Research Article: Two-Year Morbidity–Mortality and Alternatives to Prolonged Breast-Feeding among Children Born to HIV-Infected Mothers in Côte d’Ivoire

Date Published: January 16, 2007

Publisher: Public Library of Science

Author(s): Renaud Becquet, Laurence Bequet, Didier K Ekouevi, Ida Viho, Charlotte Sakarovitch, Patricia Fassinou, Gédéon Bedikou, Marguerite Timite-Konan, François Dabis, Valériane Leroy, Lynne Mofenson

Abstract: BackgroundLittle is known about the long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa.Methods and FindingsIn 2001–2005, HIV-infected pregnant women having received in Abidjan, Côte d’Ivoire, a peripartum antiretroviral prophylaxis were presented antenatally with infant feeding interventions: either artificial feeding, or exclusive breast-feeding and then early cessation from 4 mo of age. Nutritional counseling and clinical management were provided for 2 y. Breast-milk substitutes were provided for free. The primary outcome was the occurrence of adverse health outcomes in children, defined as validated morbid events (diarrhea, acute respiratory infections, or malnutrition) or severe events (hospitalization or death). Hazards ratios to compare formula-fed versus short-term breast-fed (reference) children were adjusted for confounders (baseline covariates and pediatric HIV status as a time-dependant covariate). The 18-mo mortality rates were also compared to those observed in the Ditrame historical trial, which was conducted at the same sites in 1995–1998, and in which long-term breast-feeding was practiced in the absence of any specific infant feeding intervention. Of the 557 live-born children, 262 (47%) were breast-fed for a median of 4 mo, whereas 295 were formula-fed. Over the 2-y follow-up period, 37% of the formula-fed and 34% of the short-term breast-fed children remained free from any adverse health outcome (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI], 0.87–1.38; p = 0.43). The 2-y probability of presenting with a severe event was the same among formula-fed (14%) and short-term breast-fed children (15%) (adjusted HR, 1.19; 95% CI, 0.75–1.91; p = 0.44). An overall 18-mo probability of survival of 96% was observed among both HIV-uninfected short-term and formula-fed children, which was similar to the 95% probability observed in the long-term breast-fed ones of the Ditrame trial.ConclusionsThe 2-y rates of adverse health outcomes were similar among short-term breast-fed and formula-fed children. Mortality rates did not differ significantly between these two groups and, after adjustment for pediatric HIV status, were similar to those observed among long-term breast-fed children. Given appropriate nutritional counseling and care, access to clean water, and a supply of breast-milk substitutes, these alternatives to prolonged breast-feeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.

Partial Text: In high human immunodeficiency virus (HIV) prevalence resource-constrained settings, HIV-infected pregnant women face a dilemma regarding the feeding practices of their forthcoming infant [1]. Indeed, in sub-Saharan Africa, where breast-feeding is widely practiced and usually prolonged at least 1 y after birth, the overall risk of HIV transmission through breast milk was estimated to be 8.9 new cases per 100 child-years of breast-feeding [2], and was thus responsible for 40% of perinatally acquired HIV infections [3]. On the other hand, in the absence of any specific nutritional counseling and adapted clinical management, nonbreast-fed children have a greater risk of dying from infectious diseases, especially early in infancy [4].

The ANRS 1202/1202 Ditrame Plus study was an open-labeled cohort, based on patients attending community-run health facilities in Abobo and Yopougon, the two most-densely populated districts of Abidjan, the economic capital of Côte d’Ivoire. In this setting, HIV prevalence was around 11% among pregnant women in 2002 [13], municipal water is of generally good quality [14], and breast-feeding is widely practiced long term [15,16].

The cohort profile from acceptance of HIV testing to enrollment in the Ditrame Plus study is described elsewhere [17,18]. Among the 643 HIV-infected pregnant women consecutively enrolled between March 2001 and March 2003, 19 with a nonconfirmed HIV-1 status, or infected with HIV-2 only, were excluded, 44 were lost to follow-up before delivery, and 580 gave birth to 612 children [18]. After exclusion of second- and third-born babies of multiple births, 580 mother–infant pairs were included in the present analysis. Of these, 11 (1.9%) were stillbirths, 11 (1.9%) died within the first 72 h of life without having received any food, and one (0.2%) was lost to follow-up before recording information on first feed. Among the 557 live-born children fed at least once, 295 (53%) constituted the formula-fed group and 262 (47%) the short-term breast-fed group.

In this large prospective cohort study, we found no difference in 2-y rates of adverse health outcomes between early weaned breast-fed and formula-fed children born to HIV-infected mothers. Moreover, the 2-y probabilities of remaining free from severe events (hospitalization or death) and from morbidity validated by an independent committee were comparable in these two groups. However, compared to short-term breast-fed children and after adjustment for potential confounders, the formula-fed ones had a slightly increased risk of diarrhea or acute respiratory infections, but this difference materialized into neither differences in malnutrition rates nor hospitalization or death rates.



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