|
13th International AIDS ConferenceDurban, South Africa - July 9-July 14, 2000 |
Int Conf AIDS 2000 Jul 9-14; 13:(abstract no. WeOrC618)
Krasovec K, Soderlund N
K. Krasovec, Abt Associates Inc., Suite 600, 4800 Montgomery Lane, Bethesda, MD 20814, United States, Tel.: +1 301 718 31 37, Fax: +1 301 652 36 18, E-mail: kathy_krasovec@abtassoc.com
BACKGROUND: Breast feeding is one of the two common ways in which children are infected with HIV from their mothers. This has prompted recommendations in most developed countries that HIV infected mothers do not breast feed their babies. Recent evidence from Durban, South Africa, suggests, however, that in these settings, exclusive breast feeding may prevent infection, and that it is the inappropriate practice of mixed feeding, in particular the introduction of supplementary food or liquids in the first 6 months of life in addition to breast feeding, that poses the greatest risk of transmission. This work updates a previously published study of the cost effectiveness of vertical transmission prevention strategies to include these new findings and examine the likely cost-effectiveness of interventions to promote exclusive breastfeeding.
METHODS: A simulated cohort of 20 000 pregnancies over one year (modeled on the number of births per annum in Soweto, Johannesburg) was followed using a Markov model documented elsewhere. Ten interventions including antiretroviral, feeding-based and combined strategies were studied. Feeding interventions assessed were: Exclusive formula feeding from birth, with or without the supply of formula, and recommendation to breast feed for 3 or 6 months, combined with advice and support to exclusively breastfeed (which was assumed to be as effective as demonstrated in the Durban study). Four anti-retroviral regimes and two combined feeding and anti-retroviral interventions were assessed. Each intervention was applied in turn to the cohort, which was then followed until simulated death, and average costs per life-year saved calculated for each intervention relative to no intervention.
RESULTS: In the current South African urban context, where mixed feeding is common (64% in the Durban study), we would estimate that none of the exclusive breast or exclusive formula feeding interventions would result in a significant net number of lives gained or lost. If more than 75% of exclusively breastfeeding mothers introduced other foods of liquids in the first three months, then exclusive formula feeding would be a cost effective intervention. Time-limited breast feeding programmes, followed by complete weaning at 4 or 7 months would be the most cost-effective feeding intervention if no more than one third of infants received supplementation of any kind during the first three months. Any intervention that reduced the proportion of breastfeeding mothers who give supplements would be highly effective in saving lives. For example, a reduction in the percentage mixed feeding from 75% to 25% in the first three months would save around 200 additional lives, compared to an estimated 250 lives saved by short-course zidovudine administration.
CONCLUSIONS: In developing country settings where mixed breast and supplementary feeding is common, significant numbers of child deaths and HIV infections would be prevented by interventions that increased exclusive breastfeeding, followed by abrupt weaning from 4 months onwards. Research is urgently required into ways of effectively promoting exclusive breast feeding in Africa, as this is likely to be highly effective. Research and programmatic experience in other parts of the world, particularly from Latin America, have shown great progress in increasing rates of exclusive breastfeeding in relatively short time frames with focused interventions. Unfortunately, evidence from the Durban study suggests that mixed-feeding practices are deeply entrenched, and interventions to change these practices have not been systematically attempted. If mixed feeding practices cannot be influenced, recommendations to HIV positive mothers to formula feed or breast feed should be tailored according to the prevalence of mixed feeding. Where mixed feeding is common and entrenched, short course anti-retroviral regimes alone are probably the most cost effective vertical transmission prevention strategy, with recommendations to exclusively formula feed only where mixed feeding rates are very high and infant mortality relatively low. Where mixed feeding is uncommon, exclusive breast feeding with early weaning, combined with short course anti-retrovirals, would be most cost effective. In each case, the best interventions would be highly cost effective, saving both lives and health care costs.
Copyright © 2000 - International AIDS Society (IAS). Reproduction of this abstract (other than one copy for personal reference) must be cleared through the IAS.
