HIV and Breastfeeding

[Guest guest]

Should HIV-infected women in developing countries

breast-feed their infants?

There was much debate at the XIII International Conference on AIDS, held

in Durban, South

Africa, in July 2000, on the pros and cons of breast-feeding, and the

latest data emerging from the

various breast-feeding studies has divided opinion into 2 main camps.

First, there are those who

strongly believe in the benefits of exclusively breast-feeding infants

born to HIV-infected mothers.

The opposing camp remains wary of the dangers of HIV transmission

through breast milk and would

prefer to use formula feeds in these children. Most of the data

presented at the conference

supported one view or the other.

The controversy regarding feeding options for infants born to

HIV-positive mothers in poor

countries was sparked by a recent report in The Lancet by Coutsoudis and

colleagues, which

suggested that infants who were exclusively breast-fed had similar HIV

transmission rates to those

infants who received only formula feeds. New data on HIV transmission

rates at 15 months

continued to emphasize the superiority of exclusive breast-feeding over

mixed feeding (24.7% vs

35.5%, respectively), while concluding that there was no significant

difference in HIV transmission

rates between infants exclusively breast-fed and infants given formula

(24.7% vs 19.4%). Dr.

Coutsoudis recommended that exclusive breast-feeding should be the

feeding option of choice for

HIV-infected women in developing and developed countries. However, the

proportion of mothers

who exclusively breast-feed their infants is extremely low, and present

social and cultural norms

promote the use of mixed feeding. In the Durban cohort, only 26% of the

women who chose to

breast-feed fed their infants with breast milk exclusively.

Adding to the controversy is a recent report by Nduati and coworkers in

Kenya that attributed 44%

of all infant HIV infections to the effects of breast-feeding. Although

this was a randomized

controlled clinical trial, the breast-feeding group was not clearly

delineated into exclusive and mixed

feeders. A new analysis presented at Durban concluded that infants

younger than 4 months had a

1.9-fold higher chance of being infected through breast-feeding than

infants older than 4 months. In

addition, the cumulative maternal mortality rate at 24 months was higher

in the breast-feeding arm

compared with the formula-feeding arm (10.5% vs 3.8%, respectively).

Although this was a

randomized controlled trial with an intent-to-treat analysis, other

confounders, such as maternal

illness, viral load, and CD4+ counts, were not controlled for. Maternal

death was also strongly

associated with subsequent infant death (RR, 7.8).

It is extremely difficult to base recommendations on feeding practices

for women in resource-poor

settings on the present data from the Durban and Kenyan cohorts. Further

data are vital before any

recommendations are made, particularly with regard to women in

resource-poor settings who cannot

afford replacement feeding.

Source: Lala S, Sanne I.: Vertical transmission of HIV: recent

developments. Medscape

Conference Summaries from the XIII International AIDS Conference, 2000.

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