Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission: ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d'Ivoire

doi:10.1016/j.ypmed.2007.11.014

Preventive Medicine

Volume 47, Issue 1, July 2008, Pages 27-33

https://doi.org/10.1016/j.ypmed.2007.11.014 Get rights and content

Abstract

Objective.

To evaluate the risk of postnatal HIV transmission among women in Abidjan, Côte d'Ivoire offered alternatives to prolonged breastfeeding, and to assess the impact of the breastfeeding pattern and duration on this risk.

Methods.

In 2001–2003, HIV-infected pregnant women received peri-partum antiretroviral prophylaxis and were counselled antenatally regarding infant feeding options: formula feeding or exclusive breastfeeding with early cessation from 4 months of age. The primary outcome was HIV postnatal transmission by 18 months of age, defined by a positive HIV test after a negative test ≥ 30 days. The effect of the pattern (mixed feeding, defined as breastmilk plus food-based fluid, solid food or non-human milk) and duration (less vs. more than 6 months) of breastfeeding on postnatal transmission was assessed.

Results.

Of 622 live-born infants who were HIV uninfected at or after 30 days, 15 were infected postnatally, 13/324 among breastfed, and 2/298 among formula-fed infants. The 18-month probability of remaining free from HIV infection was 0.95 [95% CI, 0.92–0.97] and 0.99 [95% CI, 0.97–1.00] in the breastfeeding and formula-feeding groups respectively (p < 0.001). In adjusted analysis, breastfeeding for more than 6 months and mixed feeding during the first month of life were independently associated with a 7.5 (AOR 95% CI, 2.0–28.2, p = 0.003)- and a 6.3 (95% CI, 1.1–36.4, p = 0.04)-fold increase of postnatal transmission among breastfed children.

Conclusions.

Mixed feeding during the first month of life and breastfeeding beyond 6 months are strong determinants of HIV transmission and should be avoided when replacement feeding after breastfeeding cessation can be safely and sustainably provided.

Introduction

The efficacy of peri-partum antiretroviral regimens in preventing mother-to-child transmission of HIV around delivery has been demonstrated in Africa (Leroy et al., 2005). However, postnatal HIV transmission remains responsible for at least 40% of paediatric HIV infections in settings where prolonged breastfeeding is widely practised (Breastfeeding and HIV International Transmission Study Group (BHITS), 2004). Modifications of breastfeeding practices in terms of duration (complete avoidance of breastfeeding or early weaning) and pattern (promotion of exclusive breastfeeding) aim to reduce this risk (Becquet and Newell, 2007, Rollins et al., 2004). Although exclusive breastfeeding has been reported to carry a lower risk of postnatal HIV transmission than breastfeeding with introduction of other fluids, feeds or milk (Coovadia et al., 2007, Iliff et al., 2005), the effect of both breastfeeding pattern and duration on this risk has not yet been quantified.

The aim of this study was to evaluate the risk of postnatal HIV transmission among HIV-infected West African women counselled on alternatives to prolonged breastfeeding and to assess the effect of the breastfeeding pattern and duration on this risk.

Section snippets

Study design and follow-up procedures

The inclusion procedures and research design of the ANRS 1201/1202 Ditrame Plus study have been described in detail (Becquet et al., 2005b, Leroy et al., 2007). Briefly, this study was an open-labelled cohort, based on women attending any one of six community-run health facilities in Abidjan, Côte d'Ivoire. Between March 2001 and July 2003, pregnant women aged 18 years and over, diagnosed as HIV-infected within one of these selected facilities, were eligible for enrolment into the study. All

Results

Of the 808 HIV-infected pregnant women enrolled in the Ditrame Plus study, 34 with a non-confirmed HIV-1 status, or infected with HIV-2 only, were excluded, 44 were lost to follow-up before delivery, and 730 gave birth to 763 infants. Of these, 33 second- and third-born babies of multiple births and 19 stillbirths were excluded, as were 21 neonates not tested for HIV infection, 3 with unknown timing of infection, 42 infected in the peri-partum period, 2 with unknown mode of feeding and 21 with

Discussion

We have quantified the impact of modifying breastfeeding pattern and duration on the risk of postnatal HIV transmission. In our study, mixed feeding during the first month of life and breastfeeding beyond 6 months of age were strong independent risk factors for acquisition of HIV postnatally. These results are consistent with previously published studies from other African settings reporting the association between mixed feeding (Coovadia et al., 2007, Coutsoudis et al., 1999, Iliff et al., 2005

Conclusions

We have previously reported that, in this urban African setting, and with appropriate nutritional counselling and care, alternatives to prolonged breastfeeding were safe (Becquet et al., 2007), socially acceptable and feasible (Becquet et al., 2005b, Leroy et al., 2007), allowing optimal long-term effectiveness of peri-partum antiretroviral prophylaxis. We here show that this strategy also leads to low HIV postnatal transmission rates. Ideally, emphasis should now be placed on the provision of

Acknowledgments

The primary sponsor of the ANRS 1201/1202 Ditrame Plus study was the French Agence Nationale de Recherches sur le Sida (ANRS). Renaud Becquet was funded by the French charity SIDACTION as a visiting epidemiologist at the Africa Centre for Health and Population Studies (University of KwaZulu Natal, South Africa). Laurence Bequet was supported by the French Ministry of Foreign Affairs. Didier K. Ekouevi was a fellow at the European and Developing Countries Clinical Trial Partnership (EDCTP).

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Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission: ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d'Ivoire

Abstract

Objective.

Methods.

Results.

Conclusions.

Introduction

Section snippets

Study design and follow-up procedures

Results

Discussion

Conclusions

Acknowledgments

Lancet

Lancet

Lancet

Lancet, Infect Dis.

Lancet

Lancet

Estimating the efficacy of interventions to prevent mother-to-child transmission of HIV in breast-feeding populations: development of a consensus methodology

Stat. Med.

Estimating the efficacy of interventions to prevent mother-to-child transmission of human immunodeficiency virus in breastfeeding populations: comparing statistical methods

Am. J. Epidemiol.

Knowledge, attitudes, and beliefs of health care workers regarding alternatives to prolonged breast-feeding (ANRS 1201/1202, Ditrame Plus, Abidjan, Cote d'Ivoire)

J. Acquir. Immune Defic. Syndr.

Acceptability of exclusive breastfeeding with early cessation to prevent HIV transmission through breastmilk, ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d'Ivoire

J. Acquir. Immune Defic. Syndr.

Two-year morbidity-mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Côte d'Ivoire

PLoS Medicine

Prevention of postnatal HIV infection: infant feeding and antiretroviral interventions

Curr. Opin. HIV AIDS

Maternal recall of exclusive breast feeding duration

Arch. Dis. Child

Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis

J. Infect. Dis.

Preserving breastfeeding practice through the HIV pandemic

Trop. Med. Int. Health