Although breastfeeding is essential to prevent malnutrition and infectious diseases in resource-limited settings, it carries a significant risk of transmission of HIV, especially in later stages of infection. The Kesho Bora study aimed to protect children from being infected with HIV by the mother during pregnancy, while making sure that the mother receives proper treatment that is safe for her child. The study investigated the safety and efficacy of antiretroviral regimens containing drugs such as tenofovir, lamivudine and nevirapine, mostly used in combination to prevent drug resistance in preventing mother to child transmission of HIV.

Professor Marie-Louise Newell of the Africa Centre for Health and Population Studies, South Africa, conducted a study on the impact of Highly Active Anti-Retroviral Therapy (HAART) during pregnancy and breastfeeding on mother-to-child transmission of HIV as part of the WHO-sponsored Kesho Bora study. The aim of the study was to evaluate the use of combination antiretroviral therapy (ART) starting in late pregnancy and continued throughout six months of breastfeeding, following the World Health Organisation (WHO) guidelines at the time for HIV-infected mothers on the prevention of postnatal mother-to-child transmission.

A multicentre randomised controlled trial was set up with two arms: the intervention arm of combination ART and a control arm of the standard therapy to prevent mother-to-child transmission administered during pregnancy and delivery, but not continued postnatally. Centres in South Africa, Kenya and Burkina Faso were involved in the study.

The study showed improved efficacy of maternal combination ART prophylaxis during pregnancy and the breastfeeding period in reducing the risk of HIV-1 transmission to infants. These findings strongly influenced the revision of WHO 2010 guidelines that recommended antiretroviral prophylaxis (either to the mother or to the child) during breastfeeding, in case the mother was not already receiving antiretroviral treatment for her own health. The subsequent 2013 WHO guidelines now recommend combination ART for all HIV-infected women, irrespective of CD4 count, from early pregnancy throughout breastfeeding, and where possible, for life.

Further analyses of the Kesho Bora trial data confirmed that breastfeeding is not associated with disease progression in women. Women benefit from the exposure to combination ART in terms of delayed HIV disease progression, but only while receiving combination ART. In addition, infants born to HIV-infected mothers on combination ART are not only less likely to become HIV-infected but also benefit from the breastfeeding which results in an improved survival rate.

Relevant publications:

1. The Kesho Bora Study Group (authors include Mepham, S; Naidu, K and Newell, ML). (2011) ‘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 Infectious Diseases. 11(3): 171-180 2. Bork, K; Cames, C; Cournil, A; Musyoka, F; Ayassou, K; Naidu, K; Mepham, S; Gichuhi, C; Read, JS; Gaillard, P; de Vincenzi, I for the Kesho Bora Study Group. (2013) ‘Infant feeding modes and determinants among HIV-1–infected African women in the Kesho Bora Study’. Journal of Acquired Immune Deficiency Syndromes. 1;62(1):109-18

 

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