TB testing in HIV-positive patients prior to antiretroviral treatment

BACKGROUND: TB diagnosis in patients with HIV is challenging due to the lower sensitivities across tests. Molecular tests are preferred and the Xpert^® MTB/RIF assay has limitations in lower-income settings. We evaluated the performance of loop-mediated isothermal amplification (LAMP) and the lipoarabinomannan (LAM) test in HIV-positive, ART-naïve clinic patients.METHODS: A total of 783 eligible patients were enrolled; three spot sputum samples of 646 patients were tested using TB-LAMP, Xpert, smear microscopy and culture, while 649 patients had TB-LAM testing. Sensitivity, specificity, and negative and positive predictive values were estimated with 95% confidence intervals.RESULTS: Sensitivities for smear microscopy, TB-LAMP and Xpert were respectively 50%, 63% and 74% compared to culture, with specificities of respectively 99.2%, 98.5% and 97.5%. An additional eight were positive on TB-LAM alone. Seventy TB patients (9%) were detected using standard-of-care testing, an additional 27 (3%) were detected using study testing. Treatment was initiated in 57/70 (81%) clinic patients, but only in 56% (57/97) of all those with positive TB tests; 4/8 multidrug-resistant samples were detected using Xpert.CONCLUSION: TB diagnostics continue to miss cases in this high-burden setting. TB-LAMP was more sensitive than smear microscopy, and if followed by culture and drug susceptibility testing as required, can diagnose TB in HIV-positive patients. TB-LAM is a useful add-in test and both tests at the point-of-care would maximise yield.

Are we doing enough? Improved breastfeeding practices at 14 weeks but challenges of non-initiation and early cessation of breastfeeding remain: findings of two consecutive cross-sectional surveys in KwaZulu-Natal, South Africa

Background

KwaZulu-Natal (KZN) Initiative for breastfeeding support (KIBS) was a multipronged intervention to support the initiation and sustaining of breastfeeding, implemented between 2014 and 2017. We present results of two surveys conducted before and after KIBS implementation to assess changes in infant feeding practices in KZN over this time period.

Methods

Two cross-sectional surveys were conducted in primary health care clinics. Multistage stratified random sampling was used to select clinics and participants. Sample size was calculated to provide district estimates of 14-week exclusive breastfeeding (EBF) rates at baseline (KIBS1), and provincial estimates at endpoint (KIBS2). At KIBS1 the sample required was nine participating clinics in each of 11 districts (99 clinics) with 369 participants per district (N = 4059), and at KIBS2 was 30 clinics in KZN with 30 participants per clinic (N = 900). All caregivers aged ≥15 years attending the clinic with infants aged 13- < 16 weeks were eligible to participate. Data was collected using structured interviews on android devices. Multi-variable logistic regression was used to adjust odds ratios for differences between time points.

Results

At KIBS1 (May2014- March2015), 4172 interviews were conducted with carers, of whom 3659 (87.6%) were mothers. At KIBS2 (January–August 2017), 929 interviews were conducted which included 788 (84.8%) mothers. Among all carers the proportion exclusively breastfeeding was 44.6 and 50.5% (p = 0.1) at KIBS1 and KIBS2 respectively, but greater improvements in EBF were shown among mothers (49.9 vs 59.1: p = 0.02). There were reductions in mixed breastfeeding among all infants (23.2% vs 16.3%; p = 0.016). Although there was no change in the proportion of carers who reported not breastfeeding (31.9% vs 32.8%; p = 0.2), the duration of breastfeeding among mothers who had stopped breastfeeding was longer at KIBS2 compared to KIBS1 (p = 0.0015). Mothers who had returned to work or school were less likely to be breastfeeding (adjusted odds ratio [AOR] 3.76; 95% CI 3.1–4.6), as were HIV positive mothers (AOR 2.1; 95% CI 1.7–2.6).

Conclusion

Despite improvements to exclusive breastfeeding, failure to initiate and sustain breastfeeding is a challenge to achieving optimal breastfeeding practices. Interventions are required to address these challenges and support breastfeeding particularly among working mothers and HIV positive mothers.

Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now?

Background

Increasing the rate of exclusive breastfeeding (EBF) to 50% in the first six months of life is one of six major global targets set by the United Nations Decade of Nutrition, and is essential to achieve the sustainable development goals to eradicate hunger and end malnutrition by 2030.

Methods

A survey using multistage random sampling design included 99 primary health care (PHC) clinics in all 11 districts in KwaZulu-Natal (KZN). All mothers and caregivers of infants 14 weeks of age attending the clinics in the study period were requested to participate in a structured interview to explore feeding practices since birth. As non-maternal caregivers may not have detailed knowledge of feeding practices, they provided limited information about current feeding practices. Respondents who consistently reported giving no other food or fluids except breastmilk since birth were classified as practising exclusive breastfeeding (EBF), and those who were currently breastfeeding but had given other food or fluids since birth were categorised as practising mixed breastfeeding (MBF).

Results

A total of 4172 interviews were conducted with mothers and caregivers of 14 week old infants. Among mothers 49.8% were EBF, 23.1% were MBF and 27.0% were not breastfeeding. Among non-maternal caregivers 11.8% reported EBF, 23.4% MBF and 62.3% were not giving breastmilk. Higher education (OR 0.6, 95% CI 0.4–0.8) and being in the highest socio-economic tertile (OR 0.7, 95% CI 0.6–0.9) were risk factors for not practising EBF, while returning to work (OR 0.3, 95% CI 0.2–0.3) or school (OR 0.2 95% CI, 0.1–0.3) was associated with less EBF. HIV-positive mothers were more likely to have never started breastfeeding (OR 3.6, 95% CI 2.7–4.8). However, they were similar in having stopped breastfeeding by 14 weeks (OR 1.1, 95% CI 0.9–1.4) compared to HIV-negative mothers, and, they had similar rates of EBF at 14 weeks of age (OR 1.0, 95% CI 0.9–1.3).

Conclusions

Estimates of breastfeeding practices at 14 weeks in KZN are higher than previously shown. However, particular challenges that should be addressed if international targets for EBF are to be achieved include improving breastfeeding practices of HIV positive mothers and supporting all mothers, particularly working or schooling mothers to continue giving breastmilk while they are away from their children.

Detecting Mycobacterium tuberculosis using the loop-mediated isothermal amplification test in South Africa

SETTING

In South Africa, KwaZulu-Natal is the epicentre of the human immunodeficiency virus (HIV) epidemic, where approximately 70% of people with tuberculosis (TB) are co-infected with HIV. Undiagnosed TB contributes to high mortality in HIV-infected patients. Delays in diagnosing TB and treatment initiation result in prolonged transmission and increased infectiousness.

OBJECTIVE

To evaluate the LoopampTM MTBC Detection kit (TB-LAMP; based on the loop-mediated isothermal amplification assay), smear microscopy and Xpert test with the gold standard of mycobacterial culture.

METHODS

Sputum samples were collected from 705 patients with symptoms of pulmonary TB attending a primary health care clinic.

RESULTS

The TB-LAMP assay had significantly higher sensitivity than smear microscopy (72.6% vs. 45.4%, P < 0.001), whereas specificity was slightly lower (99% vs. 96.8%, P = 0.05), but significantly higher than Xpert (92.9%, P = 0.004). There was no significant difference in sensitivity of smear-positive, culture-positive and smear-negative, culture-positive sputum samples using TB-LAMP vs. Xpert (respectively 95.9%/55.9% vs. 97.6%/66.1%; P =0.65, P = 0.27). The positive predictive value of TB-LAMP was significantly higher than that of Xpert (87.5% vs. 77.0%; P = 0.02), but similar to that of smear microscopy (94.2%; P = 0.18). The negative predictive value was respectively 91.9%, 92.5% (P = 0.73) and 83.1% (P = 0.0001).

CONCLUSION

Given its ease of operability, the TB-LAMP assay could be implemented as a point-of-care test in primary health care settings, and contribute to reducing treatment waiting times and TB prevalence.

Weight evolution and perceptions of adults living with HIV following initiation of antiretroviral therapy in a South African urban setting

BACKGROUND

Obesity and undernutrition are common in South Africa and influence the health outcomes of people living with the human immunodeficiency virus (PLHIV).

AIM

To describe the anthropometric changes and perceptions of body weight in adults initiated on antiretroviral therapy (ART).

METHODS

A cohort of 230 PLHIV was enrolled at an HIV clinic in Durban. Changes in their body mass index, and waist and hip girth were measured 6-monthly in the 12 months following initiation of ART. Data on demographic and socio-economic variables, CD4 counts, opportunistic infections and drug regimens used were recorded. Perceptions of body weight and desire to change these were ascertained.

RESULTS

Weight perceptions of respondents were incongruent with their body mass index, with the trend being to judge themselves as weighing less than their actual weight. Those wanting to gain weight gained an average of 7.8 kg - 2.8 times more than those satisfied with their weight (p<0.001). After 12 months on ART, there was a statistically significant increase in anthropometric measurements (p<0.001) with 43 of the 110 women having waist circumferences that increased their risk of cardiovascular disease; the incidence of lipodystrophy was 35% (62/177) (95% confidence interval 27-42%), 36% (64/177) were overweight and 22% (39/177) were obese, compared with 21% (49.230) and 12% (28/230) respectively at baseline (p=0.002).

CONCLUSION

There is a strong association between PLHIV's perception of body weight, their desire to gain weight and their actual weight gain on ART. Lipodystrophy, weight gain and truncal obesity are common among PLHIV after initiating ART.

Prioritising prevention strategies for patients in antiretroviral treatment programmes in resource-limited settings

Expanded access to antiretroviral therapy (ART) offers opportunities to strengthen HIV prevention in resource-limited settings. We invited 27 ART programmes from urban settings in Africa, Asia and South America to participate in a survey, with the aim to examine what preventive services had been integrated in ART programmes. Twenty-two programmes participated; eight (36%) from South Africa, two from Brazil, two from Zambia and one each from Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe and one occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda and Burundi). Twenty-one sites (96%) provided health education and social support, and 18 (82%) provided HIV testing and counselling. All sites encouraged disclosure of HIV infection to spouses and partners, but only 11 (50%) had a protocol for partner notification. Twenty-one sites (96%) supplied male condoms, seven (32%) female condoms and 20 (91%) provided prophylactic ART for the prevention of mother-to child transmission. Seven sites (33%) regularly screened for sexually transmitted infections (STI). Twelve sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) in activities aimed at serodiscordant couples. Stigma and discrimination, gender roles and funding constraints were perceived as the main obstacles to effective prevention in ART programmes. We conclude that preventive services in ART programmes in lower income countries focus on health education and the provision of social support and male condoms. Strategies that might be equally or more important in this setting, including partner notification, prompt diagnosis and treatment of STI and reduction of stigma in the community, have not been implemented widely.

Rapid testing may not improve uptake of HIV testing and same day results in a rural South African community: a cohort study of 12,000 women

BACKGROUND

Rapid testing of pregnant women aims to increase uptake of HIV testing and results and thus optimize care. We report on the acceptability of HIV counselling and testing, and uptake of results, before and after the introduction of rapid testing in this area.

METHODS AND PRINCIPAL FINDINGS

HIV counsellors offered counselling and testing to women attending 8 antenatal clinics, prior to enrolment into a study examining infant feeding and postnatal HIV transmission. From August 2001 to April 2003, blood was sent for HIV ELISA testing in line with the Prevention of Mother-to-Child Transmission (PMTCT) programme in the district. From May 2003 to September 2004 women were offered a rapid HIV test as part of the PMTCT programme, but also continued to have ELISA testing for study purposes. Of 12,323 women counselled, 5,879 attended clinic prior to May 2003, and 6,444 after May 2003 when rapid testing was introduced; of whom 4,324 (74.6%) and 4,810 (74.6%) agreed to have an HIV test respectively. Of the 4,810 women who had a rapid HIV test, only 166 (3.4%) requested to receive their results on the same day as testing, the remainder opted to return for results at a later appointment. Women with secondary school education were less likely to agree to testing than those with no education (AOR 0.648, p<0.001), as were women aged 21-35 (AOR 0.762, p<0.001) and >35 years (AOR 0.756, p<0.01) compared to those <20 years.

CONCLUSIONS

Contrary to other reports, few women who had rapid tests accepted their HIV results the same day. Finding strategies to increase the proportion of pregnant women knowing their HIV results is critical so that appropriate care can be given.

Messages about dual contraception in areas of high HIV prevalence are not heeded

BACKGROUND

Dual protection is recommended for prevention of unwanted pregnancies and protection against sexually transmitted infections, including HIV. It is critical for HIV-negative women to prevent seroconversion and HIV transmission to their infants during pregnancy and breastfeeding.

METHODS

Women were followed up after delivery, monthly for the first 9 months and then 3-monthly to 24 months, in a cohort study investigating postnatal HIV transmission. Study nurses discussed family planning, including condom use, at each visit. Contraceptive methods used since the last visit were recorded. All women knew their HIV status, and most women breastfed for a minimum of 6 months.

RESULTS

Among 1,137 HIV-positive and 1 220 HIV-negative women the most common contraceptive method was the hormonal injectable; few women used condoms alone or as dual contraception (0-3 months 6.8%; 7-12 months 16.3%; 19-24 months 14.4%). Compared with uninfected women, HIV-positive women were more likely to use condoms in years 1 and 2 after delivery (adjusted odds ratio (AOR) 1.72, 95% confidence interval (CI) 1.38-2.14, p<0.001; AOR 1.61, 95% CI 1.15-2.25, p=0.006 respectively). Compared with women with a flush toilet, those with a pit latrine were less likely to use condoms in years 1 and 2 (AOR 0.22, 95% CI 01.7-0.28, p<0.001; AOR 0.27, 95% CI 0.19-0.39, p<0.001). Older women were more likely to use condoms in the first postpartum year (AOR 1.78, 95% CI 1.03-3.09, p=0.040).

CONCLUSIONS

More creative ways of promoting condoms and dual contraception need to be found if new HIV infections, in women and children, are to be prevented.

Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa

BACKGROUND

Breast problems, including mastitis, can interfere with the duration and exclusivity of breast-feeding. However, there are no large prospective studies documenting the prevalence, duration, and timing of such problems in breast-feeding women, particularly those who are infected with human immunodeficiency virus (HIV).

METHODS

Women enrolled prenatally underwent a breast-feeding counseling intervention until 6 months after delivery. Breast health problems were documented per breast for 180 days after delivery, with 14-day recall histories.

RESULTS

Breast health problems were rare, and there were no significant differences between HIV-infected and HIV-uninfected women for any of the following conditions: engorgement, 39 HIV-infected women (3.5%) versus 33 HIV-uninfected women (2.7%; P=.30); breast thrush, 17 (1.5%) versus 12 (1.0%; P=.25); bleeding nipple, 6 (0.5%) versus 4 (0.3%; P=.45); and mastitis/abscess, 11 (1.0%) versus 6 (0.5%; P=.17). Most problems occurred during the first month after birth, with few additional mothers experiencing problems after this point: at 1 and 6 months, 13% and 17% of all mothers, respectively, had experienced a minor or major breast health problem, including sore nipples. Women who had not exclusively breast-fed their infants were more likely to experience any of the breast health problems than were women who had exclusively breast-fed their infants (time-dependent variable; adjusted odds ratio, 1.46; 95% confidence interval, 1.13-1.87; P=.003). HIV-infected women who experienced any serious breast health problem (i.e., bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess) were 3.55 times (95% confidence interval, 0.86-14.78 times; P=.08) more likely to transmit HIV postnatally to their infant.

CONCLUSIONS

With encouragement to exclusively breast-feed, women experienced few breast health problems. When those problems did occur, HIV-infected women with bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess were more likely to transmit HIV to their infants.

Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice

OBJECTIVE

To examine infant feeding intentions of HIV-infected and uninfected women and the appropriateness of their choices according to their home resources; and to determine their adherence to their intentions in the first postnatal week.

METHODS

Feeding intentions of pregnant women were compared against four resources that facilitate replacement feeding: clean water, adequate fuel, access to a refrigerator and regular maternal income. First-week feeding practices were documented.

FINDINGS

The antenatal feeding intentions of 1253 HIV-infected women were: exclusive breastfeeding 73%; replacement feeding 9%; undecided 18%. Three percent had access to all four resources, of whom 23% chose replacement feeding. Of those choosing replacement feeding, 8% had access to all four resources. A clean water supply and regular maternal income were independently associated with intention to replacement feed (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI) 1.2-3.2; AOR 2.1, 95% CI: 1.2-3.5, respectively). Significantly more HIV-infected women intending to exclusively breastfeed, rather than replacement feed, adhered to their intention in week one (exclusive breastfeeding 78%; replacement feeding 42%; P<0.001). Of 1238 HIV-uninfected women, 82% intended to exclusively breastfeed; 2% to replacement feed; and 16% were undecided. Seventy-five percent who intended to exclusively breastfeed adhered to this intention postnatally, and only 11 infants (<1%) received no breast milk. The number of antenatal home visits significantly influenced adherence to feeding intention.

CONCLUSION

Most HIV-infected women did not have the resources for safe replacement feeding, instead choosing appropriately to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counselling and support, spillover of suboptimal feeding practices to HIV-negative women is minimal.

Bacterial safety of flash-heated and unheated expressed breastmilk during storage

Heat-treated breastmilk is one infant-feeding option recommended by the WHO to reduce mother-to-child transmission of HIV in developing countries. Flash-heat, a simple pasteurization method that a mother could perform in her home, has been shown to inactivate cell-free HIV-1. Since heating may affect the naturally occurring antimicrobial properties found in breastmilk, storing heated breastmilk may present a safety issue in resource-poor settings due to lack of refrigeration and potential contamination. To address this, we investigated the ability of flash-heat to eliminate bacteria and to prevent growth over time compared with unheated breastmilk. We collected breastmilk samples from 38 HIV positive mothers in South Africa and aliquoted them to flash-heated and unheated controls. Samples were stored at room temperature for 0, 2, 6 and 8 h and then plated and incubated for 24 h at 37 degrees C in CO(2). We performed total colony counts and identified Escherichia coli, Staphylocuccus aureus and Group A and Group B streptococci. Unheated samples had a significantly higher number of samples positive for bacterial growth at each time point (p < 0.0001), as well as mean colony-forming units (CFU)/ml in those samples that were positive at each time point (p < 0.0001). In addition, unheated samples had a significantly higher rate of bacterial propagation over time than flash-heated samples when comparing log values of CFU/ml across 0-8 h (p < 0.005). No pathogenic growth was observed in the flash-heated samples, while the unheated samples showed growth of E. coli (n = 1) and S. aureus (n = 6). Our data suggest that storage of flash-heated breastmilk is safe at room temperature for up to 8 h.

Routinely available cotrimoxazole prophylaxis and occurrence of respiratory and diarrhoeal morbidity in infants born to HIV-infected mothers in South Africa

OBJECTIVES

To examine the influence of cotrimoxazole (CTM) prophylaxis on incidence of lower respiratory tract infections (LRTIs) and diarrhoea.

DESIGN

A prospective observational cohort study. Morbidity and feeding data on infants born to HIV-infected mothers were collected routinely at clinic visits at 1 week, 6 weeks and 3 months, and 3-monthly thereafter, with blood drawn for determining HIV status.

SETTING

Two hospitals in Durban, South Africa. In one hospital (King Edward VIII Hospital), infants born to HIV infected mothers received CTM prophylaxis and in the other (McCord Hospital) infants did not receive CTM prophylaxis.

SUBJECTS

Infants born to HIV-infected mothers. Outcome measures. Incidence of LRTI and diarrhoea.

RESULTS

In multivariate analysis controlling for breast-feeding status, number of clinic visits and HIV infection status, HIV infected infants with access to CTM prophylaxis had a significantly lower incidence of LRTI (82%) than those without access to prophylaxis. However in HIV-uninfected infants, this was not the case. CTM prophylaxis was associated with a non-significant increased risk for diarrhea in both infected (odds ratio (OR) 1.58, p = 0.45) and uninfected infants (OR 1.52, p = 0.10).

CONCLUSIONS

This observational study confirms current thinking that CTM prophylaxis is protective against LRTIs in HIV-infected children. However, because of a possible association between CTM prophylaxis and an increased risk of diarrhoea, HIV status of infants should be determined as early as possible in order to prevent unnecessary exposure of uninfected infants to CTM prophylaxis, while further studies to quantify both beneficial and adverse effects of CTM prophylaxis are undertaken.

Morbidity in children born to women infected with human immunodeficiency virus in South Africa: does mode of feeding matter?

AIM

To examine infant morbidity risks associated with refraining from breastfeeding where it is used in an attempt to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV).

METHODS

The population consisted of infants born to HIV-infected women in South Africa who were participating in a vitamin A intervention trial to prevent MTCT of HIV. Women chose to breastfeed or formula feed their infants according to UNAIDS guidelines. Actual feeding practices and morbidity were recorded at clinic follow-up visits at I wk, 6 wk, 3 mo and every 3 mo thereafter until 15 mo of age or cessation of breastfeeding. The infant's HIV status was assessed according to a predetermined algorithm.

RESULTS

HIV-infected infants who were never breastfed had a poorer outcome than those who were breastfed; 9 (60%) of those who were never breastfed had 3 or more morbidity episodes compared with 15 (32%) of breastfed children [odds ratio (OR) 4.05, 95% confidence interval (95% CI) 0.91-20.63, p = 0.05]. During the first 2 mo of life, never-breastfed infants (regardless of HIV status) were nearly twice as likely to have had an illness episode than breastfed infants (OR 1.91, 95% CI 1. 17-3.13, p = 0.006).

CONCLUSION

The significant extra morbidity experienced in the first few months by all never-breastfed infants and at all times by HIV-infected infants who are not breastfed needs to be considered in all decisions by mothers, health workers and policy makers so as not to offset any gains achieved by decreasing HIV transmission through avoiding breastfeeding.

Breastfeeding practices in an area of high HIV prevalence in rural South Africa

Exclusive breastfeeding (EBF) from 0 to 6 mo of age is recommended by the World Health Organization as the optimal feeding method for infants, including infants of human immunodeficiency virus (HIV)-infected women from developing countries who choose to breastfeed. EBF may be associated with less risk of postnatal HIV transmission than mixed feeding, but is still uncommonly practised for reasons that are poorly understood. This study aimed to assess EBF rates and the impediments to EBF in a South African rural area of high HIV prevalence where most mothers are unaware of their status. In a longitudinal study, 130 women attending 3 clinics, chosen for their disparate socioeconomic characteristics, were interviewed at weekly postnatal intervals. Follow-up to 16 wk was completed on 119 infants. In an additional cross-sectional survey mothers of 445 infants, aged 0-12 mo, attending immunization clinics were interviewed. In the longitudinal study 46% of infants received non-breast-milk fluids or feeds within 48 h of birth; only 10% were exclusively breastfed for 6 wk and 6% for 16 wk. Supplements, most commonly formula milk, were introduced for perceived milk insufficiency. Feeding choices were mainly self-determined (43% of women), but health staff (22%) and grandmothers (16%) were cited as sources of advice. In the cross-sectional survey caregivers reported that 47% of infants aged 2 wk, 40% aged 6 wk and 33% aged 12 wk had been exclusively breastfed since birth.

CONCLUSION

EBF is uncommon in this area in spite of a baby-friendly hospital initiative in the district. Strategies to promote exclusive breastfeeding in developing countries where HIV and infant feeding policies are being formulated must strongly address local perceptions on the need for supplements and sources of feeding advice.

Free formula milk for infants of HIV-infected women: blessing or curse?

There is vigorous controversy around whether HIV-infected women in developing countries should choose formula or breastfeeding for their infants. Formula eliminates HIV transmission but incurs risk of increased mortality, whereas breastfeeding has multiple benefits but entails risk of HIV transmission. International guidelines are available but need to be strengthened. This commentary summarizes data on the scale and rate of mother-to-child transmission (MTCT) of HIV through breastfeeding, and the hazards and benefits of breast- and formula-feeding. The case against providing free or subsidized formula to HIV-infected mothers is based on the following: it exacerbates disadvantages of formula feeding; compromises free choice; targets beneficiaries erroneously; creates a false perception of endorsement by health workers; compromises breastfeeding; results in disclosure of HIV status; ignores hidden costs of preparation of formula; increases mixed breastfeeding, which is an unsatisfactory method for all women; requires organization and management of programmes that are complicated and costly; and finally increases the 'spill-over' effect into the normal breastfeeding population. Recommendations to minimize these drawbacks include use of affordable antiretrovirals to reduce MTCT; investments in high-quality, widely available HIV counselling; support for choice of feeding; and exclusive breastfeeding for those who choose to breastfeed.

Epidemiology of helminth infections: implications for parasite control programmes, a South African perspective

OBJECTIVES

To determine the epidemiology of helminthic infections and the efficacy of parasite treatment among rural South African primary school children in the province of KwaZulu-Natal. To assess the South African government's parasite control policy.

METHODS

The study recruited 268 school children, aged 8 to 10, and randomly allocated them into treatment and placebo groups (treatment consisted of a single dose of albendazole (400 mg) and praziquantel (40 mg/kg)). Anthropometric measurements and the prevalence and intensity of helminth infections were taken at baseline (prior to treatment) and 16 weeks post treatment. Two weeks after treatment prevalence and intensity were again measured for an approximate 50% sub-sample of the children to investigate efficacy of treatment. An analysis of the South African government's policies concerning parasite control is assessed in the light of these epidemiological findings.

RESULTS

Low levels of both stunting and wasting were observed throughout the study (approximately 10% and 1%, respectively), but did not vary significantly across either treatment group or time period (P >0.50). At baseline the observed prevalences for the three main helminths found in this study among the treated children were Ascaris lumbricoides 29.5%, Trichuris trichiura 51.9% and Schistosoma haematobium 22.3%. These prevalences declined significantly to 4.7% (P <0.0005), 38.0% (P < 0.03), and 3.3% (P < 0.0002), respectively, 16 weeks post treatment. The majority of infections observed at baseline were of light intensity, namely A. lumbricoides (50%), T. trichiura (80%) and S. haematobium (100%), and following treatment these levels were reduced significantly (P <0.0001, P< 0.05 and P < 0.005, respectively). The levels of both prevalence and intensity in the untreated group remained constant. The cure rates over the first two weeks of the study were found to be 94.4% for A. lumbricoides, 40% for T. trichiura and 72.2% for S. haematobium.

CONCLUSION

The benefits of targeted, school-based treatment in reducing the prevalence and intensity of infection supports the South African government's focus of using school-based interventions as part of an integrated parasite control programme. These strategies and programmes are consistent with recommendations of the World Health Organization (WHO) and The United Nations Children's Fund (UNICEF).

A randomized controlled trial of the effect of antihelminthic treatment and micronutrient fortification on health status and school performance of rural primary school children

Single interventions for helminthic infections and micronutrient deficiencies are effective, but it is not clear whether combined interventions will provide equal, additive or synergistic effects to improve children's health. The study objective was to determine the impact of single and combined interventions on nutritional status and scholastic and cognitive performance of school children. A double-blind, randomized, placebo-controlled trial in 11 rural South African primary school randomly allocated 579 children aged between 8 and 10 years into six study groups, half of whom received antihelminthic treatment at baseline. The de-wormed and non-de-wormed arms were further divided into three groups and given biscuits, either unfortified or fortified with vitamin A and iron or with vitamin A only, given daily for 16 weeks. The outcome measures were anthropometric, micronutrient and parasite status, and scholastic and cognitive test scores. There was a significant treatment effect of vitamin A on serum retinol (p < 0.01), and the suggestion of an additive effect between vitamin A fortification and de-worming. Fortified biscuits improved micronutrient status in rural primary school children; vitamin A with de-worming had a greater impact on micronutrient status than vitamin A fortification alone and antihelminthic treatment significantly reduced the overall prevalence of parasite infection. The burden of micronutrient deficiency (anaemia, iron and vitamin A) and stunting in this study population was low and, coupled with the restricted duration of the intervention (16 weeks), might have limited the impact of the interventions.

Subclinical mastitis as a risk factor for mother-infant HIV transmission

Subclinical mastitis, as diagnosed by an elevated sodium/potassium ratio in milk accompanied by an increased milk concentration of the inflammatory cytokine, interleukin-8 (IL8), was found to be common among breast feeding women in Bangladesh and Tanzania. Subclinical mastitis results in leakage of plasma constituents into milk, active recruitment of leukocytes into milk, and possible infant gut damage from inflammatory cytokines. Therefore, we wished to investigate whether subclinical mastitis was related to known risk factors for postnatal mother-to-child HIV transmission, that is, high milk viral load or increased infant gut permeability. HIV-infected South African women were recruited at the antenatal clinic of McCord's Hospital, Durban. Risks and benefits of different feeding strategies were explained to them and, if they chose to breast feed, they were encouraged to do so exclusively. Women and infants returned to the clinic at 1, 6 and 14 weeks postpartum for an interview about infant health and current feeding pattern, a lactulose/mannitol test of infant gut permeability, and milk sample collection from each breast separately for analysis of Na/K ratio, IL8 concentration and viral load in the cell-free aqueous phase. Only preliminary cross-sectional analyses from an incomplete database are available at this point. Moderately (0.6-1.0) or greatly (>1.0) raised Na/K ratio was common and was often unilateral, although as a group right and left breasts did not differ. Considering both breasts together, normal, moderately raised or greatly raised Na/K was found, respectively, in 51%, 28%, 21% of milk samples at 1 week (n=190); 69%, 20%, 11% at 6 weeks (n=167); and 72%, 16%, 12% at 14 weeks (n=122). IL8 concentration significantly correlated with both Na/K and viral load at all times. Na/K correlated with viral load at 1 and 14, but not 6 weeks. At 1 and 14 weeks, geometric mean viral loads in samples with Na/K > 1.0 were approximately 4 times those in samples with Na/K < 0.6. At 1 week but not later times, exclusive breast feeding was associated with lower milk viral load than was mixed feeding. Gut permeability was unrelated to milk Na/K ratio or IL8 concentration and was not significantly increased by inclusion of other foods than breast milk in the infant's diet. The results suggest that subclinical mastitis among HIV-infected women may increase the risk of vertical transmission through breast feeding by increasing milk viral load. The importance of various causes of subclinical mastitis, which likely differ at 1 week from at later times and may include local infection or sterile inflammation, systemic infection, micronutrient deficiencies, or poor lactation practices, needs to be further clarified so that appropriate interventions can be implemented.

Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women

Exclusive breast feeding has been associated with a lower rate of mother-to-child HIV transmission than breast feeding plus other foods. To obtain further information on biologic outcomes of different feeding modes, we examined 272 infants of HIV-infected South African women at ages 1, 6, and 14 weeks. At each visit information about infant diet and morbidity was collected and infants underwent a lactulose/mannitol dual sugar intestinal permeability test. In a subset of infants, urinary neopterin excretion was measured as an indicator of immune system activation. Infants who had themselves become HIV-infected by 14 weeks had higher ( p <.01) intestinal permeability at 6 and 14 weeks and slightly (.05 < p <.1) higher neopterin excretion at all times than uninfected infants. At 1 week infants given no breast milk had higher ( p <.05) intestinal permeability than infants given breast milk exclusively or with other foods. Intestinal permeability in infants fed breast milk plus other foods was never increased relative to that of exclusively breastfed infants. Feeding mode had no effect on neopterin excretion. Thus, infant HIV infection induces changes in gut permeability and possibly immune system activation before clinical symptoms become apparent. The effects of feeding mode on infant intestinal permeability or urinary neopterin excretion do not explain a possible protective effect of exclusive breast feeding on mother-to-child transmission of HIV.

Variation in breastmilk HIV-1 viral load in left and right breasts during the first 3 months of lactation

The mechanism and risk factors associated with mother-to-child transmission of HIV-1 through breastfeeding remain unclear; breastmilk viral load may be an important determinant of transmission. Analysis of breastmilk cell-free viral load in samples taken from each breast at 1, 6 and 14 weeks postpartum showed that HIV-1 is shed intermittently and load may differ considerably between breasts of an individual woman at any given time. Breastmilk HIV-1 load was undetectable in approximately one-third of samples.

Effects of vitamin A supplementation during pregnancy and early lactation on body weight of South African HIV-infected women

Effects of vitamin A supplementation during pregnancy and early lactation on maternal weight among HIV-1-seropositive South African women were examined. Three hundred twelve HIV-seropositive pregnant women between 28 and 32 weeks gestation were studied as part of a randomized, double-blind, placebo-controlled trial at the King Edward VIII Hospital in Durban, South Africa. Patients were randomized to receive placebo or 5,000 IU of retinyl palmitate and 30 mg of beta-carotene daily during pregnancy. At delivery, patients received placebo or 200,000 IU of retinyl palmitate. The main outcome measures were prenatal and postnatal maternal weight and weight loss at three months after delivery as measured in body mass index (BMI). Supplementation of vitamin A was not associated with improvements in prepartum weight gain but was significantly associated with improved weight retention three to six months after delivery (p = 0.02). The benefit of vitamin A supplementation appeared to be confined to subgroups with baseline CD4+ count < 200 cells/microL and serum retinol 0-20 micrograms/dL. Similar trends were observed in maintenance of postpartum BMI. However, no statistically significant associations were observed. Although there was no benefit of vitamin A supplementation on prepartum weight gain, a benefit on maintenance of postnatal weight was observed. The benefit was highest among those who were vitamin A-deficient or whose CD4+ count was < 200 cells/microL presupplementation. In populations for whom antiretroviral therapy is not readily available or accessible, the finding that vitamin A may improve postpartum weight lends some hope to a relatively inexpensive treatment which could be used for helping ameliorate some weight loss which is common during HIV infection.

Growth in early childhood in a cohort of children born to HIV-1-infected women from Durban, South Africa

This study describes growth in a cohort of black South African children born to HIV-1-infected women in Durban. Children born to HIV-1-seropositive women were followed up from birth to early childhood. At birth and at each visit, growth parameters were measured. Mean Z-scores were calculated for weight-for-length, weight-for-age and length-for-age and, if they were low, the children were regarded as wasted, malnourished or stunted, respectively. At the end of the study, there were 48 infected and 93 uninfected children. There were no significant differences between the two groups at birth. Thereafter, the infected group was found to have early and sustained low mean Z-scores for length-for-age and weight-for-age but not for weight-for-length. The means reached significance at ages 3, 6 and 12 months for length and at 3, 6 and 9 months for weight. Infected children who died early had more severe stunting, wasting and malnutrition than infected children who survived. Infected children born to HIV-positive women have early and sustained stunting and are malnourished but not wasted. Children with rapidly progressive disease have both stunting and wasting and are more severely affected. Early nutritional intervention might help prevent early progression or death in HIV-infected children, particularly in developing countries without access to anti-retroviral therapy in state hospitals.

Interferon-gamma and interleukin-10 production among HIV-1-infected and uninfected infants of HIV-1-infected mothers

Immunologic consequences of exposure to HIV-1 in utero are still poorly understood. This study investigates relationships between type-1 [interferon-gamma (IFN-gamma)] and type-2 (IL-10) cytokine production and maternal-infant HIV-1 transmission. Cord blood leukocytes from deliveries of 71 HIV-1-infected and 11 uninfected mothers were tested for in vitro IFN-gamma and IL-10 production after phytohemagglutinin (PHA) stimulation. The infants of these HIV-1-infected mothers were followed prospectively after birth to determine HIV vertical transmission, and IFN-gamma and IL-10 production was measured again at 6 mo. Median PHA-stimulated IFN-gamma production was 210 pg/mL in cord blood cells from infected and 73 pg/mL from uninfected mothers (p = 0.12), and median PHA-stimulated IL-10 production was 491 pg/mL in cord blood cells from infected and 161 pg/mL from uninfected mothers (p = 0.004). PHA-stimulated IFN-gamma and IL-10 production alone were not significantly associated with transmission, but relationships between the two cytokines differed among infected and uninfected infants of HIV-1-infected mothers. PHA-stimulated IFN-gamma and IL-10 production was positively correlated among infected (r = 0.7, p = 0.12 in cord blood and r = 0.66, p = 0.03 at 6 mo) but not uninfected infants, and stronger relative production of IFN-gamma to IL-10 was observed among exposed uninfected than among infected infants (p = 0.04). Exposure in utero to HIV-1 may augment production of IL-10 detectable in fetal cord blood. Stronger relative production of IFN-gamma to IL-10 in cord blood cells from infants of HIV-1-infected mothers may be associated with protection against perinatal HIV infection.

The effect of antenatal vitamin A and beta-carotene supplementation on gut integrity of infants of HIV-infected South African women

BACKGROUND

Vitamin A is important for protection against diarrhea, and supplements may benefit gut function of infants of HIV-infected mothers.

METHODS

We studied 238 infants of HIV-infected South African women participating in a randomized, double-blind, placebo-controlled trial of vitamin A during pregnancy (1.5 mg retinyl palmitate and 30 mg beta-carotene daily) plus 60 mg retinyl palmitate at delivery. The placebo group received identical placebo capsules at the same times. When infants were 1, 6, and 14 weeks of age, lactulose/mannitol dual sugar intestinal permeability tests were performed.

RESULTS

Maternal vitamin A supplementation did not significantly affect infant gut permeability in the group as a whole at any time. By multiple regression analysis, HIV infection of the infant by 14 weeks was significantly associated with increased gut permeability at both 6 and 14 weeks. After controlling for birth weight, gestational age, current weight, feeding mode and recent morbidity, there was a trend toward an interaction between vitamin A supplementation and HIV infection (P = 0.086) at 14 weeks. Vitamin A made no difference to gut permeability of uninfected infants (lactulose/mannitol ratio for vitamin A group: 0.11, 95% confidence interval [CI] 0.08, 0.15, n = 73 and for placebo group: 0.09, 95% CI 0.06, 0.12, n = 76), but largely prevented the increase in the ratio of HIV-infected infants (vitamin A group: 0.17, 95% CI 0.13, 0.23, n = 23; placebo group: 0.50, 95% CI 0.37, 0.68, n = 20). The effects on the lactulose/mannitol ratio were related to changes in lactulose, not mannitol, excretion. Vitamin A supplementation was associated with significantly lower lactulose excretion at 1 and 14 weeks, suggesting the major effect of vitamin A was on maintaining the integrity of gut tight junctions.

CONCLUSIONS

Vitamin A supplementation of HIV-infected pregnant women may prevent the deterioration in gut integrity in the subgroup of their infants who themselves become infected. Improving vitamin A status of HIV-infected infants may decrease their gastrointestinal morbidity.

A health and nutritional profile of rural school children in KwaZulu-Natal, South Africa

A community-based cross-sectional study was undertaken to measure anthropometric indices, micronutrient status and prevalence of parasite infections in 579 rural South African primary school children. Eleven schools were selected randomly from a Magisterial District in southern KwaZulu-Natal (KZN). In each school, all pupils aged between 8 and 10 years were selected. The following outcome measures were obtained: anthropometric--height for age, weight for age and body mass index; micronutrient status--anaemia, serum ferritin and vitamin A; and prevalence of parasite infections--Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium. The observed prevalences were: stunting 7.3%, underweight for age 0.7%, and obesity 3.1%; anaemia 16.5% (Hb < 12 g/dl), vitamin A deficiency 34.7% (serum retinol < 20 micrograms/dl) and 28.1% with reduced serum ferritin (< 12 ng/ml); Trichuris trichiura 53.9%, Ascaris lumbricoides 27.3% and Schistosoma haematobium 24.5%. We conclude that micronutrient deficiency, parasitic infestations and stunting remain significant problems among school-aged children in South Africa. Micronutrient supplementation and de-worming provide opportunities for school-based health promotion and primary health care interventions, and might produce significant health and educational benefits.

Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa

OBJECTIVE

To determine the risk of HIV transmission by infant feeding modality.

DESIGN AND SETTING

A prospective study in two hospitals in Durban, South Africa.

PARTICIPANTS

A total of 551 HIV-infected pregnant women enrolled in a randomized trial of vitamin A.

INTERVENTIONS

Women self-selected to breastfeed or formula feed after being counselled. Breastfeeders were encouraged to practice exclusive breastfeeding for 3-6 months.

MAIN OUTCOME MEASURES

Cumulative probabilities of detecting HIV over time were estimated using Kaplan-Meier methods and were compared in three groups: 157 formula-fed (never breastfed); 118 exclusively breastfed for 3 months or more; and 276 mixed breastfed.

RESULTS

The three feeding groups did not differ in any risk factors for transmission, and the probability of detecting HIV at birth was similar. Cumulative probabilities of HIV detection remained similar among never and exclusive breastfeeders up to 6 months: 0.194 (95% CI 0.136-0.260) and 0.194 (95% CI 0.125-0.274), respectively, whereas the probabilities among mixed breastfeeders soon surpassed both groups reaching 0.261 (95% CI 0.205-0.319) by 6 months. By 15 months, the cumulative probability of HIV infection remained lower among those who exclusively breastfed for 3 months or more than among other breastfeeders (0.247 versus 0.359).

CONCLUSION

Infants exclusively breastfed for 3 months or more had no excess risk of HIV infection over 6 months than those never breastfed. These findings, if confirmed elsewhere, can influence public health policies on feeding choices available to HIV-infected mothers in developing countries.

Secretory leukocyte protease inhibitor in vaginal fluids and perinatal human immunodeficiency virus type 1 transmission

The presence of both viral particles and antiviral mucosal proteins may represent critical determinants of perinatal human immunodeficiency virus type 1 (HIV-1) transmission. In 60 HIV-1-infected women, concentrations of the innate mucosal protein, secretory leukocyte protease inhibitor (SLPI), were lower in vaginal fluid samples from 17 women whose babies became infected than in samples from nontransmitting women (mean+/-SE, 57+/-11 vs. 557+/-177 ng/mL, respectively; P=.01). Rates of transmission among women with higher SLPI concentrations (>100 ng/mL) were lower than those among women with lower concentrations (<100 ng/mL; 8.7% vs. 40.5%, respectively; P=.01). Concentrations of other putative HIV-1-inhibitory innate immune factors were similar in both groups. Concentrations of vaginal HIV-1 tended to be higher in transmitting than in nontransmitting women (407 vs. 174 virions/mL; P=.09). Increased concentrations of selected innate mucosal immune factors, such as SLPI, seem to be associated with reduced rates of perinatal HIV-1 transmission and may contribute to natural antiretroviral defense.

T-helper cell responses to HIV envelope peptides in cord blood: protection against intrapartum and breast-feeding transmission

BACKGROUND

Acquired HIV-specific cell-mediated immune responses have been observed in exposed-uninfected individuals, and it has been inferred, but not demonstrated, that these responses constitute a part of natural protective immunity to HIV. This inference was tested prospectively in the natural exposure setting of maternal-infant HIV transmission in a predominantly breast-fed population.

METHODS

Cord blood from infants of HIV-seropositive women in Durban, South Africa, were tested for in vitro reactivity to a cocktail of HIV envelope peptides (Env) using a bioassay measuring interleukin-2 production in a murine cell line. Infants were followed with repeat HIV RNA tests up to 18 months of age to establish which ones acquired HIV-infection.

RESULTS

T-helper cell responses to Env were detected in 33 out of 86 (38%) cord blood samples from infants of HIV-seropositive women and in none of nine samples from seronegative women (P = 0.02). Among infants of HIV-seropositive mothers, three out of 33 with T-helper responses to Env were already infected before delivery (HIV RNA positive on the day of birth), two were lost to follow-up, and none of the others (out of 28) were found to be HIV infected on subsequent tests. In comparison, six out of 53 infants unresponsive to Env were infected before delivery, and eight out of 47 (17%) of the others were found to have acquired HIV infection intrapartum or post-partum through breast-feeding (P = 0.02).

CONCLUSIONS

T-helper cell responses to HIV envelope peptides were detected in more than one-third of newborns of HIV-infected women; no new infections were acquired by these infants at the time of delivery or post-natally through breast-feeding if these T-helper cell responses were detected in cord blood.

Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa

Previous studies on the effect of breastfeeding on mother-to-child transmission (MTCT) of HIV have not attempted to examine the influence of different types of breastfeeding practice. To attempt to address some of these inadequacies, infant feeding practices of 549 HIV-infected women involved in a trial in Durban, South Africa were documented prospectively. Women were counseled on infant feeding choices according to UNAIDS guidelines, and those who chose to breastfeed were encouraged to practice exclusive breastfeeding. The MTCT rates of HIV-1 at 3 months were compared in the three different feeding groups (never breastfed, exclusive breastfeeding, and mixed breastfeeding). At 3 months, 18.8% of 156 never-breastfed children were infected compared to 21.3% of 393 breastfed children (p = 0.50). Children exclusively breastfed to at least 3 months (n = 103) were less likely to be infected (14.3%) than those receiving mixed feeding before 3 months (24.1%) (p = 0.03). After adjustment for potential confounders (maternal CD4:CD8 ratio, syphilis screening test results, and preterm delivery), exclusive breastfeeding carried a significantly lower risk of HIV-1 transmission than mixed feeding (hazard ratio [HR] 0.52, 95% CI: 0.28-0.98) and an equivalent risk to no breastfeeding (HR 0.85, 95% CI: 0.51-1.42). Our findings have important implications for HIV and infant feeding policies in developing countries, and it is critical that further research be undertaken. In the meantime, breastfeeding policies for HIV-infected women require urgent review. If confirmed, exclusive breastfeeding may offer HIV-infected women in developing countries an affordable, culturally acceptable, and effective means of reducing MTCT of HIV-1 while maintaining the overwhelming benefits of breastfeeding.

HIV in pregnancy: strategies for management

HIV/AIDS is now the leading cause of mortality in Africa. Measures for preventing HIV infection in women are central to any strategy to manage this disease in pregnancy. The use of anti-retrovirals (ARVs) has reduced vertical transmission in industrialized countries by about two-thirds. Recent ARV trials in developing countries reveal relative efficacies at 6 months of about 40% in breast feeding and 50% in non-breast feeding populations. New data on breast feeding adds to the information on the pathogenesis of postnatal transmission and can influence feeding recommendations. Strategies suitable and inappropriate for developing countries, and operational difficulties, are discussed.

Cell-free virus in breast milk of HIV-1-seropositive women

To examine the prevalence, quantification, and factors that influence HIV in the cell-free compartment of breast milk, we performed reverse transcription polymerase chain reaction (RT-PCR) on samples obtained from HIV-1-infected study subjects. Virus was detected in 86 of 136 samples (63.2%) from 79 study subjects. HIV RNA quantity ranged from undetectable to 227,586 copies/ml. Prevalence and mean viral load were not affected by postnatal ages or maternal vitamin A supplementation. Among study subjects with multiple samples, breast milk viral load did not change at different postnatal ages. Breast milk viral load correlated positively with plasma viral load (r = 0.47; p =.005) and negatively with maternal CD4 count at entry to the study (r = -0.26; p =.02). Mothers of HIV-infected children had a higher proportion of detectable HIV RNA in their breast milk than mothers of uninfected children (p =.03) and higher mean log10 HIV RNA quantities (p =.04). In a multivariate logistic regression model, log10 HIV RNA quantity in breast milk was significantly associated with the risk of mother-child transmission (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.22-6.51). Thus, prevention and treatment of opportunistic infections and of mastitis and early weaning may be important elements of a public health policy that is relevant to women in developing countries with HIV infection. Where available, antiretrovirals may also have an impact on opportunistic infections and mastitis.

Effect of vitamin A supplementation on morbidity of low-birth-weight neonates

BACKGROUND

Low-birth-weight (LBW) infants (< 2,500 g) are at increased risk of respiratory infection in the first few months of life and have low liver stores of vitamin A. As retinol is essential for respiratory epithelial cell differentiation, deficiency could result in pathological changes in the respiratory epithelium, with respiratory problems.

OBJECTIVE

A randomised, double-blind, placebo-controlled trial to investigate the effect of vitamin A supplementation on the incidence and severity of respiratory infections in LBW infants during their first year of life.

METHOD

One hundred and thirty LBW infants (gestational age < 36 weeks and birth weight 950-1,700 g) were enrolled in the study. The infants were randomly allocated to a vitamin A or placebo group. Infants in the vitamin A group received 25,000 IU of vitamin A (retinyl palmitate, Arovit drops, Roche, Basle, Switzerland) on study days 1, 4 and 8. Study day 1 was between 36 and 60 hours after delivery. Infants in the placebo group received a placebo (formulated by Roche) with a similar appearance and packed in the same dropper bottles as the vitamin A drops.

RESULTS

Vitamin A supplementation markedly improved serum retinol levels. After the last vitamin A dose, the vitamin A group had higher mean serum retinol concentrations than the placebo group (45.77 +/- 17.07 micrograms/dl v. 12.88 +/- 6.48 micrograms/dl, P = 0.0001). There was no evidence of improvement in neonatal or post-neonatal respiratory problems associated with vitamin A supplementation. Vitamin A and placebo groups did not differ in the occurrence or duration of respiratory distress or the need for head-box oxygen. There were also no significant differences in the cumulative probability of developing lower or upper respiratory tract infection through the first year of life. There was a slight suggestion of an increase in the risk of hospitalisation with pneumonia associated with vitamin A supplementation. The cumulative probability of being hospitalised with pneumonia by 6 months of age was 24.6% (7 hospitalisations) in the vitamin A group compared with 7.4% (2 hospitalisations) in the placebo group (log rank test P = 0.04). After adjusting for risk factors this difference was no longer significant.

CONCLUSION

Vitamin A supplementation in LBW neonates may not reduce incidence or severity of respiratory infections. These results do not negate the importance of improving vitamin A status in children as an important public health measure to reduce morbidity and mortality from other childhood infections.

Randomized controlled trial assessing the effect of vitamin A supplementation on maternal morbidity during pregnancy and postpartum among HIV-infected women

OBJECTIVE

To determine whether low-cost treatment of HIV using vitamin A would be beneficial, we examined the effect of vitamin A supplementation on morbidity of HIV-1 infected women.

METHODS

We conducted a randomized, double blind placebo-controlled trial at King Edward VIII Hospital, in Durban, South Africa. In total, 312 HIV-seropositive pregnant women between 28 and 32 weeks' gestation were recruited into this trial. Patients were randomized to receive placebo or 5,000 IU retinyl palmitate and 30 mg beta-carotene daily. At delivery of their children, patients received placebo or 200,000 IU retinyl palmitate. The main outcome measures were pre- and postnatal report of HIV-related symptoms.

RESULTS

Vitamin A did not confer any significant beneficial effect on the report of either HIV or pregnancy-related symptoms during the pre- or postnatal period.

CONCLUSION

In this study of HIV-infected pregnant women, vitamin A supplementation given in doses designed to decrease mother-to-infant transmission did not result in significant beneficial effect on reported symptoms pre- or postnatally. Further investigation with larger number of participants, tailoring supplementation for specific clinical conditions, outside the context of pregnancy, is required to help clarify the possible clinical benefits of vitamin A.

Randomized trial testing the effect of vitamin A supplementation on pregnancy outcomes and early mother-to-child HIV-1 transmission in Durban, South Africa. South African Vitamin A Study Group

OBJECTIVE

Poor vitamin A status has been associated with a higher risk for mother-to-child transmission of HIV-1 and there is contradictory evidence on the impact of vitamin A on perinatal outcome. We therefore assessed the effect of vitamin A supplementation to mothers on birth outcome and mother-to-child transmission of HIV-1.

DESIGN AND METHODS

In Durban, South Africa 728 pregnant HIV infected women received either vitamin A (368) or placebo (360) in a randomized, double-blind trial. The vitamin A treatment consisted of a daily dose of 5000 IU retinyl palmitate and 30 mg beta-carotene during the third trimester of pregnancy and 200000 IU retinyl palmitate at delivery. HIV infection results were available on 632 children who were included in the Kaplan-Meier transmission analysis. Results are reported on mother-to-child transmission rates up to 3 months of age.

RESULTS

There was no difference in the risk of HIV infection by 3 months of age between the vitamin A [20.3%; 95% confidence interval (CI), 15.7-24.9] and placebo groups (22.3%; 95% CI, 17.5-27.1), nor were there differences in foetal or infant mortality rates between the two groups. Women receiving vitamin A supplement were, however, less likely to have a preterm delivery (11.4% in the vitamin A and 17.4% in the placebo group; P = 0.03) and among the 80 preterm deliveries, those assigned to the vitamin A group were less likely to be infected (17.9%; 95% CI, 3.5-32.2) than those assigned to the placebo group (33.8%; 95% CI, 19.8-47.8).

CONCLUSION

Vitamin A supplementation, a low-cost intervention, does not appear to be effective in reducing overall mother-to-child transmission of HIV; however, its potential for reducing the incidence of preterm births, and the risk of mother-to-child transmission of HIV in these infants needs further investigation.

Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group

BACKGROUND

The observation that mother-to-child transmission of HIV-1 can occur through breastfeeding has resulted in policies that recommend avoidance of breastfeeding by HIV-1-infected women in the developed world and under specific circumstances in developing countries. We compared transmission rates in exclusively breastfed, mixed-fed, and formula-fed (never breastfed) infants to assess whether the pattern of breastfeeding is a critical determinant of early mother-to-child transmission of HIV-1.

METHODS

We prospectively assessed infant-feeding practices of 549 HIV-1-infected women who were part of a vitamin A intervention trial in Durban, South Africa. The proportions of HIV-1-infected infants at 3 months (estimated by use of Kaplan-Meier life tables) were compared in the three different feeding groups. HIV-1 infection was defined by a positive RNA-PCR test.

FINDINGS

At 3 months, 18.8% (95% CI 12.6-24.9) of 156 never-breastfed children were estimated to be HIV-1 infected compared with 21.3% (17.2-25.5) of 393 breastfed children (p=0.5). The estimated proportion (Kaplan-Meier) of infants HIV-1 infected by 3 months was significantly lower for those exclusively breastfed to 3 months than in those who received mixed feeding before 3 months (14.6% [7.7-21.4] vs 24.1% [19.0-29.2], p=0.03). After adjustment for potential confounders (maternal CD4-cell/CD8-cell ratio, syphilis screening test results, and preterm delivery), exclusive breastfeeding carried a significantly lower risk of HIV-1 transmission than mixed feeding (hazard ratio 0.52 [0.28-0.98]) and a similar risk to no breastfeeding (0.85 [0.51-1.42]).

INTERPRETATIONS

Our findings have important implications for prevention of HIV-1 infection and infant-feeding policies in developing countries and further research is essential. In the meantime, breastfeeding policies for HIV-1-infected women require urgent review. If our findings are confirmed, exclusive breastfeeding may offer HIV-1-infected women in developing countries an affordable, culturally acceptable, and effective means of reducing mother-to-child transmission of HIV-1 while maintaining the overwhelming benefits of breastfeeding.

Mortality in a cohort of children born to HIV-1 infected women from Durban, South Africa

OBJECTIVES

To describe mortality in a cohort of infants with vertically transmitted HIV-1 infection.

PATIENTS AND METHODS

Children of HIV-1 infected women were followed up from birth and a record was made at each visit of growth, development and all illnesses. Details surrounding death were obtained from hospital records.

RESULTS

The final cohort comprised 48 infected and 93 uninfected children; there were 25 deaths, 17 of which (35%) were regarded as being HIV-related. The mean age at death of HIV-related cases was 10.1 months (range 1-48 months), with 83% of HIV-related deaths occurring before the age of 10 months. The commonest diagnoses at the time of death were diarrhoea, pneumonia, failure to thrive and severe thrush. These findings, together with neurological abnormalities, often presaged rapid deterioration and death.

CONCLUSIONS

Mortality among children with vertically acquired HIV infection is high in the first year of life. Death in these subjects was due to the common causes of morbidity and mortality among all children in developing countries. A combination of diarrhoea, pneumonia, failure to thrive, and neurological abnormalities should alert one to the possibility of rapidly progressive disease and death.

The early natural history of vertically transmitted HIV-1 infection in African children from Durban, South Africa

Forty-eight children with vertically transmitted HIV-1 infection and 93 uninfected infants were followed up at regular intervals from birth for a mean of 26 months. They were examined physically, growth and development were assessed and illnesses recorded. Seventy per cent of infected infants were symptomatic by 6 months. Relative risks in the infected infants were highest for lymphadenopathy (4.56; CI 2.7-7.7), failure to thrive (4.48; 2.57-7.81), and neurological abnormalities (3.32; 1.9-5.58). The most frequent findings were diarrhoea (78%), pneumonia (76%) and lymphadenopathy (70%). Thrush and pneumonia occurred early but declined over time, whereas diarrhoea and neurological abnormalities occurred later and increased in frequency. A diagnosis of AIDS was made in 44% of infected infants by 12 months of age. Mortality in infected infants was 35.4%, and 76% of deaths occurred within the 1st year. About two-thirds of HIV-infected infants survived into early childhood. In South African children with vertically acquired HIV-1 infection the onset of disease is early and deterioration to AIDS and death are rapid. Infected infants can be easily recognized clinically, the majority by 6 months of age.

Breastfeeding by HIV-1-infected women and outcome in their infants: a cohort study from Durban, South Africa

BACKGROUND

Women in developing countries have the difficult choice of balancing the risk of transmitting HIV through breast milk against the substantial benefits of breastfeeding. It is not known, however, whether the benefits of breastfeeding are the same when the mother is HIV-infected. Therefore, we examined the impact of breastfeeding on infections, growth and mortality in the infants of HIV-1-infected women.

METHODS

Infants of HIV-1-positive women were followed from birth and at each visit they were examined, growth parameters were recorded and notes were made of feeding method, and of current and interim illnesses.

RESULTS

Of the 43 HIV-infected and 90 non-infected infants for whom feeding data were available, 36 infants (27%) were exclusively breastfed, 76 (57%) received mixed feeding, and 21 (16%) received formula only. The HIV transmission rate was 39% in those exclusively breastfed, 24% in those fed exclusively on formula and 32% in those receiving mixed feeding [relative risk (RR), 7.39; 95% confidence interval (CI), 1.67-32.6 between the exclusive breast and formula only groups]. There was a stepwise increase in the transmission rate with duration of exclusive breastfeeding of 1, 2 and 3 months (45%, 64%, and 75%, respectively). Of the infected infants, seven (50%) exclusively breastfed, 13 (51%) of those on mixed feeds and none on formula only developed AIDS; exclusively breastfed infants had a slower rate of progression to AIDS (mean age, 7.5 months versus 5.0 months, P = 0.2242) than those on mixed feeds. Mortality (which occurred in the infected infants only) was 19% in the exclusively breastfed infants; 13% in those on mixed feeds and 0% in those exclusively formula-fed. The frequency of failure to thrive and episodes of diarrhoea and pneumonia were not significantly different between the three groups in both the infected and non-infected infants.

CONCLUSIONS

Exclusive breastfeeding by HIV-infected women does not appear to protect their infants against common childhood illnesses and failure to thrive, nor does it significantly delay progression to AIDS. The implication of the trend towards differential mortality rates according to feeding groups is uncertain and requires further investigation.

Lead poisoning of children in Africa, II. Kwazulu/Natal, South Africa

The prevalence of elevated blood lead (PbB) levels in rural and semi-urban areas of Kwazulu/Natal (KZN) as well as the risk factors for elevation of PbB among children in informal settlements are examined. The study involved over 1200 children in two age groups: 3-5 and 8-10 years old. Average PbB level in Besters, an informal settlement in the Durban metropolitan region, was 10 micrograms/dl with 5% of the children showing PbB level of greater than 25 micrograms/dl. By comparison, average PbB value in Vulamehlo, a rural area located 90-120 km from Durban, was 3.8 micrograms/dl and 2% of the PbB was greater than 10 micrograms/dl. The results show that many children in KZN are at risk of being lead poisoned. Household factors that were significantly associated with PbB levels in children included distance from tarred roads, overcrowding, hygienic habits in the household and the burning of solid wastes for heating or cooking. Lack of significant association with child risk behaviors is attributed to the over-riding influence of high levels of contaminated dusts both indoor and outdoor. With recent introduction of unleaded gasoline in South Africa, a number of unique socio-ecological factors are expected to slow the change in PbB levels of children in some townships.