A South African cohort study has shown that it is possible to increase rates of exclusive breast feeding among HIV-positive and HIV-negative women and their newborns in KwaZulu-Natal, South Africa. The results of the study are reported in the April 23rd edition of AIDS.
Background
Recommendations regarding breast feeding in areas of high HIV prevalence underwent an abrupt about-face several years ago, when research showed that breast-fed infants actually had better health outcomes.
Historically, due to the risk of HIV transmission to the infant, breast feeding by HIV-positive mothers was strongly discouraged in favour of formula feeding, and this is still the case in developed countries.
However, more recent research has shown that weaning and formula feeding in resource-poor areas exposes babies to severe health risks from other causes.
Moreover, the risk of HIV transmission has been shown to be much lower with exclusive breast feeding than when infants are both breast- and formula-fed. An estimated 13% of deaths in children under five years of age could be prevented by exclusive breast feeding; as a result, many expert groups now recommend aggressively promoting exclusive breast feeding in these settings.
Despite this, only about a quarter of children in sub-Saharan Africa are estimated to receive exclusive breast feeding. Moreover, intervention programmes that increase breastfeeding rates do not necessarily increase exclusive breast feeding rates. Therefore, this team of South African and UK researchers chose to study the effectiveness of a strategy to improve breast feeding practices in an area with high HIV prevalence (roughly 40% among pregnant women) and low rates of exclusive breast feeding.
The study
In this non-randomised, intervention cohort study, trained lay counsellors discussed infant feeding choices and encouraged exclusive breast feeding among pregnant and nursing mothers in KwaZulu Natal, South Africa. The team included twelve HIV counsellors and thirty breast-feeding counsellors who discussed infant feeding choices according to WHO/UNAIDS guidelines current at the time.
All participating women received one home counselling visit within 72 hours of delivery; those beginning breast feeding received three more visits in the first two weeks and bi-weekly visits until six months after delivery. All infant feeding choices were discussed with the mothers during the visits, and the final choice of feeding method was up to the mothers themselves. Study nurses also supported the mothers at their regular clinic visits.
For the purposes of this study, exclusive breast feeding was defined as no other food or drink, not even water, apart from breast milk, with the exception of vitamins, mineral supplements or medications.
Between October 2001 and April 2005, a total of 2781 participating women attending nine antenatal clinics gave birth to 2831 children. Postnatal feeding data were available for 2436 single-born infants: 1219 born to HIV-negative and 1217 born to HIV-positive mothers. (Data were not available for 313 live-born infants, and 41 sets of twins were not included in the analysis.) There were 395,415 days of follow-up data in total.
Exclusive breast feeding rates in HIV-negative women were 83.1% at three months, and 76.5% at five months after birth; in HIV-positive women, rates were 72.5% at three months and 66.7% at five months. Six months after birth, the most conservative figures showed that 45% of HIV-negative and 40% of HIV-positive women were still exclusively breast feeding. Babies of HIV-negative and HIV-positive mothers were exclusively breast fed for a median of 177 and 175 days, respectively.
Breast feeding problems were fairly common (reported by one-third of the women in the first two months), and decreased the likelihood of exclusive breast feeding (adjusted hazard ratio [AHR], HIV-negative: 2.64, 95% CI, 2.13-3.28; HIV-positive: 1.75, 95% CI, 1.42-2.16). Breast health problems (reported by roughly 7% in the first two months) were also a factor (AHR, HIV-negative: 2.62, 95% CI, 1.61-4.27; HIV-positive: 4.12, 95% CI, 2.50-6.80).
The studied intervention at least doubled the likelihood of exclusive breast feeding. At four months after birth, women who had received all of their scheduled counselling visits were more than twice as likely to be exclusively breast feeding than those who had not (adjusted odds ratio for HIV-negative women, 2.07, 95% confidence interval [CI], 1.56-2.74, p
The investigators concluded that this, "one of the most stringent studies on community support for [exclusive breast feeding] among HIV-positive women", demonstrated "high rates of [exclusive breast feeding]… in [both] HIV-positive and negative women in a high HIV prevalence area." They believe that "it is feasible to promote and sustain exclusive breast-feeding for 6 months … with home support from well trained lay counselors," and that resolving "conflicting messages around the role of breast-feeding" is an integral part of this work.
Reference:
Bland RM et al. Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS 22: 883-891, 2008.