Mother-to-Child Transmission of HIV-1 Infection during Exclusive Breastfeeding in the First Six Months of Life: An Intervention Cohort Study

Centre for HIV/AIDS Networking, University of KwaZulu-Natal, South Africa.
The Lancet (Impact Factor: 45.22). 03/2007; 369(9567):1107-16. DOI: 10.1016/S0140-6736(07)60283-9
Source: PubMed


Exclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding.
2722 HIV-infected and uninfected pregnant women attending antenatal clinics in KwaZulu Natal, South Africa (seven rural, one semiurban, and one urban), were enrolled into a non-randomised intervention cohort study. Infant feeding data were obtained every week from mothers, and blood samples from infants were taken monthly at clinics to establish HIV infection status. Kaplan-Meier analyses conditional on exclusive breastfeeding were used to estimate transmission risks at 6 weeks and 22 weeks of age, and Cox's proportional hazard was used to quantify associations with maternal and infant factors.
1132 of 1372 (83%) infants born to HIV-infected mothers initiated exclusive breastfeeding from birth. Of 1276 infants with complete feeding data, median duration of cumulative exclusive breastfeeding was 159 days (first quartile [Q1] to third quartile [Q3], 122-174 days). 14.1% (95% CI 12.0-16.4) of exclusively breastfed infants were infected with HIV-1 by age 6 weeks and 19.5% (17.0-22.4) by 6 months; risk was significantly associated with maternal CD4-cell counts below 200 cells per muL (adjusted hazard ratio [HR] 3.79; 2.35-6.12) and birthweight less than 2500 g (1.81, 1.07-3.06). Kaplan-Meier estimated risk of acquisition of infection at 6 months of age was 4.04% (2.29-5.76). Breastfed infants who also received solids were significantly more likely to acquire infection than were exclusively breastfed children (HR 10.87, 1.51-78.00, p=0.018), as were infants who at 12 weeks received both breastmilk and formula milk (1.82, 0.98-3.36, p=0.057). Cumulative 3-month mortality in exclusively breastfed infants was 6.1% (4.74-7.92) versus 15.1% (7.63-28.73) in infants given replacement feeds (HR 2.06, 1.00-4.27, p=0.051).
The association between mixed breastfeeding and increased HIV transmission risk, together with evidence that exclusive breastfeeding can be successfully supported in HIV-infected women, warrant revision of the present UNICEF, WHO, and UNAIDS infant feeding guidelines.

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Available from: Hoosen Coovadia, Sep 30, 2015
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    • "Breastfeeding involves a considerable risk of HIV transmission but at the same time not breastfeeding represents a considerable risk to infant survival in low-income countries [1]. Women who practice exclusive breastfeeding (EBF) for the first 6 months postpartum are less likely to transmit HIV to their infants than women who practice mixed feeding [2]. The current WHO guidelines on infant feeding practices for HIV-positive women recommend that, in communities where breastfeeding is the norm, women should practice EBF for 6 months followed by introduction of complementary feeding thereafter [3]. "
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    ABSTRACT: The World Health Organization (WHO) recommends that HIV-infected women practice exclusive breastfeeding (EBF) for the first 6 months postpartum to reduce HIV transmission. The aim of this study was to determine the effects of HIV/AIDS knowledge and other psychosocial factors on EBF practice among pregnant and postpartum women in rural Nyanza, Kenya, an area with a high prevalence of HIV. Data on baseline characteristics and knowledge during pregnancy, as well as infant feeding practices 4-8 weeks after the birth were obtained from 281 pregnant women recruited from nine antenatal clinics. Factors examined included: fear of HIV/AIDS stigma, male partner reactions, lack of disclosure to family members, knowledge of prevention of mother-to-child transmission (PMTCT) and mental health. In the analysis, comparisons were made using chi-squared and t-test methods as well as logistic multivariate regression models. There were high levels of anticipated stigma 171(61.2%), intimate partner violence 57(20.4%) and postpartum depression 29(10.1%) and low levels of disclosure among HIV positive women 30(31.3%). The most significant factors determining EBF practice were hospital delivery (aOR = 2.1 95%CI 1.14-3.95) HIV positive serostatus (aOR 2.5 95%CI 1.23-5.27), and disclosure of HIV-positive serostatus (aOR 2.9 95% CI 1.31-6.79). Postpartum depression and PMTCT knowledge were not associated with EBF (aOR 1.1 95% CI 0.47-2.62 and aOR 1.2 95% CI 0.64-2.24) respectively. Health care workers and counselors need to receive support in order to improve skills required for diagnosing, monitoring and managing psychosocial aspects of the care of pregnant and HIV positive women including facilitating disclosure to male partners in order to improve both maternal and child health outcomes.
    BMC Public Health 04/2014; 14(1):390. DOI:10.1186/1471-2458-14-390 · 2.26 Impact Factor
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    • "It is imperative that mixed feeding (ie, part breast; part formula or semisolid foods) is avoided in the first 6 months of life; this is particularly crucial when ART is unavailable or unacceptable to the mother. In children under 6 months, a mixed feeding regimen of breastmilk and formula milk resulted in an approximately twofold increased risk of vertical transmission of HIV, while mixed feeding with solids increased the risk to 11-fold.31–34 Vertical transmission of HIV occurs when virus present in the milk infects children through the intestinal mucosa. "
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    ABSTRACT: Worldwide, more than 3 million children are infected with HIV and, without treatment, mortality among these children is extremely high. Both acute and chronic malnutrition are major problems for HIV-positive children living in resource-limited settings. Malnutrition on a background of HIV represents a separate clinical entity, with unique medical and social aetiological factors. Children with HIV have a higher daily calorie requirement than HIV-negative peers and also a higher requirement for micronutrients; furthermore, coinfection and chronic diarrhoea due to HIV enteropathy play a major role in HIV-associated malnutrition. Contributory factors include late presentation to medical services, unavailability of antiretroviral therapy, other issues surrounding healthcare provision and food insecurity in HIV-positive households. Treatment protocols for malnutrition have been greatly improved, yet there remains a discrepancy in mortality between HIV-positive and HIV-negative children. In this review, the aetiology, prevention and treatment of malnutrition in HIV-positive children are examined, with particular focus on resource-limited settings where this problem is most prevalent.
    Archives of Disease in Childhood 01/2014; 99(6). DOI:10.1136/archdischild-2012-303348 · 2.90 Impact Factor
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    • "Studies have shown that exclusive breastfeeding i.e. giving the infant breast milk only and no other liquids or solids for the first six months of life, reduces the rate of MTCT to less than one fourth compared to mixed feeding [14-16] and HIV free survival of the infants [17]. Exclusive breastfeeding by mothers is a challenge to adhere to during the first six months for most women and therefore predisposed the infant to the risk of HIV infection especially for mothers that have responsibilities that take them away from their children during the day. "
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    ABSTRACT: Zimbabwe is one of the five countries worst affected by the HIV/AIDS pandemic with HIV infection contributing increasingly to childhood morbidity and mortality. Among the children born to HIV positive mothers participating in the PMTCT programme, 25% tested positive to HIV. We investigated factors associated with HIV infection among children born to mothers on the PMTCT programme. A 1:1 unmatched case-control study was conducted at Chitungwiza Hospital, Zimbabwe, 2008. A case was defined as a child who tested HIV positive, born to a mother who had been on PMTCT programme. A control was a HIV negative child born to a mother who had been on PMTCT programme. An interviewer-administered questionnaire was used to collect data on demographic characteristics, risk factors associated with HIV infection and immunization status. A total of 120 mothers were interviewed. Independent risk factors associated with HIV infection among children included maternal CD4 count of less than 200 during pregnancy [aOR = 7.1, 95% CI (2.6-17)], mixed feeding [aOR = 29, 95% CI (4.2-208)], being hospitalized since birth [aOR = 2.9, 95% CI (1.2-4.8)] whilst being exclusively breast fed for less than 6 months [aOR = 0.1 (95% CI 0.03-0.4)] was protective. HIV infection among children increased if the mother's CD4 count was <=200 cells/muL and if the child was exposed to mixed feeding. Breastfeeding exclusively for less than six months was protective. We recommended exclusive breast feeding period for the first six months and stop breast feeding after 6 months if affordable, sustainable and safe.
    BMC Public Health 12/2013; 13(1):1181. DOI:10.1186/1471-2458-13-1181 · 2.26 Impact Factor
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