Exclusive breastfeeding in the prevention of HIV-1 transmission from mother to child : a systematic review

[摘要] ENGLISH ABSTRACT: HIV infection poses a major obstacle in breastfeeding as it represents the most common wayby which children acquire HIV. Exclusive breastfeeding has been discovered as the mosteffective intervention in preventing mother-to-child transmission of HIV, mortality andpromotion of HIV free survival.The main objective was to evaluate the evidence on the effectiveness of exclusivebreastfeeding versus formula feeding and/ or mixed feeding in the prevention of HIV-1transmission from mother to child.To identify the studies, an electronic search was conducted using PUBMED/MEDLINE,CINAHL, CENTRAL and EMBASE databases. Electronic journals, which include theSouthern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and AmericanJournal of Public Health, were also accessed. Manual searches were carried out. Inaddition, relevant experts were contacted in order to locate more data. There were nolimitations with regards to date and language.The review considered studies on infants who were vertically HIV-1 exposed (mother HIVpositive during pregnancy, birth and breastfeeding). These infants were exclusivelybreastfed for six months with administration of antiretroviral prophylaxis and were comparedto infants exclusively formula fed. The outcomes measured were vertically acquired HIVinfection; mortality and HIV free survival up to 24 months of age.Two reviewers independently selected articles which met the inclusion criteria. Theyindependently extracted the data using a data extraction tool. Disagreements were solvedby discussion. Data was then meta-analysed using Rev Man 5.1.0.Methodological quality of each trial was assessed by the reviewers using the Cochraneassessment tool for risk of bias.Two randomised clinical trials and one intervention cohort study (n=2112 infants) comparingexclusive breastfeeding with exclusive formula feeding were included. HIV infection wasassociated with exclusive breastfeeding as compared with exclusive formula feeding (Riskratio 1.67, 95% CI 1.26 to 2.23, p=0.0005). Exclusive formula feeding was associated withhigh mortality from infections (Risk ratio of 0.67 95% CI 0.43 to 0.83, p=0.002 Chi²= 1.30,p=0.52, I²=0%). There were no statistically significant differences in HIV free survivalbetween exclusive breastfeeding and exclusive formula feeding as measured by trialists at 9, 18 and 24 months (Risk ratio 1.19, 95% CI, 0.92 to 1.54, p=0.19, Chi²= 3.15, p=0.21, I²=36% 3 studies, 1012 infants). None of the studies included reported on mixed feeding.Complete avoidance of breastfeeding is effective in preventing mother-to-child transmissionof HIV. HIV infection during breastfeeding might be an indicator of mixed feeding and pooradherence. Formula feeding is only applicable in settings where formula milk is accessible,feasible, acceptable, safe and sustainable (AFASS) because formula feeding carries a highrisk of mortality from causes other than HIV. If the AFASS criteria cannot be met, mothersshould be encouraged to exclusively breastfeed and ensure that their infants completelyadhere to the antiretroviral prophylaxis because they decrease the rate of vertical HIV-1transmission.

[发布机构] Stellenbosch University