Research Article: HIV-free survival and morbidity among formula-fed infants in a prevention of mother-to-child transmission of HIV program in rural Haiti

Date Published: October 12, 2011

Publisher: BioMed Central

Author(s): Louise C Ivers, Sasha C Appleton, Bingxia Wang, J Gregory Jerome, Kimberly A Cullen, Mary C Smith Fawzi.


Partners In Health (PIH) works with the Ministry of Health to provide comprehensive health services in Haiti. Between 1994 and 2009, PIH recommended exclusive formula feeding in the prevention of mother-to-child transmission (PMTCT) of HIV program and provided support to implement this strategy. We conducted this study to assess HIV-free survival and prevalence of diarrhea and malnutrition among infants in our PMTCT program in rural Haiti where exclusive formula feeding was supported.

We reviewed medical charts of PMTCT mother-infant pairs at PIH between November 2004 and August 2006 through a retrospective longitudinal study and cross-sectional survey. We performed household surveys for each pair and at control households matched by infant’s age and gender.

254 mother-infant pairs were included. 15.3% of infants were low birth weight; most births occurred at home (68.8%). 55.9% of households had no latrine; food insecurity was high (mean score of 18; scale 0-27, SD = 5.3). HIV-free survival at 18 months was 90.6%. Within the cohort, 9 children (3.5%) were HIV-infected and 17 (6.7%) died. Community controls were more likely to be breastfed (P = 0.003) and more likely to introduce food early (P = 0.003) than PMTCT-program households. There was no difference in moderate malnutrition (Z score ≤ 2 SD) between PMTCT and community groups after controlling for guardian’s education, marital status, and food insecurity (OR = 1.05; 95% CI: 0.67, 1.64; P = 0.84). Diarrhea was 2.9 times more prevalent among community children than PMTCT infants (30.3% vs. 12.2%; P < 0.0001). In a PIH-supported program in rural Haiti that addressed socioeconomic barriers to ill-health, breast milk substitution was safe, acceptable and feasible for PMTCT for HIV-infected women choosing this option.

Partial Text

It is estimated that more than 33.3 million people are living with HIV/AIDS worldwide, 2.5 million of whom are children [1]. The majority of these HIV-infected children are infected through mother-to-child transmission. Infants born to HIV-infected mothers are at risk for acquiring HIV infection in utero, at parturition, and in early life through breast milk. Although antiretroviral therapy (ART) during breastfeeding can substantially reduce the risk of transmission [2], avoidance of breastfeeding remains the only way to ensure prevention of mother-to-child transmission of HIV postnatally. In resource-rich settings, universal HIV testing and counseling, ART, and complete avoidance of breastfeeding have reduced of the risk of mother-to-child transmission to less than 2% [3]. Recent studies from Botswana and Kenya have demonstrated efficacy of the strategy that continues ART during breastfeeding, reducing the risk of transmission to 1.1% and 4.2% at 1 and 6 months, respectively [4]. However, both studies have also shown some remaining risk of HIV transmission during breastfeeding, albeit small [5].

From November 1, 2004 to August 31, 2006, 351 HIV-positive women and their infants presented for care at Zanmi Lasante (Figure 1). Mothers who presented after delivery (N = 91) were ineligible for inclusion in the study. A total of 260 mothers were enrolled in the PMTCT program. After excluding the second infant in 6 sets of twins, there was an effective sample size of 254 mother-infant pairs.

National guidelines for infant feeding in the context of HIV in Haiti are under revision at the time of writing this manuscript, influenced appropriately by the new WHO guidelines [23]. In the context of informing mothers with HIV infection about infant feeding alternatives, we report in this study on the safety of non-breastfeeding for HIV-infected mothers enrolled in a comprehensive PMTCT program in rural Haiti.

3TC: Lamivudine; ART: Antiretroviral Therapy; AZT: Azidothymidine; CI: Confidence Interval; HIV: Human Immunodeficiency Virus; NVP: Nevirapine; PMTCT: Prevention of Mother-to-Child Transmission; SD: Standard Deviation; WHO: World Health Organization; ZL: Zanmi Lasante.

The authors declare that they have no competing interests.

All authors contributed to design of the study. LCI, SCA and JGJ coordinated data collection. BW and MSF performed the statistical analysis. BW, MSF, KAC and LCI helped to draft the initial manuscript. All authors read and approved the final manuscript.