Elsevier

The Lancet

Volume 349, Issue 9058, 12 April 1997, Pages 1054-1059
The Lancet

Articles
Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Côte d'lvoire

https://doi.org/10.1016/S0140-6736(96)06444-6Get rights and content

Summary

Background

HIV-1 can be transmitted from an infected mother to her infant through breastfeeding, although the precise risk of transmission by this route is unknown. A long-term follow-up of children born to HIV-infected women in Abidjan, Côte ďIvoire, has enabled us to estimate this risk.

Methods

Children born to 138 HIV-1-seropositive women, 132 HIV-2-seropositive women, 69 women seroreactive to both HIV-1 and HIV-2, and 274 HIV-seronegative women were enrolled at birth and followed up for as long as 48 months. All chidren were breastfed (median duration 20 months). Blood samples for either or both HIV PCR and HIV serology were obtained at 1, 2, and 3 months of age, and every 3 months thereafter. Early HIV infection was defined as a positive HIV-1 PCR result obtained in the first 6 months of life. Late postnatal transmission was diagnosed when a child had a negative PCR at 3 or 6 months of age, followed by either or both a positive HIV-1 PCR at 9 months or older, or persistently positive HIV-1 serology at 15 months or older.

Findings

82 children born to HIV-1-seropositive mothers and 57 children born to mothers seropositive for both HIV-1 and HIV-2 had PCR results for samples taken within the first 6 months. By 6 months of age, 23 (28%; 95% CI 19–39) of the 82 children born to HIV-1-seropositive mothers and ten (18%; 95% CI 9–30) of the 57 children born to dually seropositive mothers were HIV-1 infected. Among children whose PCR results were negative at or before age 6 months, and who were followed up beyond 6 months, an additional four (9%) of the 45 children born to HIV-1-seropositive mothers and two (5%) of the 39 children born to dually seropositive mothers became HIV infected. The estimated rates of late postnatal transmission, with account taken of loss to follow-up and the observed pattern of weaning, were 12% (95% CI 3–23) and 6% (0–14), respectively. One of the five children whose mothers seroconverted from HIV-negative to HIV-1, and one of seven children whose mothers seroconverted from HIV-2 to dual reactivity, became HIV-1 positive. No case of late postnatal transmission occurred in children born to HIV-2-positive or persistently HIV-negative mothers.

Interpretation

Breastfed children born to mothers seropositive for HIV-1 alone or seropositive for HIV-1 and HIV-2 in Abidjan are at substantial risk of late postnatal transmission. Early cessation of breastfeeding at 6 months of age should be assessed as a possible intervention to reduce postnatal transmission of HIV.

Introduction

HIV-1 can be transmitted from an infected mother to her offspring during pregnancy (in utero), during labour and delivery (intrapartum), and after delivery.1 There is substantial evidence that postnatal transmission of HIV-1 occurs predominantly through breastfeeding. Not only has HIV-1 been detected in human breastmilk by viral culture,2 but also mother-to-child transmission of HIV-1 has occurred among breastfeeding women who acquired HIV after delivery.3, 4, 5 In several studies of mother-to-child transmission, moreover, a higher proportion of breastfed than formula-fed children were HIV infected at the end of follow-up.69 To estimate the risk of HIV transmission through breastfeeding from these reports is difficult owing to the small number of breastfeeding women studied, and the varied methods used. However, from a meta-analysis of such reports, this risk has been estimated at 14% for children born to mothers who were seropositive before delivery, and 29% for children born to mothers infected postnatally.10 But the risk of transmission through breastfeeding has not been well characterised. To distinguish postnatal transmission from in-utero or intra-partum transmission more reliably, a defined population of children born to seropositive mothers must be studied by means of virological techniques, such as PCR testing.

Accurate estimates of the risk of HIV-1 transmission through breastfeeding would allow public-health authorities to improve breastfeeding guidelines for HIV-infected women. Such an estimate would also help in the evaluation of interventions currently being investigated to prevent perinatal transmission of HIV-1 in breastfeeding populations. In this study, we assessed the rate of late postnatal mother-to-child HIV transmission among breastfed children in Abidjan, Côte ďIvoire.

Section snippets

Selection of participants and follow-up

Data for this analysis were collected from September, 1990 to October, 1994 in Abidjan, Côte ďIvoire. The study methods and transmission rates among a subset of the cohort have been reported previously.11 Women were screened for HIV-1 and HIV-2 antibodies at delivery. All women residing in Abidjan whose serum was positive for antibodies to HIV-2 or to both HIV-1 and HIV-2 were asked to enrol, as were selected women who were positive for HIV-1 antibody or negative for HIV antibody. Each child

Results

613 mother-child pairs were enrolled. The median follow-up of this population was 27 months, and ranged from 1 to 48 months for all children, and from 30 to 48 months for children who were not lost to follow-up and did not die. All children were breastfed; among children followed up for at least 24 months, the median duration of breastfeeding was 20 months (range 6–33 months). Three HIV-2-seropositive and three HIV-negative women gave birth to twins; these children are excluded from further

Discussion

This study found that 12% of breastfed children of HIV-1-seropositive mothers who escape HIV infection during the first 6 months of life will become HIV infected by 24 months of age. Moreover, among children who escape early infection and who are breastfed until age 24 months, 20% will acquire HIV infection by that age. 28% of children acquired HIV infection in the first 6 months of life. The transmission rates were lower for children born to mothers seropositive for both HIV-1 and HIV-2, but

References (20)

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