Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Prevention of HIV transmission during breastfeeding in resource-limited settings

Grace John-Stewart, MD
Section Editor
Lynne M Mofenson, MD
Deputy Editor
Allyson Bloom, MD


Mother-to-child HIV-1 transmission occurs in utero, peripartum, and postnatally via breastfeeding; without interventions the risk of perinatal HIV-1 transmission is 20 to 45 percent [1].

Over the past two decades, clinical trials have demonstrated that the risk of mother-to-child transmission can be significantly reduced with the administration of antiretroviral medications during pregnancy, delivery, and the early postpartum period (eg, two to four weeks after delivery) [2-5]. However, excess HIV transmission has been observed among breastfeeding infants after short-term prophylactic strategies are completed following delivery. Since breastfeeding is important for the nutritional and overall health of the infant, subsequent studies have been designed to evaluate the role of antiretroviral medications during the postnatal period in preventing HIV transmission during breastfeeding.

This topic will discuss clinical data from resource-limited settings on the prevention of HIV transmission during the breastfeeding period. Advice on the use of antepartum and intrapartum antiretroviral prophylaxis for prevention of mother-to-child HIV transmission in low- to mid-resource countries are discussed in detail elsewhere and in the 2016 World Health Organization consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. (See "Prevention of mother-to-child HIV transmission in resource-limited settings".)


Transmission risk during breastfeeding — Early evidence for HIV transmission via breast milk included detection of virus in breast milk, higher rates of mother-to-infant HIV transmission in regions where women mostly breastfed (eg, Africa) than in areas where they mainly replacement fed (eg, the United States and Europe), observational studies in which breastfed infants had higher transmission than non-breastfed infants, and cases in which women acquired HIV after pregnancy and then transmitted to their breastfeeding infant [1]. There have also been reports of infection in infants born to HIV-uninfected mothers but breastfed by HIV-infected surrogates [6]. Additionally, there have been rare reports of HIV transmission in the opposite direction from nosocomially-infected (eg, through blood transfusion) infants to HIV-uninfected mothers through breastfeeding [7]. In such cases, transmission likely occurs as a result of breastfeeding contact during a period of epithelial disruption such as maternal skin fissures or infant stomatitis.

HIV detection in infants during the first two weeks of life may represent transmission that has occurred in utero, during delivery, or within the early days of breastfeeding [8]. This complicates estimation of early breast milk HIV transmission risk during the first month of life. Most studies that have evaluated the risk of infant acquisition of HIV infection through breastfeeding have begun data collection at one month of life to avoid this overlap of potential transmission routes.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Mar 10, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. John GC, Kreiss J. Mother-to-child transmission of human immunodeficiency virus type 1. Epidemiol Rev 1996; 18:149.
  2. Kesho Bora Study Group, de Vincenzi I. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. Lancet Infect Dis 2011; 11:171.
  3. Marazzi MC, Nielsen-Saines K, Buonomo E, et al. Increased infant human immunodeficiency virus-type one free survival at one year of age in sub-saharan Africa with maternal use of highly active antiretroviral therapy during breast-feeding. Pediatr Infect Dis J 2009; 28:483.
  4. Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med 2010; 362:2282.
  5. Chasela CS, Hudgens MG, Jamieson DJ, et al. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med 2010; 362:2271.
  6. Goedhals D, Rossouw I, Hallbauer U, et al. The tainted milk of human kindness. Lancet 2012; 380:702.
  7. Little KM, Kilmarx PH, Taylor AW, et al. A review of evidence for transmission of HIV from children to breastfeeding women and implications for prevention. Pediatr Infect Dis J 2012; 31:938.
  8. Bryson YJ, Luzuriaga K, Sullivan JL, Wara DW. Proposed definitions for in utero versus intrapartum transmission of HIV-1. N Engl J Med 1992; 327:1246.
  9. Van de Perre P, Simonon A, Msellati P, et al. Postnatal transmission of human immunodeficiency virus type 1 from mother to infant. A prospective cohort study in Kigali, Rwanda. N Engl J Med 1991; 325:593.
  10. Rousseau CM, Nduati RW, Richardson BA, et al. Association of levels of HIV-1-infected breast milk cells and risk of mother-to-child transmission. J Infect Dis 2004; 190:1880.
  11. Koulinska IN, Villamor E, Chaplin B, et al. Transmission of cell-free and cell-associated HIV-1 through breast-feeding. J Acquir Immune Defic Syndr 2006; 41:93.
  12. Nduati R, Mbori-Ngacha D, John G, et al. Breastfeeding in women with HIV. JAMA 2000; 284:956.
  13. Miotti PG, Taha TE, Kumwenda NI, et al. HIV transmission through breastfeeding: a study in Malawi. JAMA 1999; 282:744.
  14. Breastfeeding and HIV International Transmission Study Group, Coutsoudis A, Dabis F, et al. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis 2004; 189:2154.
  15. John GC, Nduati RW, Mbori-Ngacha DA, et al. Correlates of mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission: association with maternal plasma HIV-1 RNA load, genital HIV-1 DNA shedding, and breast infections. J Infect Dis 2001; 183:206.
  16. Sabbaj S, Ghosh MK, Edwards BH, et al. Breast milk-derived antigen-specific CD8+ T cells: an extralymphoid effector memory cell population in humans. J Immunol 2005; 174:2951.
  17. Rousseau CM, Nduati RW, Richardson BA, et al. Longitudinal analysis of human immunodeficiency virus type 1 RNA in breast milk and of its relationship to infant infection and maternal disease. J Infect Dis 2003; 187:741.
  18. Drake AL, Wagner A, Richardson B, John-Stewart G. Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: a systematic review and meta-analysis. PLoS Med 2014; 11:e1001608.
  19. Ndirangu J, Viljoen J, Bland RM, et al. Cell-free (RNA) and cell-associated (DNA) HIV-1 and postnatal transmission through breastfeeding. PLoS One 2012; 7:e51493.
  20. Van de Perre P, Simonon A, Hitimana DG, et al. Infective and anti-infective properties of breastmilk from HIV-1-infected women. Lancet 1993; 341:914.
  21. Kuhn L, Coutsoudis A, Moodley D, et al. T-helper cell responses to HIV envelope peptides in cord blood: protection against intrapartum and breast-feeding transmission. AIDS 2001; 15:1.
  22. John-Stewart GC, Mbori-Ngacha D, Payne BL, et al. HV-1-specific cytotoxic T lymphocytes and breast milk HIV-1 transmission. J Infect Dis 2009; 199:889.
  23. Lohman-Payne B, Slyker JA, Moore S, et al. Breast milk cellular HIV-specific interferon γ responses are associated with protection from peripartum HIV transmission. AIDS 2012; 26:2007.
  24. Farquhar C, VanCott T, Bosire R, et al. Salivary human immunodeficiency virus (HIV)-1-specific immunoglobulin A in HIV-1-exposed infants in Kenya. Clin Exp Immunol 2008; 153:37.
  25. Farquhar C, Mbori-Ngacha DA, Redman MW, et al. CC and CXC chemokines in breastmilk are associated with mother-to-child HIV-1 transmission. Curr HIV Res 2005; 3:361.
  26. Tiemessen CT, Kuhn L. CC chemokines and protective immunity: insights gained from mother-to-child transmission of HIV. Nat Immunol 2007; 8:219.
  27. Lehman DA, Farquhar C. Biological mechanisms of vertical human immunodeficiency virus (HIV-1) transmission. Rev Med Virol 2007; 17:381.
  28. Semba RD, Kumwenda N, Hoover DR, et al. Human immunodeficiency virus load in breast milk, mastitis, and mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 1999; 180:93.
  29. Semba RD, Kumwenda N, Taha TE, et al. Mastitis and immunological factors in breast milk of lactating women in Malawi. Clin Diagn Lab Immunol 1999; 6:671.
  30. Semba RD, Kumwenda N, Taha TE, et al. Mastitis and immunological factors in breast milk of human immunodeficiency virus-infected women. J Hum Lact 1999; 15:301.
  31. Semba RD, Neville MC. Breast-feeding, mastitis, and HIV transmission: nutritional implications. Nutr Rev 1999; 57:146.
  32. Willumsen JF, Filteau SM, Coutsoudis A, et al. Breastmilk RNA viral load in HIV-infected South African women: effects of subclinical mastitis and infant feeding. AIDS 2003; 17:407.
  33. Van de Perre P, Lepage P, Homsy J, Dabis F. Mother-to-infant transmission of human immunodeficiency virus by breast milk: presumed innocent or presumed guilty? Clin Infect Dis 1992; 15:502.
  34. Shen R, Smythies LE, Clements RH, et al. Dendritic cells transmit HIV-1 through human small intestinal mucosa. J Leukoc Biol 2010; 87:663.
  35. Veazey R, Lackner A. The mucosal immune system and HIV-1 infection. AIDS Rev 2003; 5:245.
  36. Lapenta C, Boirivant M, Marini M, et al. Human intestinal lamina propria lymphocytes are naturally permissive to HIV-1 infection. Eur J Immunol 1999; 29:1202.
  37. Kourtis AP, Ibegbu CC, Wiener J, et al. Role of intestinal mucosal integrity in HIV transmission to infants through breast-feeding: the BAN study. J Infect Dis 2013; 208:653.
  38. Abel K, Pahar B, Van Rompay KK, et al. Rapid virus dissemination in infant macaques after oral simian immunodeficiency virus exposure in the presence of local innate immune responses. J Virol 2006; 80:6357.
  39. Milush JM, Kosub D, Marthas M, et al. Rapid dissemination of SIV following oral inoculation. AIDS 2004; 18:2371.
  40. Taha TE, et al. Comparing maternal triple antiretrovirals and infant nevirapine prophylaxis for the prevention of mother-to-child transmission of HIV during breastfeeding. Presented at the 8th International Workshop on HIV Pediatrics and poster presentation at the 21st International AIDS Conference (AIDS 2016). July 2016. Durban, South Africa.
  41. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, second edition. June 2016. http://www.who.int/hiv/pub/arv/arv-2016/en/ (Accessed on June 15, 2016).
  42. Currier J, Britto P, Hoffman R, et al. Randomized Trial of Stopping or Continuing ART among Postpartum Women with Pre-ART CD4 >400 cells/mm(3) (PROMISE 1077HS). Presented at the 21st International AIDS Conference (AIDS 2016). July 2016. Durban, South Africa.
  43. 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; 355:451.
  44. World Health Organization. Guideline: Updates on HIV and infant feeding. www.who.int/nutrition/publications/hivaids/guideline_hiv_infantfeeding_2016/en/ (Accessed on February 23, 2017).
  45. Coutsoudis A, Kuhn L, Pillay K, Coovadia HM. Exclusive breast-feeding and HIV transmission. AIDS 2002; 16:498.
  46. Iliff PJ, Piwoz EG, Tavengwa NV, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005; 19:699.
  47. Coovadia HM, Rollins NC, Bland RM, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 2007; 369:1107.
  48. Kuhn L, Sinkala M, Kankasa C, et al. High uptake of exclusive breastfeeding and reduced early post-natal HIV transmission. PLoS One 2007; 2:e1363.
  49. Tomlinson M, Doherty T, Ijumba P, et al. Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township. Trop Med Int Health 2014; 19:256.
  50. http://www.who.int/hiv/pub/mtct/antiretroviral/en/index.html (Accessed on September 10, 2010).
  51. World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. September 2015. http://apps.who.int/iris/bitstream/10665/186275/1/9789241509565_eng.pdf?ua=1 (Accessed on September 30, 2015).
  52. Gallant JE, DeJesus E, Arribas JR, et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med 2006; 354:251.
  53. Ribaudo HJ, Kuritzkes DR, Lalama CM, et al. Efavirenz-based regimens in treatment-naive patients with a range of pretreatment HIV-1 RNA levels and CD4 cell counts. J Infect Dis 2008; 197:1006.
  54. Ahmed S, Kim MH, Abrams EJ. Risks and benefits of lifelong antiretroviral treatment for pregnant and breastfeeding women: a review of the evidence for the Option B+ approach. Curr Opin HIV AIDS 2013; 8:474.
  55. Centers for Disease Control and Prevention (CDC). Impact of an innovative approach to prevent mother-to-child transmission of HIV--Malawi, July 2011-September 2012. MMWR Morb Mortal Wkly Rep 2013; 62:148.
  56. Tweya H, Gugsa S, Hosseinipour M, et al. Understanding factors, outcomes and reasons for loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi. Trop Med Int Health 2014; 19:1360.
  57. Kim MH, Zhou A, Mazenga A, et al. Why Did I Stop? Barriers and Facilitators to Uptake and Adherence to ART in Option B+ HIV Care in Lilongwe, Malawi. PLoS One 2016; 11:e0149527.
  58. Haas AD, Msukwa MT, Egger M, et al. Adherence to Antiretroviral Therapy During and After Pregnancy: Cohort Study on Women Receiving Care in Malawi's Option B+ Program. Clin Infect Dis 2016; 63:1227.
  59. Zeh C, Weidle PJ, Nafisa L, et al. HIV-1 drug resistance emergence among breastfeeding infants born to HIV-infected mothers during a single-arm trial of triple-antiretroviral prophylaxis for prevention of mother-to-child transmission: a secondary analysis. PLoS Med 2011; 8:e1000430.
  60. Fogel J, Li Q, Taha TE, et al. Initiation of antiretroviral treatment in women after delivery can induce multiclass drug resistance in breastfeeding HIV-infected infants. Clin Infect Dis 2011; 52:1069.
  61. Lidstrom J, Guay L, Musoke P, et al. Multi-class drug resistance arises frequently in HIV-infected breastfeeding infants whose mothers initiate HAART postpartum. 17th Conference on Retroviruses and Opportunistic Infections, San Francisco, CA, February 16-19, 2010 (Abs. 920).
  62. Nelson JA, Fokar A, Hudgens MG, et al. Frequent nevirapine resistance in infants infected by HIV-1 via breastfeeding while on nevirapine prophylaxis. AIDS 2015; 29:2131.
  63. Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med 2004; 351:217.
  64. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994; 331:1173.
  65. Fowler MG, Qin M, Fiscus SA, et al. Benefits and Risks of Antiretroviral Therapy for Perinatal HIV Prevention. N Engl J Med 2016; 375:1726.
  66. Leroy V, Newell ML, Dabis F, et al. International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-1 infection. Ghent International Working Group on Mother-to-Child Transmission of HIV. Lancet 1998; 352:597.
  67. White AB, Mirjahangir JF, Horvath H, et al. Antiretroviral interventions for preventing breast milk transmission of HIV. Cochrane Database Syst Rev 2014; :CD011323.
  68. Taha TE, Kumwenda J, Cole SR, et al. Postnatal HIV-1 transmission after cessation of infant extended antiretroviral prophylaxis and effect of maternal highly active antiretroviral therapy. J Infect Dis 2009; 200:1490.
  69. Thomas TK, Masaba R, Borkowf CB, et al. Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding--the Kisumu Breastfeeding Study, Kenya: a clinical trial. PLoS Med 2011; 8:e1001015.
  70. Mofenson LM. Protecting the next generation--eliminating perinatal HIV-1 infection. N Engl J Med 2010; 362:2316.
  71. Shapiro RL, Kitch D, Ogwu A, et al. HIV transmission and 24-month survival in a randomized trial of HAART to prevent MTCT during pregnancy and breastfeeding in Botswana. AIDS 2013; 27:1911.
  72. Siegfried N, van der Merwe L, Brocklehurst P, Sint TT. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev 2011; :CD003510.
  73. Six Week Extended-Dose Nevirapine (SWEN) Study Team, Bedri A, Gudetta B, et al. Extended-dose nevirapine to 6 weeks of age for infants to prevent HIV transmission via breastfeeding in Ethiopia, India, and Uganda: an analysis of three randomised controlled trials. Lancet 2008; 372:300.
  74. Kumwenda NI, Hoover DR, Mofenson LM, et al. Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission. N Engl J Med 2008; 359:119.
  75. Coovadia HM, Brown ER, Fowler MG, et al. Efficacy and safety of an extended nevirapine regimen in infant children of breastfeeding mothers with HIV-1 infection for prevention of postnatal HIV-1 transmission (HPTN 046): a randomised, double-blind, placebo-controlled trial. Lancet 2012; 379:221.
  76. Hudgens MG, Taha TE, Omer SB, et al. Pooled individual data analysis of 5 randomized trials of infant nevirapine prophylaxis to prevent breast-milk HIV-1 transmission. Clin Infect Dis 2013; 56:131.
  77. Fowler MG, Coovadia H, Herron CM, et al. Efficacy and safety of an extended nevirapine regimen in infants of breastfeeding mothers with HIV-1 infection for prevention of HIV-1 transmission (HPTN 046): 18-month results of a randomized, double-blind, placebo-controlled trial. J Acquir Immune Defic Syndr 2014; 65:366.
  78. Nagot N, Kankasa C, Tumwine JK, et al. Extended pre-exposure prophylaxis with lopinavir-ritonavir versus lamivudine to prevent HIV-1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): a randomised controlled trial. Lancet 2016; 387:566.
  79. Jamieson DJ, Chasela CS, Hudgens MG, et al. Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial. Lancet 2012; 379:2449.
  80. Mirochnick M, Best BM, Stek AM, et al. Lopinavir exposure with an increased dose during pregnancy. J Acquir Immune Defic Syndr 2008; 49:485.
  81. Stek AM, Mirochnick M, Capparelli E, et al. Reduced lopinavir exposure during pregnancy. AIDS 2006; 20:1931.
  82. Best BM, Stek AM, Mirochnick M, et al. Lopinavir tablet pharmacokinetics with an increased dose during pregnancy. J Acquir Immune Defic Syndr 2010; 54:381.
  83. Chung MH, Kiarie JN, Richardson BA, et al. Breast milk HIV-1 suppression and decreased transmission: a randomized trial comparing HIVNET 012 nevirapine versus short-course zidovudine. AIDS 2005; 19:1415.
  84. Shapiro RL, Holland DT, Capparelli E, et al. Antiretroviral concentrations in breast-feeding infants of women in Botswana receiving antiretroviral treatment. J Infect Dis 2005; 192:720.
  85. Shapiro RL, Rossi S, Ogwu A, et al. Therapeutic levels of lopinavir in late pregnancy and abacavir passage into breast milk in the Mma Bana Study, Botswana. Antivir Ther 2013; 18:585.
  86. Olagunju A, Bolaji O, Amara A, et al. Breast milk pharmacokinetics of efavirenz and breastfed infants' exposure in genetically defined subgroups of mother-infant pairs: an observational study. Clin Infect Dis 2015; 61:453.
  87. Gandhi M, Mwesigwa J, Aweeka F, et al. Hair and plasma data show that lopinavir, ritonavir, and efavirenz all transfer from mother to infant in utero, but only efavirenz transfers via breastfeeding. J Acquir Immune Defic Syndr 2013; 63:578.
  88. Dryden-Peterson S, Shapiro RL, Hughes MD, et al. Increased risk of severe infant anemia after exposure to maternal HAART, Botswana. J Acquir Immune Defic Syndr 2011; 56:428.
  89. Feiterna-Sperling C, Weizsaecker K, Bührer C, et al. Hematologic effects of maternal antiretroviral therapy and transmission prophylaxis in HIV-1-exposed uninfected newborn infants. J Acquir Immune Defic Syndr 2007; 45:43.
  90. Heidari S, Mofenson L, Cotton MF, et al. Antiretroviral drugs for preventing mother-to-child transmission of HIV: a review of potential effects on HIV-exposed but uninfected children. J Acquir Immune Defic Syndr 2011; 57:290.
  91. Njuguna I, Reilly M, Jaoko W, et al.. Infant neutropenia associated with breastfeeding during maternal antiretroviral treatment for prevention of mother-to-child transmission of HIV. Retrovirology: Research and treatment 2014; 6:1.
  92. Kilewo C, Karlsson K, Massawe A, et al. Prevention of mother-to-child transmission of HIV-1 through breast-feeding by treating infants prophylactically with lamivudine in Dar es Salaam, Tanzania: the Mitra Study. J Acquir Immune Defic Syndr 2008; 48:315.
  93. Kankasa C, Nagot N, Meda N, et al. Infant lopinavir/r vs. lamivudine to prevent postnatal HIV-1: The ANRS 12174 trial. Presented at the 21st Conference on Retroviruses and Opportunistic Infections, Boston, MA, March 3-6, 2014. Abstract #70.
  94. John-Stewart GC. When is replacement feeding safe for infants of HIV-infected women? PLoS Med 2007; 4:e30.
  95. Centers for Disease Control (CDC). Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. MMWR Morb Mortal Wkly Rep 1985; 34:721.
  96. Kuhn L, Stein Z. Infant survival, HIV infection, and feeding alternatives in less-developed countries. Am J Public Health 1997; 87:926.
  97. Phadke MA, Gadgil B, Bharucha KE, et al. Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization. J Nutr 2003; 133:3153.
  98. Homsy J, Moore D, Barasa A, et al. Breastfeeding, mother-to-child HIV transmission, and mortality among infants born to HIV-Infected women on highly active antiretroviral therapy in rural Uganda. J Acquir Immune Defic Syndr 2010; 53:28.
  99. Thior I, Lockman S, Smeaton LM, et al. Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study. JAMA 2006; 296:794.
  100. Natchu UC, Liu E, Duggan C, et al. Exclusive breastfeeding reduces risk of mortality in infants up to 6 mo of age born to HIV-positive Tanzanian women. Am J Clin Nutr 2012; 96:1071.
  101. Nduati R, John G, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 2000; 283:1167.
  102. Shaffer N, Chuachoowong R, Mock PA, et al. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok Collaborative Perinatal HIV Transmission Study Group. Lancet 1999; 353:773.
  103. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354:795.
  104. Wiktor SZ, Ekpini E, Karon JM, et al. Short-course oral zidovudine for prevention of mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire: a randomised trial. Lancet 1999; 353:781.
  105. Kuhn L, Reitz C, Abrams EJ. Breastfeeding and AIDS in the developing world. Curr Opin Pediatr 2009; 21:83.
  106. Tonwe-Gold B, Ekouevi DK, Viho I, et al. Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: evaluation of a two-tiered approach. PLoS Med 2007; 4:e257.
  107. Kafulafula G, Hoover DR, Taha TE, et al. Frequency of gastroenteritis and gastroenteritis-associated mortality with early weaning in HIV-1-uninfected children born to HIV-infected women in Malawi. J Acquir Immune Defic Syndr 2010; 53:6.
  108. Onyango-Makumbi C, Bagenda D, Mwatha A, et al. Early weaning of HIV-exposed uninfected infants and risk of serious gastroenteritis: Findings from two perinatal HIV prevention trials in Kampala, Uganda. J Acquir Immune Defic Syndr 2010; 53:20.
  109. Arpadi S, Fawzy A, Aldrovandi GM, et al. Growth faltering due to breastfeeding cessation in uninfected children born to HIV-infected mothers in Zambia. Am J Clin Nutr 2009; 90:344.
  110. Simondon KB. Early breast-feeding cessation and infant mortality in low-income countries: workshop summary. Adv Exp Med Biol 2009; 639:319.
  111. Kuhn L, Aldrovandi GM, Sinkala M, et al. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med 2008; 359:130.
  112. Becquet R, Bland R, Leroy V, et al. Duration, pattern of breastfeeding and postnatal transmission of HIV: pooled analysis of individual data from West and South African cohorts. PLoS One 2009; 4:e7397.
  113. Rollins NC, Filteau SM, Coutsoudis A, Tomkins AM. Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women. J Acquir Immune Defic Syndr 2001; 28:132.