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Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD;
* Johns Hopkins University, Pune, India;
Directorate of Medical Education and Research, Mumbai, India; and
** Johns Hopkins University, School of Medicine, Baltimore, MD
3To whom correspondence should be addressed. E-mail: avshanka{at}jhsph.edu.
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONLITERATURE CITED |
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KEY WORDS: • infant feeding • HIV/AIDS • mother-to-infant transmission • India • breast-feeding
The global HIV/AIDS epidemic has had a major detrimental impact on maternal and child health throughout the world (1). More than 95% of the 3.2 million HIV-infected infants and young children became infected through their mothers, usually during the intrapartum period (2–4). In 2003, India had the second highest number of HIV cases in the world, with over 5 million HIV-infected individuals (5). In the last 5 y, the percentage of all HIV cases attributed to perinatal transmission has increased from 0.33% of total cases in 1999 to 2.80% in 2004 in India, a nearly 10-fold increase. Recent statistics indicate that over 130,000 infants have been infected through this route (5). With an estimated 27 million pregnancies annually, this is expected to lead to several thousand HIV-infected babies being born every year in India.
Despite recent advances in reducing in utero and interpartum transmission with the use of antiretrovirals (6,7), there is a critical need to make infant feeding safer for HIV-positive mothers. The rate of transmission of HIV through breast-feeding is estimated at 8.9 per 100 child-years of breast-feeding, based on data from Africa (8). Ongoing studies, again, primarily in Africa, are examining the feasibility and the impact of different infant-feeding alternatives, such as exclusive breast-feeding and exclusive replacement feeding, on the HIV-free survival of children. There are also currently several clinical trials underway to test the efficacy of antiretroviral drugs given either to the mother or the child, or both, during breast-feeding, as a means to prevent postnatal transmission. Definitive results of these studies are not expected for a few more years (9).
All interventions to prevent infant HIV infection require substantial input to make them successful, such as the provision of voluntary counseling and testing, continued support and equipment, antiretroviral medications, and infant-feeding counseling and support. Assessing the feasibility and the cost of these interventions is also necessary before their widespread implementation. In the absence of conclusive efficacy data, health care providers are dependent on interpreting global policy when counseling women on the best infant-feeding choices for their circumstances. The dearth of data on the risks of the different feeding alternatives in resource-poor settings and the fact that the majority of women living with HIV/AIDS have limited knowledge of the benefits of various infant feeding options makes this counseling a very challenging task.
UNAIDS/WHO/UNICEF currently recommends avoidance of all breast-feeding when replacement feeding is affordable, feasible, acceptable, sustainable, and safe. Otherwise, exclusive breast-feeding is recommended for the first months of life, followed by early breast-feeding cessation. All HIV-infected mothers should receive counseling, which includes provision of general information about the risks and the benefits of various infant-feeding options, and specific guidance in selecting the option most likely to be suitable for their situation (10).
These infant-feeding recommendations remain controversial for several reasons. This is a notable shift in policy from 1992, which highlighted the risks of not breast-feeding in regions where infectious disease and malnutrition were high (11). For the majority of HIV-positive women living in developing countries, it is rare to be able to fulfill the requirement for affordable, feasible, and acceptable replacement foods (12,13). The promotion of infant formula feeding to prevent HIV infection might increase infant morbidity, malnutrition, and mortality (14,15). In addition, the nutritional adequacy of alternative locally available replacement milks is either unknown or is found to be substantially lacking in essential nutrients (16). Moreover, the risk of transmission of HIV through breast milk is not well documented in Asian populations, thereby calling into question the decision to lose the overwhelming benefits of breast-feeding in favor of an unknown risk.
In this paper, we examine how the current UNAIDS/WHO/UNICEF recommendations have been actualized within the context of an urban government hospital in India. The social and biological challenges facing HIV-positive mothers after birth, during initiation of feeding, and the weaning process are explored. The experience of HIV-positive women presenting at the hospital over the period 2000–2004 highlight the complexities of making an informed choice under suboptimal conditions.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLITERATURE CITED |
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The following definitions will be used in this paper: exclusive breast-feeding—child is fed with only breast milk and no other foods or liquids by mouth (except for medicine) for the duration specified; exclusive replacement feeding—child does not receive any breast milk in addition to replacement foods (usually animal milks) for the duration specified; modified animal milks—usually cow or buffalo milk diluted with water and mixed with a small amount of sugar; weaning—the process of introducing complementary foods to a breast-fed baby; breast-feeding cessation—the action of stopping breast-feeding entirely for the child.
Women were eligible for both the pilot phase and the clinical trial if they were between 18 and 44 y old, over 24-wk gestation, identified as either HIV positive or negative by ELISA (Lab Systems OY) or 2 rapid HIV tests and were mentally and physically healthy enough to participate (as assessed by a doctor). Semistructured interviews with women were conducted at birth, 1 wk, 6 wk, and 14 wk. The study was carried out among 2 cohorts of women. The first cohort included a representative sample of HIV-positive women who enrolled in the pilot phase of the nevirapine trial (December 2000 to April 2002, n = 94), and the second cohort was composed of a representative sample of women enrolled in the actual clinical trial (May 2003 to July 2004, 146 HIV-positive mothers and 29 HIV-negative mothers). Of the breast-feeding women in this second cohort, 79 HIV-positive and 26 HIV-negative women were interviewed at 6 to 9 mo to examine weaning and cessation of breast-feeding.
All women in the study received HIV education and counseling, provided consent, and were tested for HIV. The post-test counseling sessions stressed the risks and the benefits of feeding choices in the context of HIV. Emphasis was placed on the dangers of mixed feeding of any kind.
The first semistructured interview on infant feeding was conducted at the postpartum ward, within 72 h after delivery, to observe women feeding and to ask them about feeding initiation. In the subsequent interviews conducted at 1-, 6-, and 14-wk infant-feeding patterns, perceptions and social consequences of infant feeding choice, and health and morbidity of the mother and the child were assessed. If a weaning interview was conducted, women were asked to describe beliefs about weaning, recount types of foods given, morbidity of the mother and the child, and social consequences of early weaning and/or cessation of breast-feeding.
All interviews were conducted by a trained behavioral scientist, having a graduate-level degree in the social sciences and additional interviewer training. All open-ended responses were coded by thematic category. Significant response patterns were identified by counting the number of instances a view was expressed and observing thematic patterns in responses to related questions (17). For structured interview questions, bivariate comparisons relevant to the study questions are presented using nonparametric statistics, such as chi-square test or Fisher’s exact test. Data analysis was conducted using SAS Version 9 (18).
For all women, the nature of the study was explained, and written informed consent was obtained. The study was approved by 2 ethics committees in Pune, India, and the Joint Committee on Clinical Investigations, at Johns Hopkins University in the United States.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLITERATURE CITED |
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We identified 4 possible options for infant feeding for HIV-positive women in India. They include 1) exclusive breast-feeding and early weaning, 2) infant formula, 3) modified animal milks, and 4) heat-treated breast milk. Based on information from the experience of HIV-positive mothers, we developed a ranking of the difficulties related to each feeding choice. The primary difficulties identified included risk of transmission, cost of milks, preparation time and equipment, social stigma, and social pressures to mix feed. This nonparametric ranking revealed that exclusive breast-feeding, despite the risk of HIV transmission and social pressures to mix feed, was associated with the least amount of difficulty. This was followed by the use of modified animal milks, which was considered difficult because of the cost and the stigma associated with the practice of replacement feeding. The least likely options for these women were infant formula, because of the prohibitive cost, and heat-treated breast milk, because of the enormous difficulty associated with expressing and preparing the milk for consumption and the stigma associated with not putting the child to the breast.
Changes in feeding choices: 2000–2004
Comparing our 2 cohorts, we find a significant increase in the percentage of women intending to and ultimately choosing to breast-feed in our population of HIV-positive women from 2000 to 2004. Intention to breast-feed has risen from 47% (44/94) in 2000–2002 to 87% (127/146) in 2003–2004 (P < 0.0001). Women who actually initiated breast-feeding rose from 60% (56/94) in 2000–2002 to 88% (129/146) in 2003–2004 (P < 0.0001).
We attribute some of this change to modifications to the counseling that occurred in late 2002, where counselors presented data detailing the risks of replacement feeding on infant health based on data collected from this hospital. These data showed an increase in hospitalizations and death for infants of HIV-infected mothers who were replacement fed compared with breast-fed (19). Concurrently, we noted a change in women’s perception of the value of breast milk for infant health. In 2000–2002, only 20% (11/56) of women felt that breast feeding was optimal despite HIV risk compared with 58%, 76/129 in 2003–2004, P < 0.0001. For women who decided to replacement feed, the majority did so to reduce the risk of HIV transmission (82% in 2000–2002 and 76% in 2003–2004).
The increase in women’s choice to breast-feed over the 2 periods from 2000 to 2004 are shown in Figure 1. Also included in this graph are data from the National AIDS Control Organization from 11 sentinel surveillance sites throughout India for the years 2000, 2002, and 2003. Although it is clear that breast-feeding rates for HIV-positive women are increasing throughout the country, a greater proportion of women in our study appear to be choosing this option.
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In the sample of women from cohort 2, 17 women chose to exclusively give replacement milks to their infants, and 29% (38/129) of the breast-feeding mothers gave some animal milk to their infants within 14 wk postpartum. Despite extensive counseling, preparation of the modified animal milks was variable in our sample. The predominant mixture consisted of diluted cow’s milk combined with sugar. Although several women reported using a combination of boiled water, cow’s milk, and sugar, many others reported using diluted powdered milks, coconut oils, and unboiled milks at some time during the 14-wk period. In addition, none of the mothers who replacement fed their child reported regular use of micronutrient supplements of any kind, as recommended by WHO, when this option is followed. No woman in our sample reported use of infant formula for their infant.
Mixed feeding among study women who initiated breast-feeding
Comparisons of infant feeding practices of HIV-positive and HIV-negative women are displayed in Table 1. The most common types of foods or liquids given in conjunction with breast milk included water, sugar water, or gripe water (a local mix of herbs in water to help digestion). Of HIV-positive mothers, 62%, and 55% of HIV-negative mothers reported some mixed feeding during the first 14 wk postpartum. A higher proportion of HIV-positive mothers (29%) provided animal milks to their child than was found in the HIV-negative group of mothers (17%). HIV-positive mothers were significantly more likely to feed modified animal milks compared with their HIV-negative counterparts during the first week after birth. This is directly related to morbidity experienced by the mother in the first week postpartum, because many HIV-positive mothers were too ill to breast-feed. After the first week, mixed feeding rates were similar between the 2 groups.
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Weaning
As part of the clinical trial procedures, all HIV-positive women received counseling regarding optimal breast-feeding patterns that stressed exclusive breast-feeding, weaning beginning at 6 mo, and cessation of breast-feeding as soon as possible thereafter. We compared perceptions of the weaning process and weaning practices between HIV-positive mothers in our study and HIV-negative mothers who had not received any such counseling (Table 2). The majority of women from both groups reported that food should be introduced to babies about 4 mo as a means of ensuring optimal nutrition for the baby. However, in actuality, the HIV-positive women were more likely to have begun the weaning process by 6 mo than their HIV-negative counterparts, 94% (75/79) and 69% (18/26), respectively.
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Cessation of breast-feeding
Of HIV-positive mothers, 27% (21/79) reported that transmission of HIV was an important reason to stop breast-feeding as soon as possible; however, nearly all of these mothers continued to breast-feed at 6 mo. There was considerable difficulty expressed by the women regarding cessation of breast-feeding. By 6 mo, only 9% (7/79) of the women reported that they had completely stopped breast-feeding. None of the HIV-negative mothers stopped breast-feeding by 6 mo, in keeping with traditional practices. Of the 7 women who completely stopped breast-feeding, all had begun introduction of foods by 3–4 mo and reported few difficulties in completely weaning their child.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLITERATURE CITED |
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The most recent UNAIDS/WHO/UNICEF recommendations advise HIV-positive women against breast-feeding if an appropriate replacement food is identified and can be sustained. Although it is expected that WHO recommendations will be considered within the local context, the lack of adequate empirical data at the local level make it very difficult for health care providers to know how best to counsel women. Within any resource-poor health care setting policy is constantly evolving based on the reality of achievable gains. The data indicate that women are overwhelmingly relying on their counselor or their health care provider for advice on how to feed their child (20), despite the fact that it is expected that women make an informed choice on their own. For HIV-positive mothers in India until about 2001–2002, this has resulted in the widespread "choice" to use replacement milks. This shift from breast-feeding to widespread use of replacement milks by HIV-positive mothers appears to be unique to India and has not been witnessed or described in other settings.
Our data describe how local information on health outcomes were crucial to changing infant feeding practices at a microlevel and, ultimately, at a national level after 2002. Data from an observational study conducted at this hospital documented a substantial increase in hospitalizations in replacement-fed infants compared with their breast-fed counterparts (19). Armed with this information, using an evidence-based counseling approach, counselors informed their patients of the increased morbidity risks for infants that may result from replacement feeding. By 2004, the pattern of feeding decisions had shifted with the majority of HIV-positive women "choosing" to breast-feed. This choice continues to be supported with additional data from Pune, further documenting a 3-fold increase in morbidity, especially with pneumonia, acute gastroenteritis, and sepis among infants who are not breast-fed (21).
The policy of complete avoidance of breast-feeding has been evaluated by several recent studies in Africa. Based on a review of these studies, Rollins (12) suggests that "formula feeding was an acceptable feeding option for many HIV-positive women living in an urban setting with education or intensive counseling and adequate water supply, and when formula was provided for free." We are aware of one program in Pune, conducted through a private clinic, which has demonstrated tremendous success in providing free formula for 4 mo to infants of women with HIV in addition to lactation inhibition. With intensive health monitoring and treatment, the infants and the mothers in this program have experienced little or no morbidity and no cases of HIV transmission in their group. However, this program can only service a limited number of HIV-positive women, and free infant formula will only continue as funding is made available. The conditions described in such a program are unlikely to exist in most regions of India or for the majority of women living in developing country settings.
Without any definitive data from India on HIV transmission rates during breast-feeding, we can only speculate on the likelihood of transmission for this population. In a recent study in West Africa, researchers demonstrated that breast-feeding transmission was considerably lower in women with CD4 counts > 500 (22). Although the immunological status of the women in our sample is not yet available, preliminary data from another study of 40 HIV-positive women from this clinic demonstrated the median CD4 count to be 400 (range 36–1063) and a median viral load of 12,564 copies/mL (560–252,714 copies/mL) (23). This suggests that it is possible that women in this population are still reasonably healthy and that transmission of HIV through breast milk may be lower than documented elsewhere.
Our results should also be placed within the larger perspective of the global epidemic of HIV/AIDS. Previously published data show that the majority of women attending this antenatal clinic attained some secondary education (67%) and their husbands had regular work (57%). They also had relatively good knowledge of HIV before voluntary counseling and testing in this clinic, including that HIV could be transmitted from mother to child during pregnancy (68%) and through breast milk (61%) (24). It is unclear how many HIV-positive women living in India have this level of access to health care services or knowledge of HIV.
Even if a suitable replacement-feeding regime is identified, the natural conveniences of breast-feeding combined with the stigma associated with not breast-feeding have significant impacts on infant-feeding patterns (12,25–27). In this population of antenatal clinic women who recently learned of their HIV-positive status, few had yet experienced direct stigma and discrimination as a result of having HIV. However, a majority stated that there is significant stigma associated with not breast-feeding. Those women who chose to replacement feed despite these obstacles did so with substantial household support, especially from their husbands (20). Despite this support and the extensive counseling received, nearly 30% of women who had chosen to replacement feed still ended up partially breast-feeding because of social and familial pressures. It therefore is likely that replacement feeding, without concomitant lactation inhibition, will not drastically reduce rates of HIV transmission.
The debate regarding the benefits of breast-feeding in areas where HIV is present is not a new one (28–31). However, with these data from India, we can see more clearly the implications of implementation of a global mandate without local evidence. In an attempt to reduce the risk of HIV transmission through the use of replacement milks and without sufficient knowledge of the adequacy of these alternatives, health care providers have put forth suggestions of alternative feeding strategies that appear feasible within the local cultural context. Over the past 5 y, this has lead to a significant proportion of women choosing to replacement feed, placing infants at increased risk of morbidity and mortality, and women faced stigma and discrimination because of their feeding choices. The fear of contracting HIV/AIDS should not be so high as to overshadow other competing risks to the mother or the child.
If breast-feeding is the chosen feeding regimen, exclusive breast-feeding for up to 6 mo and rapid weaning (cessation) thereafter appears optimal for infant health and reduced risk of HIV transmission (32–35). However, there are many challenges to exclusive breast-feeding, early weaning, and cessation of breast-feeding as highlighted in our data that require further attention. In our sample, mixed feeding with animal milks in the first week postpartum was the most difficult to overcome. The majority of these women, either recovering from a caesarian section delivery or other illness, were unable to breast-feed their infant. Continued support within the health care setting immediately postpartum for the mother and the infant is critical. After these women returned home, mixed feeding with animal milks was evident up to 14 wk postpartum. Despite substantial counseling, these patterns were not significantly different from those observed in the HIV-negative breast-feeding population. There was also considerable mixed feeding with waters mixed with sugar or herbs. Given that the strong social pressures to provide infants with such fluids, additional research is necessary to identify the differential risks of HIV transmission if mixed feeding with waters compared with more complex foodstuffs.
Is breast-feeding the best choice for the majority of HIV-positive women living in India? We feel that global recommendations that do not take into consideration site-specific evidence-based evaluation are likely to lead to micropolicy that may not emphasize the healthiest choice for the mother and the infant. We propose that in lieu of such mandates, a decision-making algorithm be presented to assist health care providers and policy makers. Such an algorithm, which allows for the inclusion of locally available data, would include biological factors affecting HIV transmission, available data on infant and maternal morbidity and mortality, as well as economic, social, and behavioral factors affecting feeding.
The use of algorithms for the clinical management of HIV/AIDS and other infectious diseases has been successfully adopted as a strategy for improving health care in resource-poor settings (36–39). Similar rapid assessment decision-making tools combined with clear management guidelines would provide a critical tool for health care providers to assist women in making the best-informed choice regarding infant feeding. This would also minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.
Research on infant-feeding practices and HIV transmission will continue to shape our understanding of the risks of morbidity and mortality for these infants. However, it is important that the data that is available now is optimally used and integrated into voluntary counseling and testing programs.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 This study was supported by a grant from the US National Institutes of Health (NIH, NIAID) (R01 AI45 462) and was undertaken with the BJ Medical College in Pune, India, Sassoon General Hospital, Pune, India, and the National AIDS Control Organization (NACO).
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LITERATURE CITED |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLITERATURE CITED |
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1. Lepage, P., Spira, R., Kalibala, S., Pillay, K., Giaguinto, C., Castetbon, K., Osborne, C., Courpotin, C. & Dabis, F. (1998) Care of human immunodeficiency virus-infected children in developing countries. International Working Group on Mother-to-Child Transmission of HIV. Pediatr. Infect. Dis. J. 17:581-586.[Medline]
2. Joint United Nations Programme on HIV/AIDS (UNAIDS) & WHO (2003) AIDS epidemic update [Online]. http://www.unaids.org/worldaidsday/2003/press/Epiupdate.html [accessed August 2, 2004].
3. Fowler, M. G., Simonds, R. J. & Roongpisuthipong, A. (2000) Update on perinatal HIV transmission. Pediatric Clin. North. Am. 47:21-38.
4. Minkoff, H. (2001) Prevention of mother-to-child transmission of HIV. Clin. Obstet. Gynecol. 44:210-225.[Medline]
5. National AIDS Control Organization website http://naco.nic.in/vsnaco/indianscene/executive.htm [accessed August 2, 2004] .
6. Lallemant, M., Jourdain, G., Le Coeur, S., Mary, J. Y., Ngo-Giang-Huong, N., Koetsawang, S., Kanshana, S., McIntosh, K. & Thaineua, V., the Perinatal HIV Prevention Trial (Thailand) Investigators (2004) Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N. Engl. J. Med. 351:217-228.
7. Leroy, V., Karon, J. M., Alioum, A., Ekpini, E. R., Meda, N., Greenberg, A. E., Msellati, P., Hudgens, M. & Dabis, F., et al (2002) Twenty-four month efficacy of a maternal short-course zidovudine regimen to prevent mother-to-child transmission of HIV-1 in West Africa. AIDS 16:631-641.[Medline]
8. The Breastfeeding and HIV International Transmission Study Group (2004) Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J. Infect. Dis. 189:2154-2166.[Medline]
9. Gaillard, P., Fowler, M. G., Dabis, F., Coovadia, H., van der Horst, C., van Rompay, K., Ruff, A., Taha, T. & Thomas, T., et al (2004) Use of antiretroviral drugs to prevent HIV-1 transmission through breast-feeding: from animal studies to randomized clinical trials. J. Acquir. Immune Defic. Syndr. 35:178-187.
10. WHO (2001) New data on the prevention of mother-to-child transmission of HIV and their policy implications: conclusions, and implications. WHO Technical Consultation on Behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-Agency Task Team on Mother-to-Child Transmission of HIV, Geneva 11–13 October, 2000. Report No. WHO/RHR/01.28 2001 WHO Geneva, Switzerland.
11. WHO Global Programme on AIDS (1992) Consensus Statement from the WHO/UNICEF Consultation on HIV Transmission and Breast-Feeding. Report No. WHO/GPA/INF/92.1 1992 WHO Geneva, Switzerland.
12. Rollins, N., Meda, N., Becquet, R., Coutsoudis, A., Humphrey, J., Jeffrey, B., Kanshana, S., Kuhn, L. & Leroy, V., et al (2004) Preventing postnatal transmission of HIV-1 through breast-feeding: modifying infant feeding practices. J. Acquir. Immune Defic. Syndr. 35:188-195.
13. Nduati, R., John, G., Mbori-Ngacha, D., Richardson, B., Overbaugh, J., Mwatha, A., Ndinya-Achola, J., Bwayo, J. & Onyango, F. E., et al (2000) Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. J. Am. Med. Assoc. 283:1167-1174.
14. Latham, M. C. (1999) Breast feeding reduces morbidity. The risk of HIV transmission requires risk assessment–not a shift to formula feeds. Br. Med. J. 318:1303-1304.
15. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality (2000) Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 355:451-455.[Medline]
16. Papathakis, P. C. & Rollins, N. C. (2004) Are WHO/UNAIDS/UNICEF-recommended replacement milks for infants of HIV-infected mothers appropriate in the South African context?. Bull. World Health Organ. 82:164-171.[Medline]
17. Miles, M. B. & Huberman, A. M. (1994) Qualitative Data Analysis: An Expanded Sourcebook 2nd ed. 1994 Sage Publications Thousand Oaks, CA.
18. SAS Institute Inc (2000) SAS/STAT User’s Guide, Version 9 2000 SAS Institute Cary, NC.
19. Phadke, M. A., Gadgil, B., Bharucha, K. E., Shrotri, A. N., Sastry, J., Gupte, N. A., Brookmeyer, R., Paranjape, R. S. & Bulakh, P. M., et al (2003) Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization. J. Nutr. 133:3153-3157.
20. Suryavanshi, N., Jonnalagadda, S., Erande, A., Sastry, J., Pisal, H., Bharucha, K. E., Shrotri, A., Bulakh, P. M. & Phadke, M. A., et al (2003) Infant feeding practices of HIV-positive mothers in India. J. Nutr. 133:1326-1331.
21. Sastry, J., Bollinger, R. C., Malwade, S., Bhujbal, R., Bhide, P., Phadke, M. A., Bharucha, K. E., Nair, S. & Sujir, S., et al (2004) HIV-associated postpartum infant morbidity and mortality in Pune, India. Abstract No. ThPeB7210 2004 XV International AIDS Conference Bangkok, Thailand.
22. Leroy, V., Karon, J. M., Alioum, A., Ekpini, E. R., van de Perre, P., Greenberg, A. E., Msellati, P., Hudgens, M. & Dabis, F., et al (2003) Postnatal transmission of HIV-1 after a maternal short-course zidovudine peripartum regimen in West Africa. AIDS 17:1493-1501.[Medline]
23. Gupta, A., Sastry, J., Suryawanshi, N., Pisal, H., Kulkarni, P., Bharucha, K. E., Bulakh, P., Gupte, N. & Krisagar, A., et al (2004) HIV transmission from non-breastfeeding mothers to their infants in Pune, India. Abstract No. ThPeB7040 2004 XV International AIDS Conference Bangkok, Thailand.
24. Shrotri, A., Shankar, A. V., Sutar, S., Joshi, A., Suryawanshi, N., Pisal, H., Bharucha, K. E., Phadke, M. A., Bollinger, R. C. & Sastry, J. (2003) Awareness of HIV/AIDS and household environment of pregnant women in Pune, India. Int. J. STD AIDS 14:835-839.
25. Kiarie, J. N., Richardson, B. A., Mbori-Ngacha, D., Nduati, R. W. & John-Stewart, G. C. (2004) Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J. Acquir. Immune Defic. Syndr. 35:75-81.
26. Poggensee, G., Schulze, K., Moneta, I., Mbezi, P., Baryomunsi, C. & Harms, G. (2004) Infant feeding practices in western Tanzania and Uganda: implications for infant feeding recommendations for HIV-infected mothers. Trop. Med. Int. Health 9:477-485.[Medline]
27. Manuela de Paoli, M., Manongi, R. & Klepp, K. I. (2004) Are infant feeding options that are recommended for mothers with HIV acceptable, feasible, affordable, sustainable and safe? Pregnant women’s perspectives. Public Health Nutr. 7:611-619.[Medline]
28. Ross, J. S., Piwoz, E. G. & Habicht, J. P. (2004) Is breastfeeding best for HIV-positive mothers?. AIDS 18:363.[Medline]
29. Latham, M. C. & Preble, E. A. (2000) Appropriate feeding methods for infants of HIV infected mothers in sub-Saharan Africa. Br. Med. J. 320:1656-1660.
30. Humphrey, J. & Iliff, P. (2001) Is breast not best? Feeding babies born to HIV-positive mothers: bringing balance to a complex issue. Nutr. Rev. 59:119-127.[Medline]
31. Coutsoudis, A., Pillay, K., Kuhn, L., Spooner, E., Tsai, W. Y. & Coovadia, H. M, the South African Vitamin A Study Group (2001) Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 15:379-387.[Medline]
32. John-Stewart, G., Mbori-Ngacha, D., Ekpini, R., Janoff, E. N., Nkengasong, J., Read, J. S., Van de Perre, P. & Newell, M. L., the Ghent IAS Working Group on HIV in Women Children (2004) Breast-feeding and transmission of HIV-1. J. Acquir. Immune Defic. Syndr. 35:196-202.
33. Ogundele, M. O. & Coulter, J. B. (2003) HIV transmission through breastfeeding: problems and prevention. Ann. Trop. Paediatr. 23:91-106.[Medline]
34. Piwoz, E. G., Iliff, P. J., Tavengwa, N., Marinda, E., Lunney, K., Zunguza, C., Nathoo, K. J., the ZVITAMBO Study Group & Humphrey, J. H. (2005) An education and counseling program for preventing breastfeeding-associated HIV transmission in Zimbabwe: Design and impact on maternal knowledge and behavior. J. Nutr. 135:000-000.
35. Anandaiah, R. & Choe, M. K. (2000) Are the WHO/UNICEF guidelines on breastfeeding appropriate for India? National Family Health Survey Bulletin. Number 16 2000 International Institute for Population Sciences Mumbai, India and the East-West Center Honolulu, HI.
36. WHO (1998) Clinical Management of HIV and AIDS at District Level 1998 WHO Regional Office for South-East Asia New Delhi, India.
37. Horwood, C., Liebeschuetz, S., Blaauw, D., Cassol, S. & Qazi, S. (2003) Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm. Bull. World Health Organ. 81:858-866.[Medline]
38. Weber, M. W., Mulholland, E. K., Jaffar, S., Troedsson, H., Gove, S. & Greenwood, B. M. (1997) Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia. Bull. World Health Organ. 75(suppl. 1):25-32.
39. Kolstad, P. R., Burnham, G., Kalter, H. D., Kenya-Mugisha, N. & Black, R. E. (1997) The integrated management of childhood illness in western Uganda. Bull. World Health Organ. 75(suppl. 1):77-85.
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  E. G. Piwoz and M. E. Bentley Women's Voices, Women's Choices: The Challenge of Nutrition and HIV/AIDS J. Nutr., April 1, 2005; 135(4): 933 - 937. [Abstract] [Full Text] [PDF]
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