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Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa
Global Health Sciences Literature Digest
Published February 25, 2008
Journal Article

Bland RM, Becquet R, Rollins NC, Coutsoudis A, Coovadia HM, Newell ML. Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa. Clin Infect Dis. 2007 Dec 1; 45(11):1502-10.


To report the prevalence, duration, timing, and determinants of breast health problems in HIV-infected and HIV-uninfected women in rural and urban Africa who underwent an intervention designed to improve exclusive breastfeeding rates in the first 6 months after birth.

Study Design

Prospective nonrandomized intervention cohort study.


Nine clinics (eight rural and one urban) in KwaZulu Natal, South Africa.


Both HIV-infected and HIV-uninfected pregnant women who delivered a live birth and initiated breastfeeding in the first 2 days after delivery were included in the analysis.


At the prenatal clinic, lay HIV counselors provided all pregnant women with individual counseling on infant feeding options, according to WHO/UNAIDS recommendations. HIV-uninfected women were counseled to exclusively breastfeed for the first 6 months of life (180 days), with sustained breastfeeding to at least 2 years. The option of replacement feeding (commercial formula feeds) or exclusive breastfeeding for the first 6 months of life was discussed with HIV-infected women, who made decisions based on their home circumstances. Being exclusively breast-fed at a given age is defined as breast milk only since birth and thus no water, other fluids or foods. Lay breastfeeding counselors blinded to the HIV status of the women visited all enrolled women at home to discuss feeding practices and study involvement. Women choosing to breastfeed were visited regularly at home by breastfeed counselors for up to four visits prenatally, then four visits in the first 2 weeks after delivery, followed by a visit once every 2 weeks up to 6 months. At each postnatal visit, the breastfeed counselors asked mothers to describe any breast health problems they had experienced between the current and last visit (14-day recall). Breast health problems for each breast were documented separately. The breastfeed counselors were trained in the diagnosis, management, and appropriate referral of breast health problems. In the case of serious breast problems (see definitions below), HIV-uninfected women were encouraged to continue to breastfeed, whereas HIV-infected women were advised to stop breastfeeding from the affected breast until the problem resolved, but to maintain milk production by hand milk expression. In addition, field monitors visited all mothers weekly to document all feeds (milk and solids) and fluids for each day of the preceding week (7-day recall). Due to safety concerns, women in the urban clinic received all support and monitoring at the clinic.

Primary Outcomes

The primary outcome was the occurrence of breast health problems during the first 6 months after delivery documented in three ways: 1. any of the following breast health problems: painful nipple, cracked nipple, bleeding nipple, engorgement, blocked milk duct, breast thrush, nipple oozing pus, breast oozing pus, mastitis, abscess; 2. any breast health problem, excluding sore nipples; and 3. any of the following breast health problems considered to be the most painful and serious and also associated with postnatal HIV transmission: bleeding nipple, pus oozing from the nipple or breast, mastitis, or breast abscess. In particular, whether women had exclusively breast-fed or engaged in "mixed" breastfeeding before the occurrence of the breast health problem was examined as an outcome. The effect of breast health problems on the risk of postnatal transmission of HIV also was examined.


The number of women with a known HIV status who delivered a live infant totaled 2,755, of whom 429 were excluded from the study (40 because the infant died in the first week, 152 moved from the area or withdrew in the first week, 47 had unknown feeding data during the first 2 days, and 190 did not breastfeed during the first 2 days). Therefore, data from 2,326 women (1,119 HIV-infected women and 1,207 HIV-uninfected women) were included in the analysis. There were no significant differences in basic sociodemographic characteristics between women included and excluded from the analysis. Compared to HIV-uninfected women, HIV-infected women statistically were older; more were urban, peri-urban, currently at school, and main income providers; and more had a previous live-born child. Fewer had a child still breast-fed at 180 days.

Breast health problems were rare: 17% of HIV-infected women and 15% of HIV-uninfected women experienced a breast health problem (including sore nipples), and 2% and 1% experienced a serious breast health problem, respectively. 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=0.30); breast thrush, 17 (1.5%) versus 12 (1.0%; p=0.25); bleeding nipple, 6 (0.5%) versus 4 (0.3%; p=0.45); and mastitis/abscess, 11 (1.0%) versus 6 (0.5%; p=0.17). Most breast health problems occurred during the first month. By 1 and 6 months, an estimated 13% and 17% of women, respectively, had experienced any minor or major breast health problem, including sore nipples. The probability of a woman having any breast health problem was associated with characteristics possibly indicating the intensity of support available, including no home visits in urban areas (adjusted odds ratio [AOR], 1.38; 95% confidence interval [CI], 1.11-1.72; p=0.003) and receipt of fewer prenatal visits (AOR, 1.25; 95% CI, 1.00-1.55; p=0.05). Women who had not exclusively breast-fed their infants immediately before occurrence of the breast health problem also were more likely to experience any breast health problem than were women who had exclusively breast-fed (time-dependent variable; AOR, 1.46; 95% CI, 1.13-1.87; p=0.003). HIV-infected women were twice as likely as HIV-uninfected women to experience a serious pathology (AOR, 2.12; 95% CI, 1.02-4.43; p=0.05), and nonexclusive breastfeeding was significantly associated with the risk of the serious breast pathology (AOR, 2.58; 95% CI, 1.22-5.43; p=0.01).

The adjusted hazard ratios of occurrence of breast health problems on the risk of postnatal HIV transmission was assessed among the 860 children born to HIV-infected mothers who were HIV-negative during the peripartum period. Adjustment was made for baseline maternal CD4 cell count, maternal level of education, and maternal employment in the formal economic sector. Although HIV-infected women who experienced any breast health problems or who experienced a breast health problem other than painful nipples were, respectively, 1.68 (95% CI, 0.97-2.94; p=0.05) and 1.88 (95% CI, 0.98-3.61; p=0.06) times more likely to subsequently transmit HIV postnatally, women with the most painful and serious breast health problems were 3.55 times (95% CI, 0.86-14.78 times; p=0.08) more likely to transmit HIV postnatally to their infant than were those without breast health problems.


The authors conclude by encouraging exclusive breastfeeding among women who 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.

Quality Rating

Using the Newcastle-Ottawa grading system, this study received an excellent rating because of the prospective daily documentation with 14-day and 7-day recall histories of breast health problems and feeding practices, respectively, in a large cohort of HIV-infected and HIV-uninfected women. The lack of a control group, however, limits the ability to assess the role of the intervention.

In Context

A lower prevalence of all breast health problems, particularly mastitis/abscess, was found in this study compared with other reports (1,2,3) and with findings in KwaZulu Natal, where 19% of women complained of a breastfeeding difficulty in the first 16 weeks after delivery, before the implementation of the breastfeeding intervention.(4) The authors state that the decreased rates are most likely associated with the quality of support the women received as part of the intervention and the high rates of exclusive breastfeeding achieved.

Programmatic Implications

The low rates of breast health problems found in this study are encouraging; however, the intervention studied was resource-intensive and may not easily be implemented in many settings. Importantly, although women in the urban areas who received clinic-based counseling were more likely to experience any breast health problem, they were not more likely to experience serious breast health pathology. Clinic-based support for infant feeding may be a more feasible intervention on a large scale and could be complemented by community health worker home visits, where available. Additional studies of such interventions that also include a control group are needed. This study also found that most breast health problems occurred during the first month of breastfeeding, emphasizing the importance of support during this time, especially with primiparous women. The increased rate of serious breast health problems and of HIV transmission to infants in HIV-infected women emphasizes the importance of breastfeeding support and early detection and treatment of breast pathology in HIV-infected women. When problems do occur, healthcare workers should counsel HIV-infected women to express and discard milk from the affected side until the problems resolve. Finally, the increased breast health problems in women who did not exclusively breastfeed underscores the importance of avoiding mixed feeding, which is commonly practiced in many developing areas.


  1. Riordan JM, Nichols FH. A descriptive study of lactation mastitis in longterm breastfeeding women. J Hum Lact 1990;6:53-8.
  2. John GC, Nduati RW, Mbori-Ngacha DA, Richardson BA, Panteleeff D, Mwatha A, et al. Correlates of mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission: association with maternal plasma HIV-1 RNA load, genital HIV-1DNA shedding, and breast infections. J Infect Dis 2001;183:206-12.
  3. Semba RD, Kumwenda N, Hoover DR, Taha TE, Quinn TC, Mtimavalye L, et al. Human immunodeficiency virus load in breast milk, mastitis, and mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 1999;180:93-8.
  4. Bland RM, Rollins NC, Coutsoudis A, Coovadia HM; Child Health Group. Breastfeeding practices in an area of high HIV prevalence in rural South Africa. Acta Paediatr 2002;91:704-11.