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August 23/30, 2000

Breastfeeding in Women With HIV

Author Affiliations

Stephen J.LurieMD, PhD, Contributing EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(8):956-957. doi:10.1001/jama.284.8.956

To the Editor: Dr Nduati and colleagues1 present evidence to support the importance of very early postnatal human immunodeficiency virus type 1 (HIV-1) transmission through breastfeeding. However, differences between the trial arms in HIV-1 infection rates at birth and soon after raise a potential source of bias. Randomization to breastfeed or formula feed at 32 weeks of pregnancy may have led to differences in behavioral or biological risk factors for intrapartum or late prenatal HIV-1 transmission.2,3 Women with HIV-1 who agreed to be randomized and were assigned to the formula feeding arm (213/2315 = 9% of the entire sample of HIV-1–seropositive women) received free formula and instruction sessions in late pregnancy on boiling water and minimizing bacterial contamination.

While crucial to the ethical conduct of the trial, this intervention may have resulted in differences between the groups by the time of labor and delivery, when most vertical HIV-1 transmission is believed to occur in nonbreastfeeding populations.2 Possible differences in risk factors for intrapartum or late prenatal HIV-1 transmission between the trial arms by the time of labor and delivery might include factors such as lower cervicovaginal viral load,3 reduced immune activation (eg, due to a lower parasitic infection rate),4 improved vitamin A status, and fewer recent episodes of unprotected sexual intercourse5 among women in the formula feeding arm.

The cumulative rate of HIV infection in the formula feeding arm was approximately half that of the breastfeeding arm at birth (3.1% vs 7.0%) and at 6 weeks of age (9.7% vs 19.9%, respectively). While randomization ensured that there were no differences in enrollment characteristics at 32 weeks of pregnancy, it would be helpful if Nduati et al could provide a comparison of characteristics around the time of labor and delivery between the 2 treatment arms.

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