Breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity in the Option B+ era

Abstract

In settings with universal antiretroviral coverage and high breastfeeding rates, breastfeeding mitigates the effects of in-utero HIV exposure among infants during the first year of life. These findings support previous recommendations for exclusive breastfeeding among HIV-infected women and highlight the role that breastfeeding plays on the health of infants in settings where exclusive breastfeeding is not always feasible or where replacement feeding is recommended.

Considerations in evaluating infectious morbidity and mortality in HIV-exposed uninfected infants

“…This was a cohort of very low risk infants who were close to term gestation (>36 weeks), not of low birth weight (>2.4kg), born following an uncomplicated pregnancy and labour and with no known close tuberculosis contacts [2]. These findings are thus only generalizable to infants of this low risk profile and do not relate to the 20–30% of HEU infants born preterm or of low birth weight despite antenatal maternal ART [3,4].…”

“…The study by Tchakoute et al, one of the first to evaluate infectious morbidity in HIV exposed uninfected (HEU) compared to HIV unexposed uninfected (HUU) infants in the Option B+ era, confirms the protective effect of exclusive or mixed breastfeeding over replacement feeding irrespective of infant HIV exposure [2]. Tchakoute and colleagues have drawn bold conclusions from their study that “breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity” and more broadly that “when mothers exclusively or partially breastfeed, in utero HIV exposure has no effect on morbidity during the first year of life”[2]. However, we raise three key considerations that temper these conclusions when interpreted in context.…”

“…In the era of universal maternal antiretroviral therapy (ART) women living with HIV and their HIV-uninfected infants can, with a substantially reduced risk of postnatal HIV transmission, enjoy the many benefits of breastfeeding [1]. The study by Tchakoute et al, one of the first to evaluate infectious morbidity in HIV exposed uninfected (HEU) compared to HIV unexposed uninfected (HUU) infants in the Option B+ era, confirms the protective effect of exclusive or mixed breastfeeding over replacement feeding irrespective of infant HIV exposure [2]. Tchakoute and colleagues have drawn bold conclusions from their study that “breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity” and more broadly that “when mothers exclusively or partially breastfeed, in utero HIV exposure has no effect on morbidity during the first year of life”[2].…”

Dealing With Binary Repeated Measures Data

“…In a study of 749 infants from Cape Town, South Africa, and Jos, Nigeria, researchers assessed the effects of in utero human immunodeficiency virus (HIV) exposure and breastfeeding practices on the occurrence of infections during the first year of life [1]. Infants were HIV‐negative but were considered HIV‐exposed if born to an HIV‐positive mother.…”

Infant feeding knowledge and practice vary by maternal HIV status: a nested cohort study in rural South Africa

“…An important caveat is HIV reservoirs in latent and active CD4+ T cells in breastmilk even among women on suppressive ART [9]. The benefits of exclusive breastfeeding in resource-poor settings outweigh any risks (including concerns of micronutrient deficiency without supplementary feeds after 4 months of age) [10], supporting recommendations of exclusive breastfeeding for all infants until 6 months of age regardless of maternal HIV status [11,12].…”