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.)

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).