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, 369 (9567), 1107-16

Mother-to-child Transmission of HIV-1 Infection During Exclusive Breastfeeding in the First 6 Months of Life: An Intervention Cohort Study

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Mother-to-child Transmission of HIV-1 Infection During Exclusive Breastfeeding in the First 6 Months of Life: An Intervention Cohort Study

Hoosen M Coovadia et al. Lancet.

Abstract

Background: 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.

Methods: 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.

Findings: 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).

Interpretation: 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.

Comment in

  • Exclusive breastfeeding and HIV.
    Holmes WR, Savage F. Holmes WR, et al. Lancet. 2007 Mar 31;369(9567):1065-6. doi: 10.1016/S0140-6736(07)60505-4. Lancet. 2007. PMID: 17398292 No abstract available.
  • Breastfeeding and HIV transmission.
    Silverstein G. Silverstein G. Lancet. 2007 Jun 23;369(9579):2073; author reply 2073-4. doi: 10.1016/S0140-6736(07)60966-0. Lancet. 2007. PMID: 17586292 No abstract available.
  • Breastfeeding and HIV transmission.
    Henderson P, Martines J, Mason E. Henderson P, et al. Lancet. 2007 Jun 23;369(9579):2073; author reply 2073-4. doi: 10.1016/S0140-6736(07)60967-2. Lancet. 2007. PMID: 17586293 No abstract available.
  • Breastfeeding and HIV transmission.
    Saloojee H. Saloojee H. Lancet. 2007 Jun 23;369(9579):2074; author reply 2075. doi: 10.1016/S0140-6736(07)60969-6. Lancet. 2007. PMID: 17586294 No abstract available.

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