Background:  Though breastfeeding accounts for 15 to 20% of mother-to-child transmission (MTCT) of HIV, it is not prohibited in some developing countries because of the higher mortality associated with not breastfeeding in these settings. Instead, shorter duration of exclusive breastfeeding (EBF) has been proposed. We aimed to assess the potential effect of recommending shorter duration of EBF and the potential effect of poor compliance to these recommendations on HIV infection and infant mortality.

Methods:  We developed a deterministic mathematical model using parameters from published studies conducted in Uganda, Kenya, or South Africa and took into account non-compliance resulting in mixed feeding practices. Outcomes included the number of children HIV-infected or dead (mortality) at 2 years following each of 6 scenarios of infant feeding recommendations in children of HIV-infected women:  exclusive formula feeding (EFF) with 100% compliance (scenario U), EBF for 6 months with 100% compliance (V), EBF for 4 months with 100% compliance (W), EFF with 70% compliance (X), EBF for 6 months with 85% compliance (Y), and EBF for 4 months with 85% compliance (Z). This model differs from previous ones in that it uses parameters only from studies conducted in Sub-Saharan Africa, accounts for incomplete compliance to recommendations, and considers shorter durations of EBF.

Results:  Starting with a population of 100,000 infants, the model predicted the least number of HIV-infected children (6200) with scenario U. The number of HIV-infected children increased by 57%, 38%, 24%, 60%, and 41%, respectively, for scenarios V, W, X, Y, and Z. The fewest deaths (10,534) occurred with scenario V with mortality only slightly increasing by 0.1%, 0.4%, 1.0%, 0.5%, and 0.7%, respectively, for scenarios U, W, X, Y, and Z. Reducing the duration of EBF from 6 to 4 months reduced HIV infection by 11.8% while increasing mortality by 0.4%. Mixed feeding for 15% of the infants increased HIV infection and mortality, respectively, by 2.1% and 0.5% when EBF for 6 months was recommended; and by 1.7% and 0.3% when EBF for 4 months was recommended.

Conclusions:  Recommending shorter duration of breastfeeding in infants born to HIV-infected women in Africa may substantially reduce infant HIV infection, but not mortality. When EBF for shorter duration is recommended, lower mortality could be achieved by a simultaneous reduction in HIV/AIDS mortality obtainable by the use of HAART in infants.