo R, Okanda J, Masaba R, Nyangau I, Thigpen MC, Hoekstra RM, Quick RE, , 2009. Effect of a point-of-use water treatment and safe water storage intervention on diarrhea in infants of HIV-infected mothers. J Infect Dis 200: 11861193.[Crossref] [Google Scholar]
  44. Barzilay EJ, Aghoghovbia TS, Blanton EM, Akinpelumi AA, Coldiron ME, Akinfolayan O, Adeleye OA, Latrielle A, Hoekstra RM, Gilpin U, Quick R, , 2011. Diarrhea prevention in people living with HIV: an evaluation of a point-of-use water quality intervention in Lagos, Nigeria. AIDS Care 23: 330339.[Crossref] [Google Scholar]
  45. Roberts L, Chartier Y, Chartier O, Malenga G, Toole M, Rodka H, , 2001. Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial. Bull World Health Organ 79: 280287. [Google Scholar]

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  • Received : 09 Mar 2011
  • Accepted : 17 May 2011
  • Published online : 01 Aug 2011

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