Abstract
BackgroundWe sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival.MethodsInfant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival.ResultsSix hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%).ConclusionsAlthough feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.
Highlights
We sought to investigate infant feeding practices amongst Human Immunodeficiency Virus (HIV)-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival
Mixed breastfeeding (MBF) may be further classified into predominant breastfeeding and partial breastfeeding: Predominant breastfeeding (PredBF) means giving the infant breast milk and non-nutritive liquids Partial breastfeeding (ParBF) means feeding breast milk andnon-nutritive and nutritive liquids and solids
HIV-positive women lost to 36-week follow-up had more advanced disease [log viral load 3.9 copies/ml (SD 0.79) vs. 3.7 copies/ml (SD 0.65), p = 0.005], were poorer [socio-economic-score -1.51 (Q1-Q3: -1.96-1.51) vs. 0.158 (Q1-Q3: 1.39-1.45), p < 0.05] and had less social support (16% disclosed their HIV status vs. 53%, p < 0.0001) compared with positive women remaining in the study
Summary
We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival. Compared with exclusive breastfeeding (EBF), predominant (PredBF), partial (ParBF) or not breastfeeding (NBF) are associated with a higher mortality risk in general [RR and 95% CI: 1.48 (1.13, 1.92); 2.85 (1.59, 5.10) and 14.40 (6.09, 34.05), respectively at 0 to 5 months and 3.86 (1.49, 9.29) for NBF at 6 to 23 months)], from diarrhea [RR 2.28 (0.85, 6.11), 4.62 (1.81, 11.77), 10.53 (2.80, 39.64) respectively at 0 to 5 months and 2.83 (0.15, 54.82) for NBF 6 to 23 months)] and pneumonia [RR 1.75 (0.48, 6.43); 2.49 (1.03, 6.04); 15.13 (0.61, 373.84) respectively for 0 to 5 months and 1.52 (0.09, 27.06) for NBF 6 to 23 months] [1] Despite such benefits, breast milk (BF) can transmit HIV. On a population level universal coverage with EBF for six months, and continued breastfeeding up to one year may prevent 13% of under-five deaths globally, even in the context of HIV [8]
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