Use of population-specific infant mortality rates to inform policy decisions regarding HIV and infant feeding

Mother-to-child transmission of HIV occurs during pregnancy, at the time of delivery, and through breastfeeding (BF). WHO recommends avoidance of all BF when replacement feeding (RF) is affordable, feasible, acceptable, sustainable, and safe. Otherwise, exclusive breastfeeding (EBF) followed by early BF cessation is recommended. Governments are currently scaling up programs to prevent infant HIV infection. Few data exist to guide policy decisions about the allocation of resources to prevent postnatal HIV transmission while minimizing the non-HIV-related risks of these policies. This paper presents an analysis of the impact of WHO infant feeding recommendations in different settings characterized by infant mortality rate (IMR). Mathematical simulation modeling is used to estimate the effects on HFS (HFS) through 24 mo of 3 intervention scenarios: RF from birth by HIV-positive mothers (RF24), EBF up to 6 mo followed by early BF cessation (EBF6), and the default scenario where there is no postnatal intervention (BF24). This analysis differs from earlier reports in that it uses the most recent data on risks of postnatal HIV transmission for mixed and exclusive BF. These simulations suggest that in settings where IMR is <25/1000 live births, RF24 results in the greatest HFS to 24 mo; EBF6 produces the best outcome where IMR > 25/1000 live births. RF24 results in lower HFS than no postnatal intervention where IMR >/= 101/1000. IMR-based analyses can help to guide government policy decisions about which infant feeding strategies to invest in and emphasize for HIV-positive mothers in different settings.