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Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes

Rollins, Nigel C; Becquet, Renaud; Bland, Ruth M; Coutsoudis, Anna; Coovadia, Hoosen M; Newell, Marie-Louise

doi: 10.1097/QAD.0b013e328312c740
Epidemiology and Social

Objectives: To determine the late HIV transmission and survival risks associated with early infant feeding practices.

Design: A nonrandomized intervention cohort.

Methods: HIV-infected pregnant women were supported in their infant feeding choices. Infant feeding data were obtained weekly; blood samples from infants were taken monthly to diagnose HIV infection. Eighteen-month mortality and HIV transmission risk were assessed according to infant feeding practices at 6 months.

Results: One thousand one hundred and ninety-three live-born infants were included. Overall 18-month probabilities of death (95% confidence interval) were 0.04 (0.03–0.06) and 0.53 (0.46–0.60) for HIV-uninfected and HIV-infected children, respectively. The eighteen-month probability of survival was not statistically significantly different for HIV-uninfected infants breastfed or replacement fed from birth. In univariate analysis of infant feeding practices, the probability of HIV-free survival beyond the first 6 months of life in children alive at 6 months was 0.98 (0.89–1.00) amongst infants replacement fed from birth, 0.96 (0.90–0.98; P = 0.25) and 0.91 (0.87–0.94; P = 0.03) in those breastfed for less or more than 6 months, respectively. In multivariable analyses, maternal unemployment and low antenatal CD4 cell count were independently associated with more than three-fold increased risk of infant HIV infection or death.

Conclusion: Breastfeeding and replacement feeding of HIV-uninfected infants were associated with similar mortality rates at 18 months. However, these findings were amongst mothers and infants who received excellent support to first make, and then practice, appropriate infant feeding choices. For programmes to achieve similar results, the quality of counselling and identification of mothers with low CD4 cell count need to be the targets of improvement strategies.

aDepartment of Paediatrics and Child Health, South Africa

bAfrica Centre for Health and Population Studies, University of KwaZulu-Natal, Congella, South Africa

cINSERM, Unité 897, Centre de Recherche ‘Epidémiologie et Biostatistique’

dInstitut de Santé Publique Epidémiologie Développement, Université Victor Segalen Bordeaux 2, Bordeaux, France

eDivision of Developmental Medicine, University of Glasgow, Glasgow, UK

fCentre for HIV/AIDS Networking, University of KwaZulu-Natal, Congella South Africa

gCentre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London, London, UK.

Received 31 March, 2008

Revised 25 July, 2008

Accepted 30 July, 2008

Correspondence to Nigel C. Rollins, Department of Paediatrics and Child Health, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Private Bag 7, Congella 4013, South Africa. Tel: +27 31 260 4352; fax: +27 31 260 4388; e-mail:

Copyright © 2008 Wolters Kluwer Health, Inc.