Individualizing the WHO HIV and infant feeding guidelines: Optimal breastfeeding duration to maximize infant HIV-free survival

  • AIDS, Volume 28, No. SUPPL. 3, Year 2014

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Study Justification:
The study aimed to determine how infant feeding recommendations can maximize HIV-free survival (HFS) among HIV-exposed, uninfected African infants. It sought to balance the risks of breast milk-associated HIV infection with the risks of illness and death associated with replacement feeding. The study used a mathematical model and published data from Africa to project HFS over a 24-month period.
Highlights:
– The study found that the optimal breastfeeding duration to maximize HFS depends on factors such as maternal CD4 count, availability of antiretroviral drugs, and the relative risk of mortality among replacement-fed compared to breastfed infants.
– When the relative risk of mortality is low (1.0), replacement feeding from birth maximizes HFS.
– At a commonly reported relative risk of mortality (2.0), the optimal breastfeeding duration ranges from 3 to 12 months, depending on maternal CD4 count and antiretroviral drug availability.
– As the relative risk of mortality increases, the optimal breastfeeding duration also increases.
– An individualized approach, taking into account maternal CD4 count, antiretroviral drug availability, and local replacement feeding safety, can optimize HFS among HIV-exposed infants.
– However, the gains in HFS from an individualized approach are moderate, except in cases where mortality risks from replacement feeding are very low or very high, or when access to antiretroviral drugs is limited.
– The World Health Organization (WHO) public health approach, which recommends 12 months of breastfeeding for all HIV-infected women, is beneficial in most resource-limited settings.
Recommendations:
– The study recommends an individualized approach to infant feeding, considering factors such as maternal CD4 count, antiretroviral drug availability, and local replacement feeding safety, to optimize HIV-free survival among HIV-exposed infants.
– However, the study acknowledges that the gains in HIV-free survival from an individualized approach are modest, except in specific circumstances.
– The study also supports the use of the WHO public health approach, which recommends 12 months of breastfeeding for all HIV-infected women, as it is beneficial in most resource-limited settings.
Key Role Players:
– Researchers and scientists specializing in HIV and infant feeding
– Healthcare professionals and clinicians involved in HIV prevention and treatment
– Policy makers and government officials responsible for developing and implementing guidelines on infant feeding for HIV-exposed infants
– Non-governmental organizations (NGOs) and community-based organizations working in the field of HIV prevention and support
Cost Items for Planning Recommendations:
– Research and data collection costs
– Costs associated with training healthcare professionals on the individualized approach to infant feeding
– Costs of developing and disseminating guidelines and educational materials for healthcare professionals and caregivers
– Costs of monitoring and evaluating the implementation of the individualized approach
– Costs of providing antiretroviral drugs and other necessary resources for HIV-infected women and their infants
– Costs of community outreach and awareness campaigns to promote the individualized approach to infant feeding

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some limitations. The study used a validated mathematical model and published data from Africa to project HIV-free survival (HFS) in HIV-exposed, uninfected infants. The study considered various factors such as maternal CD4 count, antiretroviral drug availability, and the relative risk of mortality among replacement-fed compared to breastfed infants. However, the study did not provide specific details about the data sources or the validation process of the mathematical model. To improve the strength of the evidence, future research could include more detailed information about the data sources and validation methods used in the study.

OBJECTIVES:: To determine how infant feeding recommendations can maximize HIV-free survival (HFS) among HIV-exposed, uninfected African infants, balancing risks of breast milk-Associated HIV infection with setting-specific risks of illness and death associated with replacement feeding. DESIGN:: Validated mathematical model of HIV-exposed, uninfected infants, with published data from Africa. METHODS:: We projected 24-month HFS using combinations of: maternal CD4, antiretroviral drug availability, and relative risk of mortality among replacement-fed compared to breastfed infants (‘RR-RF’, range 1.0-6.0). For each combination, we identified the ‘optimal’ breastfeeding duration (0-24 months) maximizing HFS. We compared HFS under an ‘individualized’ approach, based on the above parameters, to the WHO ‘public health approach’ (12 months breastfeeding for all HIV-infected women). RESULTS:: Projected HFS was 65-93%. When the value of RR-RF is 1.0, replacement feeding from birth maximized HFS. At a commonly reported RR-RF value (2.0), optimal breastfeeding duration was 3-12 months, depending on maternal CD4 and antiretroviral drug availability. As the value of RR-RF increased, optimal breastfeeding duration increased. Compared to the public health approach, an individualized approach improved absolute HFS by less than 1% if RR-RF value was 2.0-4.0, by 3% if RR-RF value was 1.0 or 6.0, and by greater amounts if access to antiretroviral drugs was limited. CONCLUSION:: Tailoring breastfeeding duration to maternal CD4, antiretroviral drug availability, and local replacement feeding safety can optimize HFS among HIV-exposed infants. An individualized approach leads to moderate gains in HFS, but only when mortality risks from replacement feeding are very low or very high, or antiretroviral drug availability is limited. The WHO public health approach is beneficial in most resource-limited settings. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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The publication recommends individualizing the World Health Organization (WHO) HIV and infant feeding guidelines to optimize breastfeeding duration and maximize HIV-free survival (HFS) among HIV-exposed, uninfected African infants. The goal is to balance the risks of breast milk-associated HIV infection with the risks of illness and death associated with replacement feeding.

The study used a mathematical model and data from Africa to project 24-month HFS based on factors such as maternal CD4 count, availability of antiretroviral drugs, and the relative risk of mortality among replacement-fed compared to breastfed infants. The researchers determined the “optimal” breastfeeding duration for each combination of factors that would maximize HFS.

The results showed that when the relative risk of mortality from replacement feeding (RR-RF) was 1.0, replacement feeding from birth maximized HFS. However, at a commonly reported RR-RF value of 2.0, the optimal breastfeeding duration ranged from 3 to 12 months, depending on maternal CD4 count and antiretroviral drug availability. As the value of RR-RF increased, the optimal breastfeeding duration also increased.

Compared to the WHO’s recommendation of 12 months of breastfeeding for all HIV-infected women, the individualized approach improved absolute HFS by less than 1% if RR-RF was between 2.0 and 4.0. However, it led to greater gains in HFS (up to 3%) if RR-RF was 1.0 or 6.0, or if access to antiretroviral drugs was limited.

In conclusion, tailoring breastfeeding duration based on maternal CD4 count, antiretroviral drug availability, and local replacement feeding safety can optimize HFS among HIV-exposed infants. The individualized approach leads to moderate gains in HFS, particularly when mortality risks from replacement feeding are very low or very high, or when access to antiretroviral drugs is limited. However, the WHO public health approach is still beneficial in most resource-limited settings.
AI Innovations Description
The recommendation described in the publication is to individualize the World Health Organization (WHO) HIV and infant feeding guidelines in order to optimize breastfeeding duration and maximize HIV-free survival (HFS) among HIV-exposed, uninfected African infants. The goal is to balance the risks of breast milk-associated HIV infection with the risks of illness and death associated with replacement feeding.

The study used a mathematical model and published data from Africa to project 24-month HFS based on different combinations of factors such as maternal CD4 count, availability of antiretroviral drugs, and the relative risk of mortality among replacement-fed compared to breastfed infants. The researchers identified the “optimal” breastfeeding duration (ranging from 0 to 24 months) that would maximize HFS for each combination of factors.

The results showed that when the relative risk of mortality from replacement feeding (RR-RF) was 1.0, replacement feeding from birth maximized HFS. However, at a commonly reported RR-RF value of 2.0, the optimal breastfeeding duration ranged from 3 to 12 months, depending on maternal CD4 count and antiretroviral drug availability. As the value of RR-RF increased, the optimal breastfeeding duration also increased.

Compared to the WHO’s “public health approach” of recommending 12 months of breastfeeding for all HIV-infected women, the individualized approach improved absolute HFS by less than 1% if RR-RF was between 2.0 and 4.0. However, it led to greater gains in HFS (up to 3%) if RR-RF was 1.0 or 6.0, or if access to antiretroviral drugs was limited.

In conclusion, tailoring breastfeeding duration based on maternal CD4 count, antiretroviral drug availability, and local replacement feeding safety can optimize HFS among HIV-exposed infants. The individualized approach leads to moderate gains in HFS, particularly when mortality risks from replacement feeding are very low or very high, or when access to antiretroviral drugs is limited. However, the WHO public health approach is still beneficial in most resource-limited settings.
AI Innovations Methodology
The methodology used in the study involved a mathematical model and published data from Africa to project 24-month HIV-free survival (HFS) among HIV-exposed, uninfected infants. The researchers considered factors such as maternal CD4 count, availability of antiretroviral drugs, and the relative risk of mortality among replacement-fed compared to breastfed infants.

For each combination of factors, the researchers determined the “optimal” breastfeeding duration (ranging from 0 to 24 months) that would maximize HFS. They compared the results of an “individualized” approach, where breastfeeding duration was tailored based on the above parameters, to the World Health Organization’s (WHO) “public health approach” of recommending 12 months of breastfeeding for all HIV-infected women.

The results showed that when the relative risk of mortality from replacement feeding (RR-RF) was 1.0, replacement feeding from birth maximized HFS. However, at a commonly reported RR-RF value of 2.0, the optimal breastfeeding duration ranged from 3 to 12 months, depending on maternal CD4 count and antiretroviral drug availability. As the value of RR-RF increased, the optimal breastfeeding duration also increased.

Compared to the WHO’s public health approach, the individualized approach improved absolute HFS by less than 1% if RR-RF was between 2.0 and 4.0. However, it led to greater gains in HFS (up to 3%) if RR-RF was 1.0 or 6.0, or if access to antiretroviral drugs was limited.

In conclusion, the study suggests that tailoring breastfeeding duration based on maternal CD4 count, antiretroviral drug availability, and local replacement feeding safety can optimize HFS among HIV-exposed infants. The individualized approach leads to moderate gains in HFS, particularly when mortality risks from replacement feeding are very low or very high, or when access to antiretroviral drugs is limited. However, the WHO public health approach is still beneficial in most resource-limited settings.

Statistics:
Citations: 9
Authors: 10
Identifiers:
DOI: 10.1097/QAD.0000000000000337
ISSN: 02699370
Research Areas:
Health System and Policy, Infectious Diseases, Maternal and Child Health
Participants Gender:
Female
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