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Preventing postnatal mother-to-child transmission of HIV: context matters

Rollins, Nigel Ca; Becquet, Renaudb,c,d; Bland, Ruth Mb,e; Coutsoudis, Annaa; Coovadia, Hoosen Mf; Newell, Marie-Louiseb,g

doi: 10.1097/QAD.0b013e328327727b

aDepartment of Paediatrics and Child Health, South Africa

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

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

Received 5 December, 2008

Accepted 10 December, 2008

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

Greiner (pp. 000–000) raises several points regarding the generalizability of the findings of our study [1]. In reply, it is important to note that the total number of events, HIV transmissions or deaths, among the HIV-exposed infants was low and this precluded in-depth analyses of some of the questions that Greiner raises. This limitation was acknowledged in both this and earlier reports of the study. We firmly agree that achieving high rates of exclusive breast or replacement feeding are dependent on the measure of support provided to women. However, this should be seen as an opportunity rather than a reason not to attempt to provide such assistance [2].

As noted, for ethical reasons, the choice of the infant feeding modality was left to the mother, and she was supported in her choice. The results reported were adjusted for potential confounders, including baseline maternal CD4 cell count. We acknowledge that there may have been confounding factors that were not taken into account by our design, but we consider that the most important ones were controlled for. We did not record actual income or expenditure of women recruited into the study and we therefore only have proxies for these resources [3]. However, money available is not the sole determinant of feeding practices but includes opportunity and social context [4,5]. A greater or lesser supportive environment is possibly even more important for a mother when considering whether to stop breastfeeding around 6 months than when making an initial choice before delivery between exclusive breast and replacement feeding.

It is true that the availability of antiretroviral therapy may alter the risks of postnatal transmission of HIV through breastfeeding and that the landscape in this respect is changing in southern Africa. However, we believe that the findings of this study remain relevant and important for programmes as mothers, even under relatively ideal circumstance and support, may still continue to breastfeed. Given the lack of data regarding the safety and feasibility of long-term antiretroviral interventions to prevent postnatal transmission, an option to safely shorten the duration of breastfeeding remains an important component of HIV prevention strategies for improving HIV-free survival.

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N.R. drafted the correspondence. All other authors reviewed and edited it.

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1. Rollins NC, Becquet R, Bland RM, Coutsoudis A, Coovadia HM, Newell ML. Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes. AIDS 2008; 22:2349–2357.
2. Bland RM, Little KE, Coovadia HM, Coutsoudis A, Rollins NC, Newell ML. Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS 2008; 22:883–891.
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