title: Individualizing the WHO HIV and infant feeding guidelines: optimal breastfeeding duration to maximize infant HIV-free survival.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: aMedical Practice Evaluation Center, Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA bUniversité Bordeaux, Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), and Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France cDivision of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA dHarvard Center for AIDS Research, Boston, Massachusetts, USA eDivision of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA fDepartment of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, USA gThe Botswana-Harvard School of Public Health, AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana hOrganization for Public Health Interventions and Development, Harare, Zimbabwe iDivision of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Ciaranello
authors.forename: Valeriane
authors.initials: V
authors.lastname: Leroy
authors.forename: Asinath
authors.initials: A
authors.lastname: Rusibamayila
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Roger
authors.initials: R
authors.lastname: Shapiro
authors.forename: Barbara
authors.initials: B
authors.lastname: Engelsmann
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Kelly
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
mesh_terms: D000328:Adult; D000349:Africa; D019380:Anti-HIV Agents / Q000627:therapeutic use; D001942:Breast Feeding; D018791:CD4 Lymphocyte Count; D002675:Child, Preschool; D005260:Female; D017408:Guidelines as Topic; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008962:Models, Theoretical; D011247:Pregnancy; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents