The Journal of Nutrition
Community and International Nutrition
Lipid-Based Nutrient Supplements Are Feasible
As a Breastmilk Replacement for HIV-Exposed
Infants from 24 to 48 Weeks of Age1–4
Valerie L. Flax,5,6* Margaret E. Bentley,5,6Charles S. Chasela,9,10Dumbani Kayira,9Michael G. Hudgens,7
Kopekani Z. Kacheche,9Charity Chavula,9Athena P. Kourtis,11Denise J. Jamieson,11
Charles M. van der Horst,8and Linda S. Adair5,6
5Carolina Population Center,6Department of Nutrition,7Department of Biostatistics, and8Division of Infectious Diseases, School of
Medicine, University of North Carolina, Chapel Hill, NC;9UNC Project, Lilongwe, Malawi;10Division of Epidemiology and
Biostatistics, School of Public Health, University of Witwatersrand, Parktown, South Africa; and11U.S. Centers for Disease Control and
Prevention, Atlanta, GA
The Breastfeeding, Antiretrovirals,and Nutrition(BAN)Study randomized HIV-infected mothers and theirinfantsto receive
either maternal lipid-based nutrient supplements (LNS) during lactation or no LNS and then to 1 of 3 antiretroviral drug
(ARV) arms (maternal, infant, or no drugs). Assigned interventions were provided from 0 to 28 wk and all infants (n = 1619)
weregiven LNS during(24–28wk)and following (28–48wk)weaning.Thispaperassessesthefeasibilityof infant LNS asa
breastmilk replacement and uses longitudinal random effects models to examine associations of interventions, morbidity,
and season with weight-for-age (WAZ), length-for-age (LAZ), and BMI-for-age (BMIZ) Z-scores from 24 to 48 wk. Infant
LNS adherence was high (94.1% ate it daily). From 24 to 48 wk, mean WAZ (20.42 to 20.76 SD; P < 0.001) and LAZ
(20.93 to 21.56 SD; P < 0.001) steadily declined, whereas BMIZ remained >0 throughout. A higher LAZ was associated
with assignment to the maternal LNS arm (b50.19; P < 0.05). Lower WAZ and BMIZ were associated with seasonal food
insecurity (b520.08 and 20.09, respectively; both P < 0.001), fever (b520.07 and 20.13; both P < 0.001), diarrhea
(b520.19 and 20.23; both P < 0.001), and assignment to the infant ARV arm (b520.17 and 20.17; both P < 0.05). The
magnitude of the season and morbidity effects was small and BAN infants had higher weights and lengths than their
counterparts in the general population. High LNS adherence and the modest impact of morbidity on growth indicate that
LNS is a feasible breastmilk replacement for HIV-exposed infantsweaned early,but controlledtrials are needed to quantify
the effects of LNS on growth in this population.J. Nutr. 143: 701–707, 2013.
In resource-poor settings, breastfeeding is essential to promote
optimal infant growth and health. However, for HIV-infected
women, breastfeeding is associated with risk of mother-to-child
transmission (MTCT)12(1–4). Early weaning, particularly with
poor quality or unhygienically prepared complementary foods, may
contribute to growth faltering in HIV-exposed infants (5–11). Thus,
it is critical to find strategies that prevent MTCT and at the same
time promote healthy growth and development.
In most countries, health workers counsel HIV-infected mothers
about infant feeding based on international recommendations,
which have changed substantially during the last decade (12–14). In
4Supplemental Table 1 and Supplemental Figure 1 are availablefrom the ‘‘Online
Supporting Material’’ link in the online posting of the article and from the same
link in the online table of contents at http://jn.nutrition.org.
12Abbreviations used: AFASS, acceptable, feasible, affordable, sustainable, and
safe; ARV, antiretroviral drug; BAN, Breastfeeding, Antiretrovirals, and Nutrition;
BMIZ, BMI-for-age Z-score; C, control; DHS, Demographic and Health Survey;
iARV, infant antiretroviral drug; LAZ, length-for-age Z-score; LNS, lipid-based
nutrient supplements; mARV, maternal antiretroviral drug; mLNS, maternal
lipid-based nutrient supplements; mLNS-iARV, maternal lipid-based nutrient
supplements/infant antiretroviral drug; mLNS-mARV, maternal lipid-based nutrient
supplements/maternal antiretroviral drug MTCT, mother-to-child transmission;
WAZ, weight-for-age Z-score.
* To whom correspondence should be addressed. E-mail: firstname.lastname@example.org.
1The Breastfeeding, Antiretrovirals, and Nutrition Study was supported by
grants from the Prevention Research Centers Special Interest Project of the CDC
(SIP 13-01 U48-CCU409660-09, SIP 26-04 U48-DP000059-01, and SIP 22-09
U48-DP001944-01), the Bill and Melinda Gates Foundation (OPP53107), the
National Institute of Allergy and Infectious Diseases, the University of North
Carolina Center for AIDS Research (P30-AI50410), and the NIH Fogarty AIDS
International Training and Research Program (DHHS/NIH/FIC 2-D43 Tw01039-06
and R24 Tw00798; the American Recovery and Reinvestment Act). The
antiretrovirals used in the BAN study were donated by Abbott Laboratories,
Squibb. The Call to Action PMTCT program was supported by the Elizabeth Glaser
Pediatric AIDS Foundation, UNICEF, the World Food Program, the Malawi
Ministry of Health and Population, Johnson and Johnson, and the U.S. Agency
for International Development.
2Author disclosures: C. M. van der Horst received grant support from Abbott
Laboratories and GlaxoSmithKline. V. L. Flax, M. E. Bentley, C. S. Chasela, D.
Kayira, M. G. Hudgens, K. Z. Kacheche, C. Chavula, A. P. Kourtis, D. J. Jamieson,
and L. S. Adair, no conflicts of interest.
3The trial was registered at clinicaltrials.gov as NCT00164736.
ã 2013 American Society for Nutrition.
Manuscript received August 14, 2012. Initial review completed October 10, 2012. Revision accepted February 5, 2013.
First published online March 6, 2013; doi:10.3945/jn.112.168245.
by guest on December 21, 2015
Supplemental Material can be found at:
2003, the WHO advised that HIV-infected mothers exclusively
breastfeed for the first months of life and rapidly wean their infants
as soon as replacement feeding was acceptable, feasible, affordable,
sustainable, and safe (AFASS) (13). Within a few years, it was
survival (15). These data prompted WHO to recommend in 2007
that HIV-infected women exclusively breastfeed for 6 mo and
continue breastfeeding after 6 mo unless replacement feeding was
AFASS (16). Additional studies showed that HIV-exposed infants
weaned early sustained higher rates of diarrheal morbidity and
mortality over time and were more likely to be underweight than
those who were breastfed longer (5–11,17,18). These data, together
with evidence that antiretroviral drugs (ARV) prevent HIV trans-
mission through breastmilk (3), led to the recommendation in 2010
that HIV-infected women exclusively breastfeed for 6 mo and
continue breastfeeding to 12 mo when ARVs are available (12).
The Breastfeeding, Antiretrovirals, and Nutrition (BAN) Study
was designed in the context of the 2003 HIV and infant feeding
recommendations. HIV-infected mothers and their infants were
randomized at delivery to receive either maternal nutrition supple-
ARV arms (maternal, infant, or no drugs). The randomized
interventions were provided from 0 to 28 wk. Mothers in the
BAN Study were counseled to exclusively breastfeed for 24 wk
then wean their infants within 4 wk (19). To address the
possibility of inadequate feeding following weaning (20), all
infants were provided with lipid-based nutrient supplements
(LNS) from 24 to 48 wk of age. LNS are ready-to-use foods
typically composed of peanut butter, milk powder, sugar,
vegetable oil, and micronutrients. They have been successfully
used for community-based care of children with severe and
moderate acute malnutrition (21,22) and there is evidence that
they promote child growth and development (23,24). LNS are
attractive for infant feeding in low-resource settings, because
they require no preparation, can be fed to the child directly, and
do not support bacterial growth (25). To our knowledge, LNS
have not previously been used as a breastmilk replacement for
HIV-exposed infants during the second half of infancy.
In many low-income countries, adherence to the current
WHO recommendations may be challenging due to inconsistent
availability and accessibility of ARVs, and maternal decisions
about infant feeding do not always conform to recommenda-
tions (26–29). Therefore, it remains important to understand
what types of strategies maintain growth and limit morbidity of
HIV-exposed infants once semi-solid and solid foods are
introduced. The use of LNS as a breastmilk replacement during
the second half of infancy could serve this purpose.
The main aims of this research were to: 1) describe infant
growth patterns from 24 to 48 wk, when LNS was given as a
breastmilk replacement; 2) identify factors that potentially
influence growth in weaned, HIV-exposed infants during the
second 6 mo of life, with a focus on morbidity, season, and
residual effects of interventions provided from 0 to 28 wk; and
3) determine if the use of LNS as a breastmilk replacement is
feasible by examining data on adherence and growth. Because
all BAN infants received LNS from 24–48 wk, we compared the
growth of study infants with that of infants of the same age in
the Malawi Demographic and Health Survey (DHS).
The BAN Study recruited HIV-1-infected, pregnant women at antenatal
clinics in Lilongwe, Malawi. The eligibility criteria have been described
in detail elsewhere (3). Briefly, at screening, mothers had CD4+ count
$250 cells/mm3, hemoglobin $70 g/L, and no prior ARV use. Infants
had a birth weight $2 kg and were excluded if they were HIV-positive
within the first 2 wk after delivery [infant HIV testing procedures
described in (30)].
Ethical approval for the study was obtained from the Malawi
National Health Science Research Committee and the institutional
review boards at the University of North Carolina at Chapel Hill and the
Following delivery, eligible mother-infant pairs were randomized using a 2 3
3factorialdesignto 1of 6studyarms:maternalLNS/maternalARV(mLNS-
mARV), maternal ARV (mARV), maternal LNS/infant ARV (mLNS-iARV),
infant ARV (iARV), maternal LNS (mLNS), or control (C). The maternal
nutrition intervention was given in the form of 140 g/d of LNS designed to
meet the energy, micronutrient, and protein needs of lactation (Supplemental
Table 1). The mARV intervention consisted of a multi-drug, highly active
regimen, while infants received daily oral nevirapine. Assigned interventions
began at birth and continued through 28 wk.
The present analysis uses data from 24 to 48 wk, during (24–28 wk)
and after weaning (28–48 wk). All infants initially received 75 g/d of
LNS startingat24wk andthe quantityincreased to100 g/d asthe infants
grew. The LNS was supplied by3 local producers (Rab Processors, Project
Peanut Butter, and Valid International). The LNS made by Rab
Processors contained sugar, peanut paste, soy milk powder, soy oil, soy
protein, vitamins and minerals, and vanilla flavor. A total of ~28 infants
(<2%) received this version of LNS for $1 mo. The study discontinued
use of Rab?s LNS in May 2005. The majority of BAN infants received
LNS made by Project Peanut Butter and Valid International using
Nutriset?s recipe containing groundnuts, dried full-cream milk, vegetable
oil, sugar, and vitamin-mineral premix. A 100 g/d LNS ration provided
2300 kJ, 15 g protein, and at least the recommended daily amount of 22
vitaminsandminerals(Supplemental Table1). Infantswere givenLNS to
replace the energy and nutrients they would have received from
breastmilk. Mothers were advised to feed their infants plain LNS from
a spoon to ensure adequate intake. They were also counseled to feed the
infant enriched porridge in addition to LNS and to increase portion size,
feeding frequency, and the variety of foods with age. To offset LNS
sharing, all BAN-enrolled women were given 2 kg/wk of maize flour for
family consumption throughout their participation in the study.
Study procedures and variable definition
Study visits and data collection took place at the BAN clinic at Bwaila
Hospital in Lilongwe, Malawi. Infant weight and recumbent length were
measured at 0, 24, 28, 32, 36, 42, and 48 wk using Tanita digital infant
scales (0.1 g increment) and length boards made to UNICEF specifica-
tions (0.1 cm increment) (31). Z-scores were calculated using the WHO
growth standards (32). Faltering was defined as a decrease in
Z-score >0.67 from 24 to 48 wk (33,34).
Infant morbidity data were collected at every study visit. Mothers
were asked if the infant had specific symptoms, clinical events, or
hospitalizations since the last study visit. If the infant was reported to
have been ill, a checklist was used to obtain details of the illness from the
mother and all reports of morbidity were recorded regardless of
duration. In addition, the infant was examined by a clinician. For the
present analysis, we focused on 2 types of infant morbidity: fever and
diarrhea. Fever and diarrhea variables were created based on both the
maternal report of illness and the clinician?s physical examination, so
they represent current illness and illness since the last visit.
Mothers reported on infant adherence to LNS use at 32, 42, and
48 wk. They were asked how often they fed the infant the recommended
amount of LNS since their last study visit: never, sometimes (1–3 d/wk),
often (4–6 d/wk), and always (7 d/wk). Information on mixed feeding
and breastfeeding cessation since the last study visit was obtained by
maternal report starting at 8 wk. Using the breastfeeding cessation data,
we created a variable with 3 categories: stopped before 24 wk, stopped
between 24 and 28 wk, and stopped after 28 wk.
Socioeconomic data were obtained from mothers during screening.
The annualperiod of food insecurity occurs during the rainy season from
702 Flax et al.
by guest on December 21, 2015
mid-December to mid-April. Seasonal food insecurity was coded as none
(<25%), partial (25–75%), or all (>75%) based on the estimatednumber
of rainy season days between the current and previous study visit.
Randomized infants were included in the analysis sample if they were
singletons and had at least one anthropometric measurement from 24 to
48 wk. Measurements were included until infants were confirmed to be
HIVinfected. Of2369 infants enrolled at birth,2320 were singletons. Of
the 1710 infants remaining in the sample at 24 wk, 1619 had at least one
measurement from 24 to 48 wk as well as data on all covariates and were
included in the longitudinal analysis of weight-for-age Z-score (WAZ).
There were no significant differences in socio-demographic characteris-
tics of the randomized sample of singleton births and the sample of
infants included in the WAZ analysis. Slightly fewer participants were
included in the length-for-age Z-score (LAZ) (n = 1609) and BMI-for-age
Z-score (BMIZ) (n = 1607) models due to missing length values.
Descriptive analyses. Descriptive data on BAN infants were compared
using paired t tests for means and x2tests for proportions. Z-scores for
infants in the Malawi DHS were recalculated using the WHO growth
standard and proportions of infants who were underweight, stunted, or
had low BMIZ were calculated using sample weights to account for the
survey design. The proportions of BAN and DHS infants were compared
and P values were calculated using the Pearson x2statistic corrected for
the survey design.
The proportion of infants with current or reported fever or diarrhea
was calculated for each study visit and for two 12-wk periods (>24–36
and >36–48 wk). We examined sex differences in morbidity across the
12-wk periods as a possible explanation for sex differences in growth.
Statistical analyses were carried out using Stata 11.2. Statistical tests
were considered significant at the a = 0.05 level. Values in the text are
means or proportions.
Modeling of growth patterns. Longitudinal random effects models
were used to quantify the association of potential determinants of
growth with infant WAZ, LAZ, and BMIZ, controlling for correspond-
ing birth Z-score and study visit. We considered these time-varying
(season, fever, diarrhea, and infant LNS adherence) and non-time–
varying (treatment arm, maternal height, maternal education, maternal
age, first birth, mother?s CD4+ count at 24 wk, timing of breastfeeding
cessation, and infant sex) predictor variables for inclusion in the models.
Final models included variables significant at the a = 0.10 level or those
shown in previous studies to have an important relationship with
growth. We found no significant interaction between treatment arm and
study visit. To characterize the impact of season and morbidity variables
in the models, we compared the overall means for WAZ, LAZ, and
BMIZ that were estimated from the fitted longitudinal models with the
means predicted for a hypothetical population with no food insecurity or
with no fever or diarrhea.
The background characteristics of mothers and infants included
in the analysis are shown in Table 1. Reported infant LNS
adherence was high, with 94.1% consuming LNS 7 d/wk and
3.5% eating LNS 4–6 d/wk.
Infants? WAZ and LAZ were less than the WHO median and
decreased throughout the analysis period (Fig. 1). From 24 to 48
wk, mean infant WAZ (20.42 to 20.76 SD; P < 0.001) and LAZ
(20.93 to 21.56 SD; P < 0.001) declined; 27.1 and 46.6%
faltered in WAZ and LAZ, respectively. BMIZ was slightly
greater than the WHO median from 24 to 48 wk and did not
differ from the beginning to the end of the analysis period (0.16
to 0.21 SD; P = 0.30).
The proportion of BAN infants who were underweight or
stunted increased at each visit, whereas the proportion with low
BMIZ was stable throughout the study period (Table 2). The
proportion of BAN infants who were underweight, stunted, or
had low BMIZ was significantly lower at all visits than for
infants of similar age in the Malawi DHS, with the exception of
underweight at 28 and 48 wk.
The proportion of infants with fever (13–18%) or diarrhea
(7–16%) increased from 24 to 32 wk (Supplemental Fig. 1).
Dividing the 24–48 wk period into two 12-wk segments, 37% of
infants had fever and 33% had diarrhea from >24 to 36 wk and
32% had fever and 31% had diarrhea from >36 to 48 wk.
Diarrhea wasmore common inboys (35%) than girls (30%) (P <
0.05) from >24 to 36 wk, but there was no significant difference
in diarrhea by sex from >36 to 48 wk and boys and girls did not
differ in fever during either 12-wk segment.
Longitudinal models indicated that fever, diarrhea, seasonal
food insecurity, and assignment to the iARV study arm were
negatively associated with WAZ and BMIZ, but not with LAZ
(Table 3). Assignment to the mLNS study arm was positively
associated with LAZ. Female sex, higher maternal education,
and greater maternal height were also positively associated with
WAZ and LAZ. Greater maternal height was positively associ-
ated with BMIZ.
To put the effects of seasonal food insecurity, fever, and
diarrhea on growth in perspective, we compared the overall
WAZ analysis sample1
Characteristics of mother-infant pairs included in the
WAZ analysis sample
(n = 1619)
Age at screening, y
Education beyond primary school, %
First birth, %
BMI ,18.5, %
BMI .25, %
Female sex, %
26.5 6 5.1
156.9 6 5.5
20.55 6 0.88
20.75 6 1.01
20.36 6 1.08
1Values are means 6 SDs or percent. BMIZ, BMI-for-age Z-score; LAZ, length-for-age
Z-score; WAZ, weight-for-age Z-score.
participating in the BAN Study. BMIZ, BMI-for-age Z-score; LAZ,
length-for-age Z-score; WAZ, weight-for-age Z-score.
Mean WAZ, LAZ, and BMIZ from 24–48 wk of infants
Feasibility of lipid-based nutrient supplements703
by guest on December 21, 2015
means estimated from the longitudinal models with those
predicted under specified conditions. At any given study visit,
infants with no fever or diarrhea would have gained 0.024–
0.048 SD for WAZ, 0.0005–0.002 SD for LAZ, and 0.034–
0.066 SD for BMIZ when compared with infants in our sample.
Likewise, infants with no seasonal food insecurity would have
gained 0.008–0.017 SD at any given study visit across all 3
The BAN Study recommended weaning at 6 mo to protect HIV-
exposed, uninfected infants from HIV transmission through
breastmilk. In an effort to limit morbidity and ensure adequate
dietary intake, infants were provided with LNS as a breastmilk
replacement from 24 to 48 wk of age. BAN infants had modest
increases in reported cases of diarrhea and fever during and after
weaning. Morbidity, particularly diarrhea, and season were
negatively associated with WAZ and BMIZ as was assignment to
the iARV arm. Assignment to the mLNS arm was positively
associated with linear growth. The proportion of BAN infants
who were underweight or stunted steadily increased from the
time of weaning to the end of the study, but these proportions
were consistently lower than those of the general population of
Malawian infants (35).
Previous research indicates that early breastfeeding cessation
is associated with increased diarrheal morbidity and mortality
(5,10,11) as well as growth faltering (17) in HIV-exposed
infants, but the relationship between morbidity and growth has
not been widely studied in this population. Our finding that
diarrhea was negatively associated with growth is consistent
with studies of children in sub-Saharan Africa who were not
HIV exposed (36–40) and with the results of a study in HIV-
exposed Tanzanian children showing an association between
diarrhea and weight-for-length (41). Despite the negative asso-
ciation of diarrhea with growth, we found the magnitude of
these effects was small in our sample. In addition, prevalence of
any diarrhea in BAN infants was lower for similar time periods
than among Zambian HIV-exposed infants who were weaned at
4 mo (43% at 7–9 mo and 44% at 10–12 mo) as well as those
who were still breastfed (38% at 7–9 mo and 39% at 10–12 mo)
(5). This could be attributable in part to the provision of LNS
(which is resistant to bacteriologic growth) as a breastmilk
replacement or to the counseling on replacement feeding
practices provided by the study (19,42).
The general pattern of growth faltering in BAN infants from
24 to 48 wk is similar to studies in mainly HIV-unexposed
infants in Malawi (43,44) and HIV-exposed infants in Malawi
(6), Zambia (17), and Kenya (45). BAN infants did not grow as
well as another group of HIV-exposed Zambian infants who
were breastfed at their mothers? discretion and who had very
little change in WAZ and small declines in LAZ from 6 to 12 mo
(18). BAN infants had similar declines in LAZ but smaller
declines in WAZ than HIV-exposed cohorts in Malawi and
Zambia (6,17), even compared with infants in these studies who
were breastfed for longer. Rapid decreases in LAZ and slower
decreases in WAZ from 6 to 18 mo resulting in weight-for-length
or BMI-for-age Z-scores above the median have been noted in
studies in Malawi (6,43) as has the more frequent occurrence of
stunting in boys (6,44,46).
The delayed effects of randomized interventions provided to
mothers and infants from 0 to 28 wk on the growth of infants
from 24 to 48 wk could potentially have important public health
implications. We previously reported that assignment to the
iARV and mARV arms was associated with lower weight and
BMI inBAN infants starting at 12–18 wk, but that assignment to
mLNS did not influence growth from 0 to 24 wk (30). Lower
WAZ and BMIZ during the second half of infancy indicate that
the effect of the infant ARV on growth continued even after its
use ended. To our knowledge, there are no comparable studies
examining the effect of ARVexposure from birth to 6 mo on the
growth of uninfected infants during the first year of life. A study
in Botswana found that infants with exposure to highly active
antiretroviral therapy in utero andthrough breastmilkhad lower
LAZ than infants exposed to zidovudine up to 6 mo of age (47).
The results of the Botswana analysis together with those from
the BAN Study suggest that some types of ARVs used for
prevention of MTCT may have a small negative effect on
growth. As was previously recommended, longer cohort studies
are needed to better understand the impact of ARVs on HIV-
exposed, uninfected children (48).
The postintervention effect of mLNS provided from 0 to 28
wk on infant LAZ during the second half of infancy is consistent
with a study showing that the effects of LNS on WAZ and LAZ
continued after the intervention ended (49). The delayed LNS
effect could be explained by better infant micronutrient status or
fatty acid profile at 24 wk compared with infants whose mothers
did not receive the supplement. It is notable that only those
infants who were not exposed to maternal or infant ARV
benefitted from mLNS, suggesting that the drugs limited the
supplements? impact on growth.
The main limitation of this study was the lack of a
comparison group, because all BAN infants received LNS from
24 to 48 wk. Comparing the growth of BAN infants to Malawi
infants compared with Malawi DHS (35)1
Underweight, stunting, and low BMIZ in BAN Study
BAN Malawi DHS 2004
Underweight infants (WAZ , 22 SD)
Stunted infants (LAZ , 22 SD)
Infants with low BMIZ (, 22 SD)
1Values are the number of underweight, stunted, or low BMI infants divided by the
total sample and the proportion at each time point. Asterisks indicate the level of
significance when proportions in BAN and DHS infants were compared: *P , 0.05,
**P , 0.01, ***P , 0.001. BAN, Breastfeeding, Antiretrovirals, and Nutrition; BMIZ,
BMI-for-age Z-score; DHS, Demographic and Health Survey; LAZ, length-for-age Z-
score; WAZ, weight-for-age Z-score.
704Flax et al.
by guest on December 21, 2015
DHS or other studies of HIV-exposed children supplies context
but does not allow us to determine the causes of the observed
growth patterns. There are differences between the BAN and
DHS samples. A large proportion of the infants in the Malawi
DHS were from rural areas, where growth is typically poorer
than in urban areas (35), where BAN infants lived. However, all
BAN infants were HIV exposed and fully weaned from
breastmilk as opposed to infants in the DHS who were still
breastfed and few of whom were HIV exposed. The lower
proportion of faltering infants in the BAN Study compared with
those in the DHS may be attributed to their participation in the
study, where supplementary food, regular health care, and
counseling on feeding practices were provided. Large beneficial
effects of study participation on the growth of HIV-exposed and
-unexposed children have previously been noted (18).
In conclusion, although the growth of BAN infants progres-
sively faltered during the second half of infancy, their levels of
morbidity were lower and their growth faltered less than those
of other HIV-exposed populations who were weaned early (5)
and were provided with milk- or cereal-based weaning supple-
ments (17,20). These findings, together with high levels of LNS
adherence, indicate that use of LNS as a breastmilk replacement
was feasible in the full BAN sample, as previously documented
in a small subsample (42). The results of the present study are
applicable in the current prevention of MTCT environment,
because ARVs are not universally available and some HIV-
infected mothers continue to wean early even when AFASS
conditions are not met. In addition, LNS could potentially
contribute to making conditions AFASS in settings with poor
hygiene. This role for LNS could be assessed as part of a
controlled trial designed to test whether LNS limits morbidity
and promotes growth in HIV-exposed children after weaning.
The authors are grateful to the following: BAN Study Team at
University of North Carolina Chapel Hill, CDC, Atlanta, and UNC
Project team in Lilongwe including: Linda Adair, Yusuf Ahmed,
Mounir Ait-Khaled, Sandra Albrecht, Shrikant Bangdiwala, Ronald
Bayer, Margaret Bentley, Brian Bramson, Emily Bobrow, Nicola
Boyle, Sal Butera, Charles Chasela, Charity Chavula, Joseph
Chimerang?ambe, Maggie Chigwenembe, Maria Chikasema, Norah
Chikhungu, David Chilongozi, Grace Chiudzu, Lenesi Chome,
Anne Cole, Amanda Corbett, Amy Corneli, Anna Dow, Ann
Duerr, Henry Eliya, Sascha Ellington, Joseph Eron, Sherry Farr,
Yvonne Owens Ferguson, Susan Fiscus, Valerie Flax, Ali Fokar,
Shannon Galvin, Laura Guay, Chad Heilig, Irving Hoffman,
Elizabeth Hooten, Mina Hosseinipour, Michael Hudgens, Stacy
Hurst, Lisa Hyde, Denise Jamieson, George Joaki (deceased),
David Jones, Elizabeth Jordan-Bell, Zebrone Kacheche, Esmie
Kamanga, Gift Kamanga, Coxcilly Kampani, Portia Kamthunzi,
Deborah Kamwendo, Cecilia Kanyama, Angela Kashuba, Damson
Kathyola, Dumbani Kayira, Peter Kazembe, Caroline C. King,
Rodney Knight, Athena P. Kourtis, Robert Krysiak, Jacob
Kumwenda, Hana Lee, Edde Loeliger, Dustin Long, Misheck
Luhanga, Victor Madhlopa, Maganizo Majawa, Alice Maida,
Cheryl Marcus, Francis Martinson, Navdeep Thoofer, Chrissie
Longitudinal models showing factors associated with infant WAZ, LAZ, and BMIZ from 24–48 wk1
n = 1619n = 1609n = 1607
Coefficient95% CI Coefficient95% CI Coefficient95% CI
Seasonal food insecurity since last visit (ref: none)
Treatment arm (ref: C)
Infant sex (ref: male)
Maternal education (ref: primary or less)
Maternal age at screening
Corresponding anthropometric Z-score at birth
Study visit (ref: 24 wk), wk
1Columns represent growth outcomes (WAZ, LAZ, and BMIZ) and rows are covariates included in the model. For continuous covariates (such as age), the coefficients are slopes,
while for indicator variables (such as mLNS), the coefficients are intercepts. *P , 0.05, **P , 0.01, ***P , 0.001. BMIZ, BMI-for-age Z-score; C, control; iARV, infant antiretroviral
drug; LAZ, length-for-age Z-score; mARV, maternal antiretroviral drug; mLNS, maternal lipid-based nutrient supplements; mLNS-mARV, maternal lipid-based nutrient supplements,
maternal antiretroviral drug; mLNS-iARV, maternal lipid-based nutrient supplements, infant antiretroviral drug; WAZ, weight-for-age Z-score.
Feasibility of lipid-based nutrient supplements705
by guest on December 21, 2015
Matiki (deceased), Douglas Mayers, Isabel Mayuni, Marita
McDonough, Joyce Meme, Ceppie Merry, Khama Mita,
Chimwemwe Mkomawanthu, Gertrude Mndala, Ibrahim
Mndala, Agnes Moses, Albans Msika, Wezi Msungama,
Beatrice Mtimuni, Jane Muita, Noel Mumba, Bonface Musis,
Charles Mwansambo, Gerald Mwapasa, Jacqueline Nkhoma,
Megan Parker, Richard Pendame, Ellen Piwoz, Byron Raines,
Zane Ramdas, John Rublein, Mairin Ryan, Ian Sanne,
Christopher Sellers, Diane Shugars, Dorothy Sichali, Wendy
Snowden, Alice Soko, Allison Spensley, Jean-Marc Steens,
Gerald Tegha, Martin Tembo, Roshan Thomas, Hsiao-Chuan
Tien, Beth Tohill, Charles van der Horst, Esther Waalberg,
Elizabeth Widen, Jeffrey Wiener, Cathy Wilfert, Patricia Wiyo,
Innocent Zgambo, and Chifundo Zimba. M.E.B., C.S.C., D.K.,
M.G.H., K.Z.K., C.C., A.P.K., D.J.J., C.M.v.d.H., and L.S.A.
designed and conducted the study; V.L.F. and L.S.A. carried out
the analysis; and V.L.F. wrote the paper and had primary
responsibility for the final content. All authors read and approved
the final manuscript.
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