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EXCLUSIVE BREASTFEEDING AND PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV AMONG PREGNANT WOMEN

ABSTRACT

HIV infection poses a major obstacle in breastfeeding as it represents the most common way by which children acquire HIV.  Exclusive breastfeeding has been discovered as the most effective intervention in preventing mother-to-child transmission of HIV, mortality and promotion of HIV free survival. The main objective was to evaluate the evidence on the effectiveness of exclusive breastfeeding versus formula feeding and/ or mixed feeding in the prevention of HIV-1 transmission from mother to child. To identify the studies, an electronic search was conducted using PUBMED/MEDLINE, CINAHL, CENTRAL and EMBASE databases. Electronic journals, which include the Southern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and American Journal of Public Health, were also accessed.  Manual searches were carried out.  In addition, relevant experts were contacted in order to locate more data.  There were no limitations with regards to date and language. The review considered studies on infants who were vertically HIV-1 exposed (mother HIV positive during pregnancy, birth and breastfeeding).  These infants were exclusively breastfed for six months with administration of antiretroviral prophylaxis and were compared to infants exclusively formula fed.  The outcomes measured were vertically acquired HIV infection; mortality and HIV free survival up to 24 months of age. Two reviewers independently selected articles which met the inclusion criteria.  They independently extracted the data using a data extraction tool.  Disagreements were solved by discussion.  Data was then meta-analysed using Rev Man 5.1.0. Methodological quality of each trial was assessed by the reviewers using the Cochrane assessment tool for risk of bias. Two randomised clinical trials and one intervention cohort study (n=2112 infants) comparing exclusive breastfeeding with exclusive formula feeding were included.  HIV infection was associated with exclusive breastfeeding as compared with exclusive formula feeding (Risk ratio 1.67, 95% CI 1.26 to 2.23, p=0.0005).  Exclusive formula feeding was associated with high mortality from infections (Risk ratio of 0.67 95% CI 0.43 to 0.83, p=0.002 Chi²= 1.30, p=0.52, I²=0%).  There were no statistically significant differences in HIV free survival between exclusive breastfeeding and exclusive formula feeding as measured by trialists at 9, 18 and 24 months (Risk ratio 1.19, 95% CI, 0.92 to 1.54, p=0.19, Chi²= 3.15, p=0.21, I²=36 % 3 studies, 1012 infants).  None of the studies included reported on mixed feeding. Complete avoidance of breastfeeding is effective in preventing mother-to-child transmission of HIV.  HIV infection during breastfeeding might be an indicator of mixed feeding and poor adherence. Formula feeding is only applicable in settings where formula milk is accessible, feasible, acceptable, safe and sustainable (AFASS) because formula feeding carries a high risk of mortality from causes other than HIV.  If the AFASS criteria cannot be met, mothers should be encouraged to exclusively breastfeed and ensure that their infants completely adhere to the antiretroviral prophylaxis because they decrease the rate of vertical HIV-1 transmission.

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