A Cochrane review [Abstract] 1 included three RCTs and one intervention cohort study with a total of 3 835 HIV-infected mothers and their infants.
The RCT on the breastfeeding vs exclusive formula feeding included a total of 401 HIV-seropositive mothers and their infants in Kenya who had access to clean municipal water. The cumulative probability of HIV infection at 24 months was found to be significantly higher in the breastfeed arm than in the exlusive formulafeed arm 36.7% (95% CI 29.4% to 44.0%) vs. 20.5% (95% CI 14.0% to 27.0%)(P = 0.001). Total mortality was not significantly different: breastfeeding arm 24.4% (95% CI 18.2-30.7%) vs. formula feeding arm 20.0% (95% CI 14.4-25.6%).
The other RCT was conducted on the efficacy of breastfeeding with extended zidovudine prophylaxis for 6 months vs exlusive formula feeding plus standard zidovudine for 1 month, including a total of 1 200 HIV-positive pregnant women in Botswana. Breastfeeding with extended zidovudine prophylaxis was not as effective as exlusive formula feeding (transmission rates by 7 months of age 9.0% vs 5.6%)(p = 0.04, 95% CI for difference -6.4% to -0.4%).
The third RCT on the efficacy of early cessation of breastfeeding included 958 HIV-infected women and their infants in Zambia. HIV-free survival at the age of 24 months was similar between those children who ceased breastfeeding around four months of age (68.4%) and those who continued breastfeeding (64.0%)(P=0.13).
The intervention cohort study on the risk of MTCT of HIV according to infant feeding modality included a total of 1 276 infants born to HIV-infected mothers in South Africa. The breastfed infants who also received solids were significantly more likely to acquire HIV-infection than those who were exclusively breastfed (the hazard ratio (HR) 10.87, 95% CI 1.51 to 78.00, p=0.018), as were the infants who at 12 weeks received both breastmilk and formula milk (HR 1.82, 95% CI 0.98 to 3.36, p=0.057). Cumulative 3-month mortality in the exclusively breastfed infants was 6.1%, 95% CI 4.74 to 7.92 versus 15.1%, 95% CI 7.63 to 28.73 in infants given replacement feeds (HR 2.06, 95% CI 1.00 to 4.27), p=0.051).
Comment: The quality of evidence is downgraded by study quality (lack of allocation concealment and appropriate blinding). The quality of evidence is upgraded by large magnitude of effect in the intervention cohort study. Morbidity associated with complete avoidance of breastfeeding (e.g., diarrheal and respiratory disease), in addition to the cost of purchasing formula or other replacement milk and the stigma associated with not breastfeeding, are significant, and in many situations make this intervention infeasible.
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