Effects of early, abrupt weaning on HIV-free survival of children in Zambia

Abstract

Background: In low-resource settings, many programs recommend that women who are infected with the human immunodeficiency virus (HIV) stop breast-feeding early. We conducted a randomized trial to evaluate whether abrupt weaning at 4 months as compared with the standard practice has a net benefit for HIV-free survival of children.

Methods: We enrolled 958 HIV-infected women and their infants in Lusaka, Zambia. All the women planned to breast-feed exclusively to 4 months; 481 were randomly assigned to a counseling program that encouraged abrupt weaning at 4 months, and 477 to a program that encouraged continued breast-feeding for as long as the women chose. The primary outcome was either HIV infection or death of the child by 24 months.

Results: In the intervention group, 69.0% of the mothers stopped breast-feeding at 5 months or earlier; 68.8% of these women reported the completion of weaning in less than 2 days. In the control group, the median duration of breast-feeding was 16 months. In the overall cohort, there was no significant difference between the groups in the rate of HIV-free survival among the children; 68.4% and 64.0% survived to 24 months without HIV infection in the intervention and control groups, respectively (P=0.13). Among infants who were still being breast-fed and were not infected with HIV at 4 months, there was no significant difference between the groups in HIV-free survival at 24 months (83.9% and 80.7% in the intervention and control groups, respectively; P=0.27). Children who were infected with HIV by 4 months had a higher mortality by 24 months if they had been assigned to the intervention group than if they had been assigned to the control group (73.6% vs. 54.8%, P=0.007).

Conclusions: Early, abrupt cessation of breast-feeding by HIV-infected women in a low-resource setting, such as Lusaka, Zambia, does not improve the rate of HIV-free survival among children born to HIV-infected mothers and is harmful to HIV-infected infants.(ClinicalTrials.gov number, NCT00310726.)

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

2008 Massachusetts Medical Society

Figures

Figure 1. Study Enrollment, Randomization, and Outcomes

Figure 2. Probability of Child Survival to 24 Months and Duration of Breast-Feeding, According to Study Group

Panel A shows survival to 24 months among 481 children assigned to the intervention group, whose mothers were counseled to wean abruptly at 4 months, and among 477 children assigned to the control group, whose mothers were counseled to breast-feed longer than 4 months and to wean according to standard practice. Panel B shows the duration of breast-feeding according to the study-group assignment.

Figure 3. Cumulative Probability of HIV-free Survival among Uninfected Children and of Survival among Infected Children, According to Study Group

Panel A shows HIV-free survival from 4 to 24 months among children who were uninfected and still breast-feeding at 4 months of age (328 children assigned to the intervention group and 333 assigned to the control group). Panel B shows survival to 24 months among children who had HIV infection by 4 months of age (71 children assigned to the intervention group and 81 assigned to the control group).