Context Breastfeeding among women infected with human immunodeficiency virus
type 1 (HIV-1) is associated with substantial risk of HIV-1 transmission,
but little is known about the morbidity risks associated with formula feeding
in infants of HIV-1–infected women in resource-poor settings.
Objective To compare morbidity, nutritional status, mortality adjusted for HIV-1
status, and cause of death among formula-fed and breastfed infants of HIV-1–infected
Design Randomized clinical trial conducted between 1992 and 1998.
Setting Four antenatal clinics in Nairobi, Kenya.
Participants Of 401 live-born, singleton, or first-born twin infants of randomized
HIV-1–seropositive mothers, 371 were included in the analysis of morbidity
Interventions Mothers were randomly assigned either to use formula (n = 186) or to
breastfeed (n = 185) their infants.
Main Outcome Measures Mortality rates, adjusted for HIV-1 infection status; morbidity; and
nutritional status during the first 2 years of life.
Results Two-year estimated mortality rates among infants were similar in the
formula-feeding and breastfeeding arms (20.0% vs 24.4%; hazard ratio [HR],
0.8; 95% confidence interval [CI], 0.5-1.3), even after adjusting for HIV-1
infection status (HR, 1.1; 95% CI, 0.7-1.7). Infection with HIV-1 was associated
with a 9.0-fold increased mortality risk (95% CI, 5.3-15.3). The incidence
of diarrhea during the 2 years of follow-up was similar in formula and breastfeeding
arms (155 vs 149 per 100 person-years, respectively). The incidence of pneumonia
was identical in the 2 groups (62 per 100 person-years), and there were no
significant differences in incidence of other recorded illnesses. Infants
in the breastfeeding arm tended to have better nutritional status, significantly
so during the first 6 months of life.
Conclusions In this randomized clinical trial, infants assigned to be formula fed
or breastfed had similar mortality rates and incidence of diarrhea and pneumonia
during the first 2 years of life. However, HIV-1–free survival at 2
years was significantly higher in the formula arm. With appropriate education
and access to clean water, formula feeding can be a safe alternative to breastfeeding
for infants of HIV-1–infected mothers in a resource-poor setting.