The South African Vertical Transmission Study (VTS) supported HIV-positive and HIV-negative women to exclusively breastfeed (EBF) their infants in a rural area of South Africa where mixed breastfeeding (i.e. breastmilk and other fluids and solids) was the norm. We aim to investigate whether this early feeding intervention is associated with further benefits for children, in terms of development, health and school readiness of HIV-negative children 7-10 years of age. We will compare their development to HIV-negative children from the same area in the Africa Centre Demographic Surveillance area whose mothers were not part of the VTS intervention (control group). Those in the control were exposed to the same standard of care provided by local clinics, including the same messages regarding HIV and early infant feeding. However, unlike the VTS cohort, they did not receive home-based counseling by lay counsellors  to support EBF. If benefits for the children are established, this will have major policy and clinical implications especially in view of the relative simplicity and low cost of the intervention and global recommendations about breastfeeding.

• Assessments conducted on 1579 children and 1579 mothers 7-10 years after the original EBF intervention.
• Assessments focused on cognitive outcomes, socio-emotional wellbeing of children, physical growth of children, and maternal mental health.
• Breastfeeding is recommended for all infants of HIV-negative mothers to 2 years of age, and also for infants of HIV-positive women for one year with antiretroviral cover, in areas of the world where formula feeding is not feasible or safe. However, there is strong evidence that without support women do not manage to EBF for 6 months, and EBF rates remain low globally. This research has the potential to demonstrate the longer term benefits of EBF using a sustainable counselor model.
• Public health investment decisions may be motivated and informed by the availability of evidence on the longer term impact for human capital potential of children born to HIV-positive and HIV-negative children provided by this work.

Funders

• The original VTS was funded by the Wellcome Trust, UK, and conducted at the Africa Centre for Health and Population Studies, South Africa. The Africa Centre is funded by the Wellcome Trust.
• Grand Challenges Canada

Key Drivers

Interventions that increase EBF are important, timely and need to be informed by cost, sustainability and suitability to a wide array of resource-poor settings. A key variable to wider implementation of the VTS intervention is that it was delivered by lay counselors, local women with no tertiary or previous health training and mostly previously unemployed. All counselors were trained in basic counseling techniques and breastfeeding support using the WHO/UNICEF Breastfeeding Counselling Course which is freely available. Ongoing in-service support was provided throughout the original VTS This training model is cost appropriate to many low resource settings and several additional resources, including a DVD, have already been developed and are available to support scale-up activities.

Challenges

EBF was not previously practiced in the area (similar to most settings globally) – most women mixed breast fed (i.e. gave breastmilk + formula/water/other fluids or foods) to their infants from early in their lives. The challenge was to change breastfeeding practice amongst both women, and to convince health workers and the families of the mothers that EBF was the optimal way to feed infants.

This current study aims to examine the development and growth of children who were EBF. Internationally recognized assessment tools, including the Kaufmann Battery Assessment for Children will be used.

The original VTS was the first unequivocal demonstration that EBF reduced the risk of mother-to-child transmission of HIV, compared to mixed breastfeeding, and demonstrated that, with support, high rates of EBF were possible in an area where mixed breastfeeding was known to be the norm. These findings have influenced national and international policy. [3]

Costs

An economic analysis of the original intervention has been conducted and published. A further cost analysis of the longer term benefits of breastfeeding, depending on the outcomes of this study, will be undertaken.

1. Bland R, et al. (2009) Cohort Profile: Mamanengane or the Africa Centre Vertical Transmission Study. Int J Epidemiol. Mar 31 2009.
2. Bland RM, et al. (2008) Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS. Apr 23 2008;22(7):883-891.
3. Coovadia HM, et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. Mar 31 2007;369(9567):1107-1116.
4. Bland RM, et al. (2007) Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ. Apr 2007;85(4):289-296.
5. Patel D, et al. (2010) Breastfeeding, HIV status and weights in South African children: a comparison of HIV-exposed and unexposed children. AIDS. Jan 28 2010;24(3):437-445.
6. Rollins NC, et al. (2008) Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes. AIDS. Nov 12 2008;22(17):2349-2357.
7. Coutsoudis A, et al. (2010) Women’s morbidity and mortality in the first 2 years after delivery according to HIV status. AIDS. Nov 27 2010;24(18):2859-2866.
8. Bland RM, et al. (2007) 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. Dec 1 2007;45(11):1502-1510.