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Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area
Global Health Sciences Literature Digest
Published July 10, 2008
Journal Article

Bland RM, Little KE, Coovadia HM, Coutsoudis A, Rollins NC, Newell M-L. Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS 2008;22:883-91.

In Context

Exclusive breast-feeding (EBF) (defined as no food or liquids other than breast milk, except for vitamin or medication drops or syrups) for the first six months of life improves child health and survival and is of particular benefit in developing countries where safe and practical alternatives are limited;(1) however, EBF is not widely practiced.(2) In areas with high prevalence of HIV, confusion over feeding recommendations has contributed to lower rates of EBF among women without HIV or with unknown HIV status.


To evaluate an intervention to increase EBF in an area with high prevalence of HIV and low rates of EBF.


Antenatal clinics (ANCs) in KwaZulu-Natal, South Africa.

Study Design

Non-randomized intervention trial.


Women attending ANCs in rural (n=7), semi-urban (n=1), or urban (n=1) areas between 2001 and 2004.


Cumulative EBF rates from birth to 6 months and predictors of EBF.


Twelve lay counselors and 30 counselors who counsel on breastfeeding discussed infant feeding options with all women according to WHO/UNAIDS guidelines. HIV-uninfected women were provided with information on EBF for 0-6 months and sustained breastfeeding thereafter. HIV-infected women were informed of EBF, replacement feeding, and criteria required for replacement feeding. Counselors met with all women at home after enrollment to review the study methods. HIV-infected women who did not intend to breastfeed were referred to an infant feeding specialist for additional support. Women who chose to breastfeed received up to three antenatal home visits by the counselors. Within 72 hours of delivery, the counselors conducted home visits with all of the women, regardless of their antenatal feeding choice. Those who initiated breastfeeding received an additional three home visits in the first two weeks followed by visits every fourth week up to six months. Supervisors conducted on-site visits of each counselor to monitor the quality of counseling and to assist when needed. In addition, nurses provided support to mothers at routine clinic visits.

Counselors recorded information on breast health and feeding technique. Study monitors conducted weekly home visits to document all feeds and fluids for each day of the preceding week. Mothers maintained feeding diaries. Health problems related to breastfeeding and difficulties with breastfeeding were recorded. When mothers were absent, follow-up visits were conducted on the following two days. The counselors and monitors were not aware of the mothers' HIV status. Safety concerns resulted in replacing home visits with clinic visits.

Kaplan-Meier curves were used to measure cumulative breastfeeding rates and Cox proportional hazards models were used to identify maternal and infant characteristics associated with EBF.


Between October 2001 and April 2005, 2781 women delivered 2831 live infants. Feeding information was available for 1219 infants born to HIV-uninfected women and to 1217 HIV-infected women. Data from 41 sets of twins was excluded from analysis. Feeding information was available for 1025 (84%) of HIV-uninfected women and for 941 (77.3%) of HIV-infected women. The median duration of EBF was 177 days (interquartile range [IQR] 150-180) for infants born to HIV-uninfected women and 175 days (IQR 137-180) for infants of HIV-infected mothers. Eighty percent of infants were EBF at one month and 60% at 5.5 months; rates were similar for HIV-infected and HIV-uninfected women. Factors that independently predicted discontinuing EBF among both infected and uninfected women included having electricity at home, intention to formula feed prior to delivery, and breast health problems or breastfeeding difficulties (P<0.05). Factors that lowered the risk of discontinuing EBF were living in an urban area and fewer antenatal visits (HIV-uninfected women only). Counseling was strongly associated with EBF at one-, two-, and four-month visits among both infected and uninfected women.


Home support is associated with improved rates of EBF.

Quality Rating

As an intervention trial, this study was of fair quality. It was not randomized, and blinding to HIV status occurred after follow-up and it may not have been sustained as women may have disclosed their status or circumstances may have led the counselors to assume participants serostatus. The follow-up period and proportion of women who completed the study was appropriate. A strength of the study was the use of a rigorous definition of EBF and documentation of feeding practices using more than one method and person.

Programmatic Implications

Although debate remains regarding optimal feeding practices for HIV-infected women whose children are uninfected, EBF is of major benefit to HIV-uninfected women in developing countries. This study found higher EBF rates in HIV-infected women than previously reported(3) and demonstrates that a simple and inexpensive counseling intervention has a great effect on EBF rates. Thus, programs on maternal-child health and prevention of mother-to-child transmission of HIV should consider adding home visits and counseling to the services they provide.


  1. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Lancet 2000 Feb 5;355(9202):451-55.
  2. Trussell J G-SL, Rodriguez G. Trends and differentials in breastfeeding behaviour: evidence from the WFS and DHS. Pop Stud 1992;46:285-307.
  3. Doherty T, Chopra M, Jackson D, Goga A, Colvin M, Persson LA. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS 2007 Aug 20;21(13):1791-7.