When Is Replacement Feeding Safe for Infants of HIV-Infected Women?

I n this issue of PLoS Medicine, Renaud Becquet and colleagues report their fi ndings from a new study looking at the long-term safety of infant feeding interventions aimed at reducing mother-to-child HIV transmission in Africa [1]. Over two years, the researchers studied the safety of infant feeding interventions (either formula feeding or shortened breast-feeding) among infants of HIV-infected mothers in Abidjan, Côte d'Ivoire. The authors chose to examine this issue because of the continued challenges faced by HIV-infected mothers regarding infant feeding. Breast-milk transmission of HIV contributes substantially to the risk of infant HIV infection; consequently HIV-infected mothers in Europe and the United States are counseled not to breast-feed their infants. However, avoiding breast-feeding or shortening the term of breast-feeding may be risky for infants in settings with inadequate sanitation, limited access to breast-milk substitutes, or unsafe water. Thus, UNAIDS (the Joint United Nations Programme on HIV/AIDS) recommends that HIV-infected women " replacement feed " their infants when it is acceptable, feasible, affordable, sustainable, and safe (" replacement feeding " is a term used to refer to feeding infants with milk other than breast milk, such as formula) [2]. Interpreting these guidelines is particularly challenging on the ground. When is replacement feeding safe for babies? This issue of safety is the focus of Becquet et al's study—by measuring severe morbidity and mortality, the authors determined how risky replacement feeding and shortened breast-feeding were for infants born to HIV-infected mothers in an urban African setting. The authors compared morbidity, hospitalization, and mortality over a two-year period among infants of HIV-infected women who had received peripartum antiretrovirals and elected to either breast-feed for four months or formula feed. In addition, the authors compared the infants in this cohort to infants in a historical cohort in the same setting with the same clinical and survival assessments who breast-fed for a prolonged duration. Becquet et al. found that at baseline, formula-feeding mothers were more educated and had better access to tap water and less shared housing than women who elected to breast-feed for a short duration. However, there was no evidence that formula-feeding mothers in this cohort had more advanced HIV disease than women who breast-fed. Overall, adverse events among HIV-uninfected infants were similar in the two groups. Formula-fed infants had signifi cantly increased risk of diarrhea and acute respiratory illnesses, while short-term breast-fed infants tended to have a higher incidence of malnutrition. …