Breastfeeding, Mother-to-Child HIV Transmission, and Mortality Among Infants Born to HIV-Infected Women on Highly Active Antiretroviral Therapy in Rural Uganda
Highly active antiretroviral therapy (HAART) drastically reduces mother-to-child transmission of HIV, but where breastfeeding is the only safe infant feeding option, HAART for the prevention of mother-to-child transmission needs to be evaluated in relation to both HIV transmission and infant mortality.
One hundred and two > or = 18-year old women on HAART in rural Uganda who delivered one or more live infants between March 1, 2003 and January 1, 2007 were enrolled in a prospective study to assess HIV transmission and infant survival. All pregnant women were counseled to exclusively breastfeed for 3-6 months according to national guidelines at the time. Infants were followed-up for > or = 7 months and were offered HIV polymerase chain reaction testing quarterly from 6 weeks of age until > or = 6 weeks after complete weaning.
Of 118 infants born during follow-up, 109 (92%) were breastfed. Median durations of exclusive and total breastfeeding were 4 months (interquartile range 3-6) and 5 months (interquartile range 3-7), respectively. None of the infants tested HIV polymerase chain reaction positive over follow-up but 16 infants died without a definitive HIV status at a median age of 2.6 months. In total, 23 (19%) infants died during follow-up at a median age of 3.7 months; 15 (65%) of whom with severe diarrhea and/or vomiting in the week preceding their death. In multivariate analysis, there was a 6-fold greater risk of death among infants breastfed for less than 6 months independent of maternal CD4 count closest to delivery, maternal marital status or maternal death (adjusted hazard ratio = 6.19; 95% confidence interval 1.41-27.0, P = 0.015).
In resource-constrained settings, HIV-infected pregnant women should be assessed for HAART eligibility and treated as needed without delay, and should be encouraged to breastfeed their infants for at least 6 months.
Available from: Michael L Power
- "se ( Bode et al . , 2012 ) . With highly active antiretroviral therapy ( HAART ) less than 3% of breastfed infants will contract HIV . In a study of 102 HIV - infected mothers undergoing HAART in Uganda , no infants were diagnosed as HIV pos - itive and the risk of infant death was six - fold higher among infants breastfed for less than 6 months ( Homsy et al . , 2010 ) . In developing countries breastfeeding in conjunction with HAART may be prefera - ble to formula feeding despite the non - zero risk of HIV transmission ."
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ABSTRACT: The developmental origins of health and disease (DOHaD) is a paradigm for understanding metabolic diseases of modern humans. Vulnerability to disease is linked to perturbations in development during critical time periods in fetal and neonatal life. These perturbations are caused by environmental signals, often generated or transduced by the mother. The regulation of mammalian development depends to a large extent on maternal biochemical signals to her offspring. We argue that this adaptation is ancient, and originated with the evolution of lactation. Lactation evolved earlier than live birth and before the extensive placental development of modern eutherian mammals. Milk contains a host of signaling molecules including nutrients, immunoglobulins, growth factors and metabolic hormones. As evidenced by marsupials, lactation originally served to supply the biochemical factors for growth and development for what is essentially a fetus to a weanling transitioning to independent existence. In placental mammals maternal signaling in earliest life is accomplished through the maternal–placental–fetal connection, with more of development shifted to in utero life. However, significant development occurs postpartum, supported by milk. Mothers of all taxa provide biochemical signals to their offspring, but for non-mammalian mothers the time window is short. Developing mammals receive maternal biochemical signals over an extended period. These signals serve to guide normal development, but also can vary in response to environmental conditions. The ancient adaptation of lactation resulted in a lineage (mammals) in which maternal regulation of offspring development evolved to a heightened degree, with the ability to modify development at multiple time points. Modern metabolic diseases may arise due to a mismatch between maternal regulation and eventual circumstances of the offspring, and due to a large proportion of mothers that exceed past evolutionary norms in body fat and pregnancy weight gain such that maternal signals may no longer be within the adaptive range.
Applied and Translational Genomics 12/2013; 2(1). DOI:10.1016/j.atg.2013.06.001
Available from: Robert E Black
- "This review did not aim to estimate the risk of suboptimal feeding practices among children born to HIV-infected mothers and is therefore limited by the inability to generalize our findings to such populations. Several studies suggest the benefits of exclusive breastfeeding among children born to HIV-infected mothers during the first six months of life [29,30], and the current WHO/UNICEF recommendation supports this practice and continued feeding during the first year in conjunction with ARV drugs during the breastfeeding period . However, further research is necessary in order to confirm the relevance of our reported effect sizes among HIV-infected mothers and infants. "
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ABSTRACT: Suboptimal breastfeeding practices among infants and young children <24 months of age are associated with elevated risk of pneumonia morbidity and mortality. We conducted a systematic review and meta-analysis to quantify the protective effects of breastfeeding exposure against pneumonia incidence, prevalence, hospitalizations and mortality.
We conducted a systematic literature review of studies assessing the risk of selected pneumonia morbidity and mortality outcomes by varying levels of breastfeeding exposure among infants and young children <24 months of age. We used random effects meta-analyses to generate pooled effect estimates by outcome, age and exposure level.
Suboptimal breastfeeding elevated the risk of pneumonia morbidity and mortality outcomes across age groups. In particular, pneumonia mortality was higher among not breastfed compared to exclusively breastfed infants 0-5 months of age (RR: 14.97; 95% CI: 0.67-332.74) and among not breastfed compared to breastfed infants and young children 6-23 months of age (RR: 1.92; 95% CI: 0.79-4.68).
Our results highlight the importance of breastfeeding during the first 23 months of life as a key intervention for reducing pneumonia morbidity and mortality.
BMC Public Health 09/2013; 13 Suppl 3(Suppl 3):S18. DOI:10.1186/1471-2458-13-S3-S18 · 2.26 Impact Factor
Available from: plosone.org
- "The proportion of mothers who practice exclusive breastfeeding may be higher since HIV-infected women are the more aware of the HIV transmission risk. A recent study from Uganda shows that up to 92% of women on ART exclusively breastfed their infants for a median duration of 4.0 months and stopped breastfeeding at a median age of 5.0 months . "
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ABSTRACT: Rwanda's National PMTCT program aims to achieve elimination of new HIV infections in children by 2015. In November 2010, Rwanda adopted the WHO 2010 ARV guidelines for PMTCT recommending Option B (HAART) for all HIV-positive pregnant women extended throughout breastfeeding and discontinued (short course-HAART) only for those not eligible for life treatment. The current study aims to assess the cost-effectiveness of this policy choice.
Based on a cohort of HIV-infected pregnant women in Rwanda, we modelled the cost-effectiveness of six regimens: dual ARV prophylaxis with either 12 months breastfeeding or replacement feeding; short course HAART (Sc-HAART) prophylaxis with either 6 months breastfeeding, 12 months breastfeeding, or 18 months breastfeeding; and Sc-HAART prophylaxis with replacement feeding. Direct costs were modelled based on all inputs in each scenario and related unit costs. Effectiveness was evaluated by measuring HIV-free survival at 18 months. Savings correspond to the lifetime costs of HIV treatment and care avoided as a result of all vertical HIV infections averted.
All PMTCT scenarios considered are cost saving compared to "no intervention." Sc-HAART with 12 months breastfeeding or 6 months breastfeeding dominate all other scenarios. Sc-HAART with 12 months breastfeeding allows for more children to be alive and HIV-uninfected by 18 months than Sc-HAART with 6 months breastfeeding for an incremental cost per child alive and uninfected of 11,882 USD. This conclusion is sensitive to changes in the relative risk of mortality by 18 months for exposed HIV-uninfected children on replacement feeding from birth and those who were breastfed for only 6 months compared to those breastfeeding for 12 months or more.
Our findings support the earlier decision by Rwanda to adopt WHO Option B and could inform alternatives for breastfeeding duration. Local contexts and existing care delivery models should be part of national policy decisions.
PLoS ONE 02/2013; 8(2):e54180. DOI:10.1371/journal.pone.0054180 · 3.23 Impact Factor
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