Abstract
BackgroundEmpirical data showing the clear benefits of exclusive breastfeeding (EBF) for HIV prevention are needed to encourage implementation of lactation support programs for HIV-infected women in low resource settings among whom replacement feeding is unsafe. We conducted a prospective, observational study in Lusaka, Zambia, to test the hypothesis that EBF is associated with a lower risk of postnatal HIV transmission than non-EBF.Methods and ResultsAs part of a randomized trial of early weaning, 958 HIV-infected women and their infants were recruited and all were encouraged to breastfeed exclusively to 4 months. Single-dose nevirapine was provided to prevent transmission. Regular samples were collected from infants to 24 months of age and tested by PCR. Detailed measurements of actual feeding behaviors were collected to examine, in an observational analysis, associations between feeding practices and postnatal HIV transmission. Uptake of EBF was high with 84% of women reporting only EBF cumulatively to 4 months. Post-natal HIV transmission before 4 months was significantly lower (p = 0.004) among EBF (0.040 95% CI: 0.024–0.055) than non-EBF infants (0.102 95% CI: 0.047–0.157); time-dependent Relative Hazard (RH) of transmission due to non-EBF = 3.48 (95% CI: 1.71–7.08). There were no significant differences in the severity of disease between EBF and non-EBF mothers and the association remained significant (RH = 2.68 95% CI: 1.28–5.62) after adjusting for maternal CD4 count, plasma viral load, syphilis screening results and low birth weight.ConclusionsNon-EBF more than doubles the risk of early postnatal HIV transmission. Programs to support EBF should be expanded universally in low resource settings. EBF is an affordable, feasible, acceptable, safe and sustainable practice that also reduces HIV transmission providing HIV-infected women with a means to protect their children's lives.Trial RegistrationClinicalTrials.gov NCT00310726
Highlights
Promotion of exclusive breastfeeding (EBF) has been a cornerstone of public health measures to promote child survival for several decades [1,2]
We improved on previous studies by including: more frequent measurements of the infants’ HIV status to more accurately determine the timing of transmission; detailed questionnaires about feeding practices including 24 hour recall and feeding history corroborated with counselors’ assessments; and collection of data necessary to make statistical adjustments for possible confounding by major risk factors for HIV transmission, namely maternal CD4 count and viral load
Cox Proportional Hazards models were used to investigate confounding as follows: characteristics were screened as potentially associated with postnatal transmission to 4 months, those associated with transmission (p,0.10) were included one-byone with non-EBF and if either significantly associated with transmission (p,0.05) or if they changed the estimate of the relative hazard (RH) associated with non-EBF by .10% were retained
Summary
Promotion of exclusive breastfeeding (EBF) has been a cornerstone of public health measures to promote child survival for several decades [1,2]. EBF facilitates normal physiological regulation of milk production, which depends on regular infant suckling, allowing for a healthy balance between the infant’s needs and the amount of milk produced [7] This regulation helps prevent milk stasis that underlies the development of mastitis and other breast problems [8] thereby being the healthiest practice for both mothers and infants. Empirical data showing the clear benefits of exclusive breastfeeding (EBF) for HIV prevention are needed to encourage implementation of lactation support programs for HIV-infected women in low resource settings among whom replacement feeding is unsafe. Observational study in Lusaka, Zambia, to test the hypothesis that EBF is associated with a lower risk of postnatal HIV transmission than non-EBF.
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