Prevention of HIV transmission through breastfeeding – a randomized trial


In fourteen sites in Sub-Saharan Africa and India HIV-infected pregnant women with CD4 > 350 or country-specific thresholds for antiretroviral therapy (ART) were included in a trial comparing ART to the mother to nevirapine to the infant to prevent transmission of HIV through breastfeeding. Treatment to the mother or the infant was given for 18 months after delivery or until breastfeeding cessation before 18 months. Primary endpoint was infant HIV infection at 24 months. 2,431 mother and infant pairs were included in the study. The median time to breastfeeding cessation was 16 months. 35 infants had no post-randomization test and were not included in the evaluation. Another 10 infants died from non HIV causes. In the final analysis 7 infants were infected in each arm corresponding to 0.57 and 0.58 % transmission rate. The enrollment period was from 2011 to 2014 which is before treatment was recommended to all HIV infected individuals

Flynn et al. J Acquir Immune Defic Syndr 2018;77:383-392

Comment: Since immediate ART is recommended to all HIV-infected individuals prolonged prophylaxis to the infant without ART to the mother is not an option. The very low transmission rate from mothers on ART raises the question whether breastfeeding can be accepted in resource rich countries in virologically well controlled mothers? In the present study viral loads were not measured. So far formula feeding is recommended for all infants born to HIV positive mothers in resource rich countries. The results of the present study are not sufficient to change our guidelines but it is a question that will be discussed in the future as many HIV-positive mothers have a strong desire to breastfeed.