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Background: Little is known about the long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa. Methods and Findings: In 2001-2005, HIV-infected pregnant women having received in Abidjan, Côte d’Ivoire, a peripartum antiretroviral prophylaxis were presented antenatally with infant feeding interventions: either artificial feeding, or exclusive breast-feeding and then early cessation from 4 mo of age. Nutritional counseling and clinical management were provided for 2 y. Breast-milk substitutes were provided for free. The primary outcome was the occurrence of adverse health outcomes in children, defined as validated morbid events (diarrhea, acute respiratory infections, or malnutrition) or severe events (hospitalization or death). Hazards ratios to compare formula-fed versus short-term breast-fed (reference) children were adjusted for confounders (baseline covariates and pediatric HIV status as a time-dependant covariate). The 18-mo mortality rates were also compared to those observed in the Ditrame historical trial, which was conducted at the same sites in 1995-1998, and in which long-term breast-feeding was practiced in the absence of any specific infant feeding intervention. Of the 557 live-born children, 262 (47%) were breast-fed for a median of 4 mo, whereas 295 were formula-fed. Over the 2-y follow-up period, 37% of the formula-fed and 34% of the short-term breast-fed children remained free from any adverse health outcome (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI], 0.87-1.38; p = 0.43). The 2-y probability of presenting with a severe event was the same among formula-fed (14%) and short-term breast-fed children (15%) (adjusted HR, 1.19; 95% CI, 0.75-1.91; p = 0.44). An overall 18-mo probability of survival of 96% was observed among both HIV-uninfected short-term and formula-fed children, which was similar to the 95% probability observed in the long-term breast-fed ones of the Ditrame trial. Conclusions: The 2-y rates of adverse health outcomes were similar among short-term breast-fed and formula-fed children. Mortality rates did not differ significantly between these two groups and, after adjustment for pediatric HIV status, were similar to those observed among long-term breast-fed children. Given appropriate nutritional counseling and care, access to clean water, and a supply of breast-milk substitutes, these alternatives to prolonged breast-feeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings. © 2007 Becquet et al.
The ANRS 1202/1202 Ditrame Plus study was an open-labeled cohort, based on patients attending community-run health facilities in Abobo and Yopougon, the two most-densely populated districts of Abidjan, the economic capital of Côte d’Ivoire. In this setting, HIV prevalence was around 11% among pregnant women in 2002 [13], municipal water is of generally good quality [14], and breast-feeding is widely practiced long term [15,16]. The Ditrame Plus study was granted ethical permission in Côte d’Ivoire from the ethical committee of the National AIDS Control Programme, and in France from the institutional review board of the French Agence Nationale de Recherches sur le Sida (ANRS). The inclusion procedures and research design undertaken in the Ditrame Plus study were described in detail in previous publications [17,18]. Briefly, from March 2001 to March 2003, any pregnant woman aged 18 y and over, diagnosed as HIV infected within one of the selected community-run health facilities, was proposed for entry into the study. Women included were systematically presented with both peripartum antiretroviral and postpartum nutritional interventions to prevent mother-to-child transmission of HIV. First, they received a short peripartum drug combination of zidovudine with or without lamivudine and nevirapine single dose [17]. Second, they were systematically and antenatally proposed to practice either complete avoidance of breast-feeding or exclusive breast-feeding with early cessation from the fourth month. Replacement feeding from birth or from breast-feeding cessation until 9 mo of age, as well as the material needed, were provided free of charge. In all cases, the staff supported the choice expressed by the women and counseled them accordingly [18]. Two centers were exclusively dedicated to the follow-up of the mother–infant pairs. From birth up to the second birthday, 19 visits were scheduled on study sites for clinical, nutritional, psychosocial, and biological follow-up of both mothers and infants. Mother–infant pairs were seen at birth, 48 h after delivery, weekly until age 6 wk, monthly until age 9 mo, and every 3 mo until the second birthday. At each contact, the medical staff documented clinical events that occurred in children since the last visit. At each scheduled visit, infant feeding practices were recorded via structured questionnaires [19]. Patients who did not keep scheduled appointments were traced and encouraged to return to the study sites. At each scheduled visit, anthropometric measurements, including height and weight, were taken by trained staff according to standard procedures [20]. Infant feeding counseling was made available at study sites whenever needed [18]. Children requiring intravenous treatment were managed at the day-care hospital units linked to the study sites. For life-threatening diseases or diseases requiring overnight care, children were immediately referred to the pediatric unit of the University Hospital of Yopougon. All transport costs were reimbursed, and all care expenses related to any clinical event were entirely supported by the project. Blood samples were collected at day 2, weeks 4, 6, and 12, and then every 3 mo until 18 mo of age or until 2 mo after complete cessation of breast-feeding if the child was ever breast-fed. A serology examination was systematically performed at age 18 mo in all children. Pediatric HIV infection was defined as a positive RNA PCR at any age or positive HIV serology if aged 18 mo or more [21]. HIV-infected children received cotrimoxazole chemoprophylaxis from the time of their HIV diagnosis. Special attention was given to the collection of data on child morbidity potentially linked to inadequate infant feeding practices: diarrhea, acute respiratory infections, or malnutrition. During the study, all reports of potential outcomes were referred for independent review and classification by an event documentation committee unaware of the child’s feeding practices. This committee used all clinical information available, including hospital records if the child had been hospitalized. The following definitions were used to validate morbidity. Diarrhea was defined as the passage of three or more loose or watery stools during a 24-h period for at least 2 d, or any reported diarrhea associated with at least one clinical sign of dehydration, or any reported diarrhea requiring care and followed by at least a second consultation for the same reason during a 72-h period. A diagnosis of acute respiratory infection was made if the child presented a cough, fever (axillary temperature greater than 37.5 °C), and focal pulmonary findings on physical examination. A diagnosis of malnutrition was considered when the child presented with growth faltering (no change or a decrease in measurements on growth charts from one visit to another) and was referred to the nutritionists to receive appropriate nutritional care, including provision of protein-enriched food. In case of child death, verbal autopsies were systematically conducted by trained psychosociologists to assign a possible cause of death [22]. The potential contributing causes of death were independently assessed by two pediatricians, unaware of the child’s feeding practices, on the basis of all the clinical information collected (including hospital records) and the verbal autopsy. In case of conflicting diagnosis between the two pediatricians, the opinion of a third one was sought. Causes of death were codified using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems [23]. The primary outcome of the study was the 2-y occurrence in children according to infant feeding practices and HIV status of adverse health outcomes: any severe event (death, or hospital admission related to any cause or in any location) or validated morbid event as defined above. The two components of this definition were also investigated separately as secondary outcomes (severe events and validated morbidity). A secondary analysis was performed to compare the 18-mo mortality among children exposed to alternatives to prolonged breast-feeding with the mortality of long-term breast-fed children using the ANRS 049 Ditrame trial. This historical trial was conducted in Abidjan, Côte d’Ivoire, and Bobo-Dioulasso, Burkina Faso, in 1995–1998, and it evaluated the efficacy of zidovudine to reduce mother-to-child transmission of HIV [24,25]. For the present analysis, we have included women from the Ditrame trial recruited in Côte d’Ivoire only. These women were recruited at the same sites and in the same population as the Ditrame Plus study. No strategy was proposed at that time to prevent the postnatal transmission of HIV: infants were long-term breast-fed as they usually are in Abidjan [9]. All live-born infants were available for analysis. In the case of multiple births, only the first born was included. Live-born infants fed at least once were classified in either the breast-fed or formula-fed group on the basis of the infant feeding practices recorded at the visit 2 d after birth, i.e., according to the feeding practice that had been actually initiated. Infants who died or were lost to follow-up before having been fed at least once were unclassified. Baseline characteristics were compared between these two groups using the Pearson χ2 test or the Fisher exact test to compare categorical variables, and the Mann-Whitney U test to compare continuous variables. Compliance with the infant feeding choice was assessed and defined as follows: breast-feeding mothers were considered noncompliant if they had ceased breast-feeding before the third month, and nonbreast-feeding mothers were considered noncompliant if they had breast-fed at least once over the study period. Total effective follow-up time expressed in person-years was compared to total expected follow-up time in both groups. The causes reported for stopping follow-up before the expected 24 mo were described. The cumulative probabilities of remaining free from an adverse health outcome, a severe event or a validated morbid event, were compared between short-term breast-fed and formula-fed infants using time-to-failure methods, including the Kaplan-Meier estimation and log-rank testing. Multivariate analysis used Cox proportional-hazard models. This approach allowed for the estimation of HRs for mortality and morbidity between the two groups, with adjustment for pediatric HIV status (time-dependent variable) and other covariates at baseline (maternal education, type of housing, type of water supply, baseline maternal CD4 count, living or not with one’s partner, study site, and low birth weight). Incidence rates of diarrhea, acute respiratory infection, and malnutrition were expressed per 100 person-year at risk, according to infant feeding practices and HIV status. Estimates were reported with their 95% confidence intervals (CIs). All statistical analyses were carried out with the use of SAS software (version 8.2; SAS Institute, http://www.sas.com).
