What Works for Women and Girls

A 2001–2005 South African intervention cohort study of 1,372 women and infantswhich examined the effect of breastfeeding by HIV-positive mothers found that exclusivebreastfeeding leads to significantly lower rates of HIV transmission and higher ratesof survival than does mixed feeding. “Infants who received formula milk in addition tobreast milk, before or after 14 weeks of age, were nearly twice as likely” and “infants whowere breastfed but also received solids were nearly 11 times” as likely to become infectedthan infants who were exclusively breastfed (Coovadia et al., 2007: 1113). HIV-positivewomen were provided during antenatal care, nevirapine, infant-feeding counseling,and no cost commercial infant formula. After delivery, clinic nurses and counselorsprovided mothers with breastfeeding and replacement feeding support, with infantfeedingcounselors visiting mothers three to four times within the first two weeks afterbirth and once every two weeks until six months after birth. Independent field monitorswho visited mothers once a week assessed infant feeding practices. The study defined“exclusive breastfeeding” as feeding a child with breast milk, providing no solid food,and not giving non-human milk or water for more than three days total. After delivery,1,132 mothers began exclusive breastfeeding, and the median duration of breastfeedingof infants for whom HIV test results were available was 159 days. Of the mothers whodecided to exclusively breastfeed, 82% exclusively breastfed for at least 6 weeks, 67%exclusively breastfed for at least three months, and 40% exclusively breastfed for 6months. The study found that 22% of exclusively breastfed infants died or becameHIV-infected, resulting in an overall Kaplan-Meier estimated HIV-free survival rate of75.4% at six months. The risk of HIV transmission was associated with low maternalCD4-cell counts. The study found that the health of mothers was strongly correlatedwith PMTCT. “Infants exclusively breastfed by women with CD4-cell counts less than200 μL were twice as likely to become infected and almost four times more likely to diebefore 6 months of age than were infants exclusively breastfed by women with CD4-cellcounts above 500 μL” (Coovadia et al., 2007: 1115). (Gray III) (breastfeeding, formulafeeding, mixed feeding, PMTCT, South Africa)A study from Zambia (2001 to 2004) enrolling HIV-positive pregnant women fromPMTCT programs, found that infants born to HIV-positive mothers who were exclusivelybreastfed up until at least 4 months were at least 50 percent less likely to acquireHIV through breastfeeding than infants fed any non-breast milk substances in additionto breast milk. Furthermore, the study found no difference in the rates of HIV transmissionbetween infants weaned at 4 months and those who continued breastfeedingpast 6 months. Overall, 734 infants who tested HIV-negative at 6 weeks of age andwere still breastfeeding at 6 months of age were included in the study. Mothers wererandomized into an intervention group in which women were counseled to exclusivelybreastfeed for 4 months and then wean abruptly, and a control group in which womenwere counseled to breastfeed for at least 6 months and then introduce complimentaryfoods while maintaining breastfeeding. At 4 months, 83.5 percent of mothers reportedexclusively breastfeeding. The risk of acquiring HIV before 4 months of age was over262 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION