Criteria to Guide Appropriate Infant Feeding Choices in the Context of HIV - Implementing the Who/Unicef Guidelines in South Africa

BACKGROUND: WHO and UNICEF recommend that HIV positive women should avoid all breastfeeding only if replacement feeding is acceptable, feasible, affordable, sustainable and safe. We sought to identify criteria to guide appropriate infant feeding choices, and to assess the effect of inappropriate choices on infant HIV-free survival.

METHODS: A prospective cohort study of 635 HIV positive mother-infant pairs across three sites in South Africa. Data were collected during home visits using semi-structured questionnaires from antenatal through 36 weeks post-delivery. Criteria associated with the WHO/UNICEF recommendations were collected to assess appropriateness of infant feeding choices. Infant HIV status was determined by HIV DNA PCR.

RESULTS: Three criteria were found to be associated with improved infant HIV-free survival amongst women choosing to formula feed: piped water; electricity, gas or paraffin for fuel; and disclosing HIV status. Using these criteria as a measure of appropriateness of choice: 95/311 (30.5%) women who chose to breastfeed made an inappropriate choice and 195/289 (67.4%) women who chose to formula feed made an inappropriate choice. Infants of women who chose to formula feed without these three criteria had the highest risk of HIV transmission/death (HR 3.63, 95%CI 1.48-8.89). Infants of women who chose to breastfeed despite having the three criteria for appropriate formula feeding also had an increased risk of transmission/death (HR 3.35, 95% CI 1.25-8.96).

CONCLUSIONS: Within operational settings the WHO/UNICEF guidelines are not being implemented effectively leading to inappropriate infant feeding choices being made. Inappropriate choices led to lower infant HIV-free survival.