Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa).
OBJECTIVE
To investigate the association between feeding patterns and HIV-free survival in children born to HIV-infected mothers and to clarify whether antiretroviral (ARV) prophylaxis modifies the association.


METHODS
From June 2005 to August 2008, HIV-infected pregnant women were counseled regarding infant feeding options, and randomly assigned to triple-ARV prophylaxis (triple ARV) until breastfeeding cessation (BFC) before age 6 months or antenatal zidovudine with single-dose nevirapine (short-course ARV). Eighteen-month HIV-free survival of infants HIV-negative at 2 weeks of age was assessed by feeding patterns (replacement feeding from birth, BFC <3 months, BFC ≥3 months).


RESULTS
Of the 753 infants alive and HIV-negative at 2 weeks, 28 acquired infection and 47 died by 18 months. Overall HIV-free survival at 18 months was 0.91 [95% confidence interval (CI): 0.88-0.93]. In the short-course ARV arm, HIV-free survival (0.88; CI: 0.84-0.91) did not differ by feeding patterns. In the triple ARV arm, overall HIV-free survival was 0.93 (CI: 0.90-0.95) and BFC <3 months was associated with lower HIV-free survival than BFC ≥3 months (adjusted hazard ratio: 0.36; CI: 0.15-0.83) and replacement feeding (adjusted hazard ratio: 0.20; CI: 0.04-0.94). In the triple ARV arm, 4 of 9 transmissions occurred after reported BFC (and 5 of 19 in the short-course arm), indicating that some women continued breastfeeding after interruption of ARV prophylaxis.


CONCLUSIONS
In resource-constrained settings, early weaning has previously been associated with higher infant mortality. We show that, even with maternal triple-ARV prophylaxis during breastfeeding, early weaning remains associated with lower HIV-free survival, driven in particular by increased mortality.
From the *UMI 233, Institut de Recherche pour le Développement, Université Montpellier 1, Montpellier, France; †Department of Bacteriology-Virology, Institut National de la Santé et de la Recherche Médicale (INSERM) U1058; Université Montpellier and CHRU Montpellier, Montpellier, France; ‡Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; §National Institutes of Health, Bethesda, Maryland; ¶International Centre for Reproductive Health (ICRH), Mombasa, Kenya; ‖International Centre for Reproductive Health, Ghent University, Ghent, Belgium; **Centre Muraz, Bobo-Dioulasso, Burkina Faso; ††University of KwaZulu-Natal, Durban, South Africa; ‡‡Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa; and §§The Kesho Bora Study Group members are listed in the Appendix.
Amandine
A
Cournil
Philippe
P
Van de Perre
Cécile
C
Cames
Isabelle
I
de Vincenzi
Jennifer S
JS
Read
Stanley
S
Luchters
Nicolas
N
Meda
Kevi
K
Naidu
Marie-Louise
ML
Newell
Kirsten
K
Bork
D000349:Africa; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018890:Chemoprevention / Q000379:methods*; D005247:Feeding Behavior; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D065129:Pre-Exposure Prophylaxis / Q000379:methods*; D011247:Pregnancy; D016019:Survival Analysis
D019380:Anti-HIV Agents