The Feasibility of Replacement Feeding as an HIV Prevention Method in Malawi

Mother-to-child-transmission (MTCT) of HIV can occur during pregnancy (5-10%), delivery (10-20%), or the postnatal period from breastfeeding (5-20%). For the purpose of reducing MTCT during the postnatal period, The World Health Organization has developed HIV and Infant feeding guidelines, which recommend exclusive breastfeeding for up to 6 months among HIV-infected mothers choosing to breastfeed, with cessation of breastfeeding once replacement feeding is acceptable, feasible, affordable, sustainable and safe. Adapting these guidelines to the local circumstances of low-income populations in resource poor settings, such as Malawi, is a great challenge. Meeting nutritional adequacy when breastfeeding is withdrawn from the infant diet is of major concern, since traditional weaning diets are often inadequate even when breast milk is included.

The Breastfeeding, Antiretroviral, and Nutrition (BAN) study is an on-going, randomized controlled trial in Lilongwe, Malawi that is evaluating antiretroviral and nutrition interventions to reduce mother-to-child transmission of HIV during breastfeeding. All enrolled mothers are counseled to exclusively breastfeed for six months, and then to gradually wean their infants from 6-7 months. At 6 months, all BAN mothers are provided with a ready-to-use therapeutic food (RUTF), which is designed to provide all the infants' micronutrient requirements and to replace the proportion of energy and protein that would be provided in breastmilk. Using quantitative data from the on-going BAN Study, this project will determine overall nutrient adequacy of the infant diet at 7-12 months. We will describe dietary composition, consumption and adequacy of energy, protein, fat and micronutrient intakes, feeding patterns, and examine the influence of season on diet. Among a sub-sample of BAN mothers and infants who have exited the BAN trial, we will explore feeding and care practices, dietary adequacy, and growth and compare these with a matched sample of mothers and infants from the community. The BAN study provides a unique opportunity to assess dietary patterns after breastmilk cessation when a high quality breastmilk substitute is provided, and to explore feeding patterns and growth when BAN children exit the trial. This information will help to guide the Malawi government policy and others on the feasibility of the provision of a high-quality breastmilk replacement for HIV positive mothers after exclusive breastfeeding counseling.

Principal Investigator: Margaret E. Bentley

Funding Source: NIH

Grant Number: 1R03HD057775

Funding Period: 09/30/07-08/31/10