Date Published: January 16, 2007
Publisher: Public Library of Science
Author(s): Grace C John-Stewart
Partial Text: In this issue of PLoS Medicine, Renaud Becquet and colleagues report their findings from a new study looking at the long-term safety of infant feeding interventions aimed at reducing mother-to-child HIV transmission in Africa . Over two years, the researchers studied the safety of infant feeding interventions (either formula feeding or shortened breast-feeding) among infants of HIV-infected mothers in Abidjan, Côte d’Ivoire.
The authors chose to examine this issue because of the continued challenges faced by HIV-infected mothers regarding infant feeding. Breast-milk transmission of HIV contributes substantially to the risk of infant HIV infection; consequently HIV-infected mothers in Europe and the United States are counseled not to breast-feed their infants. However, avoiding breast-feeding or shortening the term of breast-feeding may be risky for infants in settings with inadequate sanitation, limited access to breast-milk substitutes, or unsafe water. Thus, UNAIDS (the Joint United Nations Programme on HIV/AIDS) recommends that HIV-infected women “replacement feed” their infants when it is acceptable, feasible, affordable, sustainable, and safe (“replacement feeding” is a term used to refer to feeding infants with milk other than breast milk, such as formula) .
The authors compared morbidity, hospitalization, and mortality over a two-year period among infants of HIV-infected women who had received peripartum antiretrovirals and elected to either breast-feed for four months or formula feed. In addition, the authors compared the infants in this cohort to infants in a historical cohort in the same setting with the same clinical and survival assessments who breast-fed for a prolonged duration.
These conclusions may be slightly provocative in 2007—replacement feeding has been abandoned in many African settings as a viable intervention for prevention of breast-milk HIV transmission. The authors provide good data to suggest that with appropriate provisos, replacement feeding can be a safe option to consider for HIV-infected mothers in urban African settings. Are these conclusions valid? Yes. The study has several strengths—the authors have conducted meticulous and robust analyses with large cohorts including a long period of follow-up. The authors had adequate retention and detailed morbidity assessment, and they included independent assessment of morbidity. The authors made use of a closely linked historical cohort in order to compare prolonged breast-feeding with shortened or no breast-feeding. While exclusive breast-feeding was not practiced by the majority of women in the cohort despite counseling to do so, the proportion of predominantly breast-feeding women was similar to other African cohorts promoting exclusive breast-feeding and probably reflects the reality of breast-feeding practices in similar settings . All in all, for a woman in Abidjan, the likelihood of having a baby neither acquire HIV nor die would be highest with peripartum antiretrovirals and no or limited breast-feeding.
Current research in prevention of breast-milk HIV transmission includes evaluation of a variety of approaches, including optimizing exclusive breast-feeding, providing antiretrovirals during shortened breast-feeding to mother or infant, and, ultimately, vaccination. Preserving breast-feeding is attractive because of nutritional, growth, safety, and confidentiality issues, and in the future these approaches may enable prolonged breast-feeding. However, some of the interventions currently under study may not be as promising as initially envisioned. For example, highly active antiretroviral therapy (HAART) during shortened breast-feeding is not the panacea hoped for—it may be associated with loss of confidentiality, toxicity, resistance, and infant morbidity and growth compromise when breast-feeding is stopped at six months. It is plausible that strategizing for not breast-feeding from birth would be less problematic than first starting to breast-feed on HAART, and then stopping after six months. Thus, replacement feeding should still be considered in the mix of strategies to prevent breast-milk transmission of HIV, particularly when water safety is assured and provision of breast-milk substitutes is an option. Becquet et al’s data are reassuring that when appropriate support is provided and clean water is available, replacement feeding can be safe in an urban African setting.