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Infant feeding patterns and HIV–1 transmission

Letters in the Lancet1

In the last issue of Field Exchange we summarised an article published in the Lancet by Anna Coutsoudis and colleagues which found that there are substantial risks of HIV-1 transmission associated with non- exclusive (mixed) breastfeeding. Exclusive breastfed infants however did not seem to convey any excess risk of HIV-1 transmission over formula feeding. Subsequent correspondence in the Lancet is summarised below.

Issues raised

Issued raised were: possible confounding by reasons for choice of feeding method, viral overload or other unmeasured factors. In the Coutsoudis study the method of feeding (exclusive breastfeeding, mixed breastfeeding and artificial feeding) was chosen by the mother despite counselling promoting exclusive breastfeeding. If women who did not choose exclusive breastfeeding had higher viral loads (which are a strong risk factor for transmission) this could also explain differences in transmission between groups.

Coutsoudis responded that known risk factors for mother to child transmission were investigated and did not account for associations between HIV-1 transmission and feeding method. Also feeding groups did not differ by a marker of maternal disease severity (cd4-cell/cd8-cell ratio).

Another important point raised by the same correspondent highlighted that the RNA-positive infants who died before 3 months were not included in the group who were exclusively breastfed for at least 3 months (by definition), but were included in the other 2 groups.

Coutsoudis claims that survival bias did not account for findings as - if deaths before 3 months are excluded - transmission rates at 3 months among exclusive (14.6%) and never breastfeeding (16.1%) groups were similar, whereas transmission among mixed breastfeeders was significantly higher (21.5%)

The timings of infection and testing in the study also caused some concern. Coutsoudis acknowledges that the 1-month transmission rates reported in the study could be misleading as HIV testing was carried out at birth, at 1 week, 6 weeks and 3 months.

The following additional points were made in the subsequent correspondence:

In conclusion

Show footnotes

1Infant-feeding patterns and HIV-1 transmission, Correspondence, the Lancet, Vol. 354, November 27 1999.

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Reference this page

Infant feeding patterns and HIV–1 transmission. Field Exchange 9, March 2000. p5. www.ennonline.net/fex/9/infant