title: Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis.
abstract: To systematically review the literature on mother-to-child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART.
  
  
  
  We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta-analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle-Ottawa Scale (NOS) and GRADE.
  
  
  
  Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15-5.93%) and at 12 months 4.23% (95% CI: 2.97-5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32-1.85) at six and 2.93 (95% CI: 0.68-5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk.
  
  
  
  There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life-long ART for all.
authors.affiliation: Department of Social Statistics and Demography, University of Southampton, Southampton, UK.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Bispo
authors.affiliation: School of Languages and Area Studies, University of Portsmouth, Portsmouth, UK.
authors.forename: Lana
authors.initials: L
authors.lastname: Chikhungu
authors.affiliation: Department of Maternal, New-born, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland.
authors.forename: Nigel
authors.initials: N
authors.lastname: Rollins
authors.affiliation: Medical Research Council, Cape Town, South Africa.
authors.forename: Nandi
authors.initials: N
authors.lastname: Siegfried
authors.affiliation: Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001942:Breast Feeding; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical; D009035:Mothers; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*
chemical_list: D019380:Anti-HIV Agents
keywords: Antiretroviral therapy; HIV; breast feeding; meta-analysis; prevention of mother-to-child transmission; systematic review