The concern around increased morbidity and mortality associated with the use of FF underlies the WHO/UNICEF/UNAIDS recommendation that EBF should be practiced by HIV-infected women who cannot practice safe FF (7
). The possibility that EBF might also be associated with a lower transmission risk than MBF (8
) has prompted several clinical studies in which the feasibility of EBF at a population level is examined and to encourage women to avoid MBF. Four studies are discussed that are testing this hypothesis and the risks associated with stopping BF earlier or more abruptly than usual.
In Abidjan, Côte d’Ivoire, women taking part in the project described above who elect to BF were followed-up according to the same protocol. During follow-up the potential risks of MBF were discussed repeatedly and women were specifically counselled on how they might stop BF and when would be appropriate and possible in their circumstance. This could be any time up to six months postpartum. Counselling also included practical demonstrations on how to use a cup for giving RF and workshops on preparing complementary feeds (CF). Women were offered free FF for nine months starting from the time that they stopped BF. There was no support offered in the postnatal wards to help initiate BF or to sustain EBF in the first days, nor was there specific counselling at the antenatal clinics preparing women for initiating and sustaining EBF. One-week recall of infant feeding and morbidity data was collected at each study visit (weekly for the first six weeks, monthly until 12 months and three-monthly until two years). Forty per cent of women planned to BF, and on day two postnatally half EBF. However, within the first 48 hours post-delivery, more than 40% of mothers had already introduced additional fluids (other than FF).. None of the mothers who had introduced fluids only in the first 48 hours i.e. predominant BF (PBF) had reverted to EBF to three months. Mothers reported that stopping BF at three months was difficult, but counsellors reported fewer difficulties from mothers who ceased BF when the child was older, about 6 months.
The only study to be performed in a rural area is in KwaZulu Natal, South Africa where a large non-randomised community-based intervention study has been implemented to estimate the transmission risk with EBF (9
). HIV positive women are counselled on infant feeding options but no FF or other financial or material support is offered regardless of preferred feeding intention. Women who plan to BF are intensively supported antenatally, at delivery and postnatally to EBF. The community-based support is matched by general support for EBF in the health facilities and local district hospital which is accredited with the Baby Friendly Hospital Initiative (BFHI). In the district, between 40–60% of households use river water and up to a third of households in certain tribal areas, have no form of toilet even pit latrines. In the past five years there have been outbreaks of Shigella dysenteriae
type 1 dysentery and cholera. In contrast to some other approaches for counselling on infant feeding choices, not all infant feeding options are presented by the counsellor. Rather the counsellor explores with the HIV-positive woman how she intends to feed her child now that she has learned her HIV status. After discussing her personal circumstances and considering the feasibility of her intention, the counsellor either fully supports the intention or sensitively challenges the women if her conditions do not appear appropriate with her intention or if a better opportunity is available. This approach reflects the WHO/UNICEF/UNAIDS recommendation that HIV-infected women are given ‘specific guidance in selecting the option most likely to be suitable for their situation’.
Of 189 HIV-infected women counselled 90% planned to BF and 10% intended to FF. There were no differences between the BF and FF groups with respect to access to clean water (about 50%), access to a fridge (about 40%), gas, paraffin or electricity as a fuel source (about 65%) and a regular source of income to the household (about 75%). Only if the woman herself was the main income provider was this associated with the intention to FF (9% vs. 28%). Access to some or all of these conditions, which reflect issues of safety, affordability and sustainability of RF, was not associated with either feeding intention (). Most women who had immediate access to conditions that would enable making RF safer in fact chose to BF, suggesting that women’s choices were based on issues other than physical resources. Notably, two-thirds of women who antenatally planned to RF instead initiated and sustained BF after delivery whereas all women who planned to BF managed to do so through at least the first week. HIV counsellors reported that women were very receptive to information and support regarding good breastfeeding practices but commented that it was hard to counsel women knowing that they are hungry. Not unexpectedly they found that family concerns significantly influenced women’s decisions and practices. Interim data suggest that breast pathologies were uncommon but oral thrush was common during the first months of life in breastfed infants.
Table 3 Cumulative number of conditions (clean water; access to fridge; electricity, gas or paraffin for cooking; regular income available to household) available to HIV-infected women to make replacement feeding affordable, feasible, sustainable and safe compared (more ...)
The Zambian exclusive breastfeeding study (ZEBS) in Lusaka, Zambia is an randomised clinical trial to test the safety and efficacy of short exclusive breastfeeding to four months to reduce HIV transmission and child mortality, enrolling 1200 infected pregnant women who wish to breastfeed (10
). A counselling intervention was developed to support and encourage exclusive breastfeeding to at least four months among all women in the study. Counselling begins antenatally, breastfeeding initiation is supported by midwives after delivery, and postnatal counselling includes both a home and clinic-based component. Women randomised to abrupt cessation of all breastfeeding at four months receive an additional counselling intervention to prepare them for early cessation. Possible problems associated with breastfeeding cessation are discussed including strategies to relieve breast engorgement and comfort the child without suckling. Cup feeding is introduced and nutrition guidance is offered. Women randomised to the early cessation group are given infant formula and a fortified cereal for at least three months, as part of the study intervention. The study will monitor the risk of HIV infection and serious morbidity and mortality, and aims to quantify the risk of HIV transmission through exclusive breastfeeding and the magnitude of reduction of postnatal transmission associated with early cessation at four months.
Among the first 400 women enrolled in the study, more than 90% of all women initiated EBF. Between birth and one week, 92% of women reported breastfeeding only in the complete absence of any other liquid or semi-solid. Between one week and one month, cross-sectional recall of feeding indicated EBF was 95%, between one and two months, 96%, between two and three months 92% and between three and four months 86%. Most reports of non-EBF were single instances of water or other supplements and many mothers reverted to EBF thereafter. Among the mothers randomised to abrupt early cessation of breastfeeding at four months, 80% stopped all breastfeeding. Most women who stopped breastfeeding did so within a week (<2 days: 50%; 2–7 days: 42%) with 8% stopping within two weeks. There preliminary results suggest that exclusive breastfeeding may be a feasible intervention which can be achieved among the majority of HIV-infected women with appropriate counselling. Early and abrupt cessation also appears to be feasible with counselling and provision of infant formula and weaning foods. However, the efficacy and safety is still unknown. Early data suggest that compared to those who continued breastfeeding for longer, mothers and infants who stopped breastfeeding at four months were more likely to visit clinics and health worker, incurred a significantly greater number of diarrhoeal episodes and had lower weights.
The ZVITAMBO study in Harare, Zimbabwe was a randomised trial to investigate the effect of vitamin A supplementation on maternal and infant health, recruiting 14,110 mother-infant pairs during the immediate post partum period. At recruitment, 4,496 (32%) of mothers were HIV-infected. Detailed infant feeding and morbidity data were routinely collected and blood samples obtained at six weeks, three months, and then at three-monthly intervals over a two-year follow-up. All but four of the 14,110 mothers initiated breast feeding. During the course of the study an education and counselling programme on safer breastfeeding was introduced for the last 2,744 women enrolled. Using the definition of. cumulative practice from birth (rather than less rigorous definitions of 24 hour or 1 week histories), EBF rates increased from 7% to 28% at six weeks of age and from 3% to 19% at three months of age, for the pre- and post-education and counselling intervention cohorts, respectively. This illustrates that breastfeeding practices are amenable to change if an effective and committed approach is implemented and sustained. Similarly, in Zimbabwe when RF were given, cups are normally used rather bottle which has been the government recommendation for many years. Among infants born to HIV-positive mothers, infant mortality was more than three-fold greater (p<0.01) among infants who were MBF by three months of age compared to those who were EBF to at least three months of age.
In summary, EBF is an acceptable and feasible feeding option for many HIV positive women especially where practical support is available. Early introduction of water is common in many communities and achieving EBF beyond the first months can be difficult if only limited support is offered. Avoiding the introduction of additional FF rather than just other fluids e.g. water is more acceptable and easier to achieve. Moderate facility-based and/or community-based support both antenatally and around delivery can significantly increase EBF rates. Obvious determinants of practice such as physical resources at home are not always the principal basis of choice or practice. Women’s status in many societies often prevents her from making and exercising her choice. Counselling approaches need to effectively guide women to informed choices with support available to make these choices viable and sustainable. Further investigation is needed of methods to increase community acceptability of feeding interventions to reduce HIV transmission and increase child survival.