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HIV this week

Rwanda / Prevention: Breastfeeding with maternal antiretroviral therapy or formula feeding to prevent HIV postnatal mother-to-ch

09 Dec, 2009
By: Peltier CA, Ndayisaba GF, Lepage P, van Griensven J, Leroy V, Pharm CO, Ndimubanzi PC, Courteille O, Arendt V.

The aim of the study was to assess the 9-month HIV-free survival of children with two strategies to prevent HIV mother-to-child transmission in a nonrandomized interventional cohort study.

Four public health centres in Rwanda enrolled participants between May 2005 and January 2007. All consenting HIV-infected pregnant women were included. Women could choose the mode of feeding for their infant: breastfeeding with maternal antiretroviral therapy for 6 months or formula feeding. All received antiretroviral therapy from 28 weeks of gestation. Nine-month cumulative probabilities of HIV transmission and HIV-free survival were determined using the Kaplan-Meier method and compared using the log-rank test. Determinants were analysed using a Cox model analysis.

Of the 532 first-liveborn infants, 227 (43%) were breastfeeding and 305 (57%) were formula feeding. Overall, seven (1.3%) children were HIV-infected of whom six were infected in utero. Only one child in the breastfeeding group became infected between months 3 and 7, corresponding to a 9-month cumulative risk of postnatal infection of 0.5% [95% confidence interval (CI) 0.1-3.4%; P = 0.24] with breastfeeding. Nine-month cumulative mortality was 3.3% (95% CI 1.6-6.9%) in the breastfeeding arm group and 5.7% (95% CI 3.6-9.2%) for the formula feeding group (P = 0.20). HIV-free survival by 9 months was 95% (95% CI 91-97%) in the breastfeeding group and 94% (95% CI 91-96%) for the formula feeding group (P = 0.66), with no significant difference in the adjusted analysis (adjusted hazard ratio for breastfeeding: 1.2 (95% CI 0.5-2.9%). Maternal antiretroviral therapy while breastfeeding could be a promising alternative strategy in resource-limited countries.

HIV This Week editors’ note:

This study enrolled 562 HIV-positive pregnant women who were placed on antiretroviral treatment at 28 weeks of pregnancy regardless of CD4 count. Those who decided to formula feed stopped antiretroviral treatment after their baby’s birth if they were not eligible in Rwanda (less than 350 CD4 count) and those who decided to breastfeed continued antiretroviral treatment until 1 month after weaning their babies at 6 months of age and then stopped taking antiretroviral drugs if they were not eligible for treatment. All babies received a backbone of AZT and 3TC for seven days after they stopped being exposed to maternal antiretroviral drugs through the placenta or through breast milk to reduce the risk of resistance to the third drug (nevirapine or efavirenz).

There was no difference in HIV-free survival and, amazingly, there was no significant difference in the mortality by infant feeding mode (3.3% versus 5.7%) although virtually all studies in low- and middle-income countries have shown higher mortality with formula feeding. This may be because mothers received education and good follow-up and care, regardless of the feeding option they chose. The bottom line is that the risk of HIV transmission during breastfeeding is minimal when mothers are on antiretroviral treatment, regardless of CD4 count.