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HIV and Breastfeeding
Introduction to HIV and breastfeeding
For most babies, breastfeeding is without question the best way to be fed, but unfortunately breastfeeding can also transmit HIV. If no antiretroviral drugs are being taken, breastfeeding for two or more years can double the risk of the baby becoming infected to around 40 percent. 1 It is thought that 5-20 percent of babies infected through mother-to-child transmission aquire HIV infection via breastfeeding. 2
Breast milk provides all of the nutrients needed during the first few months of life, and it also contains agents that help to protect against common childhood illnesses such as diarrhoea and respiratory infections.
How is HIV transmitted through breastfeeding?
It is still not completely understood how HIV becomes present in breast milk. 3 There is evidence to suggest that HIV-infected CD4 cells have a greater capacity to replicate themselves in breast milk than in blood. 4 Once an infant digests this HIV-infected milk, it is believed that the virus can enter the infant’s body through breaches in the infant’s mucous membranes - the lubricating membranes lining all body passages and cavities. The most likely part of the body where this happens is in the gut. It is also considered likely that HIV transmission can happen through the tonsils as they contain cells that are capable of HIV replication. 5
Advice for HIV-positive mothers in high-income countries
National health agencies and the WHO 2013 guidelines recommend that HIV-positive mothers in high-income countries:
- avoid breastfeeding: risk of HIV transmission is far greater than the risk of replacement feeding
- replacement feed: the only infant feeding method that does not expose an infant to HIV
- administer HIV treatment: provide infants with 4-6 weeks of once-daily nevirapine (NVP) or twice-daily zidovudine (AZT). 6
Replacement feeding means giving a baby commercial infant formula (prepared from powder and boiling water) or home-modified animal milk (boiled with added water, sugar and micronutrients) instead of breast milk. In regions of the world where clean water and facilities are available; it is usually promoted as the only option.
Even in high-income countries, breastfed babies are less likely to acquire childhood illnesses than those given replacement foods. 7 8 However, the risk of HIV infection means that replacement feeding should always be given if it is feasible and safe to do so.
In some countries, including the UK and the USA, there is a possibility that HIV positive mothers who choose to breastfeed may be charged with child endangerment if they persist. Nevertheless the UK Department of Health advises that:
“Under exceptional circumstances, and after seeking expert professional advice on reducing the risk of transmission of HIV through breastfeeding, a highly informed and motivated mother might be assisted to breastfeed.” Department of Health 9
Advice for HIV-positive mothers in low and middle-income countries
National health agencies and the WHO 2013 guidelines recommend that HIV-positive mothers in low-income countries:
- breastfeed exclusively: if there is little access to clean water, sanitation and health services
- continue breastfeeding: for 6 months, then introduce complementary foods and wean baby at 12 months
- administer HIV treatment: provide infant with once-daily nevirapine (NVP) for 6 weeks
Supporting this advice to breastfeed, a study in 2012 found that HIV-neutralising antibodies are released by some B cells that are present in breast milk. A further study in 2013 identified a particular protein in breast milk, named as TNC, that actively inhibits HIV. 10 This could explain why mother-to-child transmission of HIV does not occur more often than it does. 11
Breastmilk also contains nutrients, agents and antibodies that protect the infant from the risk of childhood diseases such as diarrhoea. Without being breastfed, an infant runs the risk of becoming seriously ill with diseases other than HIV. Where treatment for them is limited or inaccessible, an infant's health can be compromised. Similarly, unsafe and unreliable replacement feeding when clean water and resources are unavailable can also be a danger to an infant's health. Breastfeeding is therefore highly recommended in low- and middle-income countries.
The latest (2013) WHO guidelines, state that ARV treatment should be provided for all pregnant and breastfeeding women living with HIV for life, previously known as Option B+. Countries who do not have the resources to provide lifelong ARVs to all pregnant women, should offer treatment to mothers living with HIV until one week after they finish breastfeeding, previously known as Option B. After this point, a mother will be assessed to see if she is eligible for treatment for her own health going forward. 12
"Mothers known to be HIV-infected… should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.” World Health Organization 13
It has been clearly shown that when antiretrovirals are taken through the pregnancy and breastfeeding stage, there is a greatly reduced HIV infection rate of 2 percent. 14 15 16 17 But there must be 100 percent adherence to taking the drugs correctly, otherwise there is a risk that the baby will become infected with HIV or resistant to the medication. 18 19 20 21 There needs to be good support for mothers to help them adhere to an extended drug regimen as well as keeping to 6 months of exclusive breastfeeding.
HIV-positive women who may not be able to obtain ARV drugs to cover both the period when they are pregnant and the breastfeeding period, should discuss the best option for them with a healthcare professional. In 2011, 56 percent of pregnant women living with HIV in low- and middle-income countries received the most effective regimens for PMTCT. 22 However this is still a fair way off the UNAIDS target of 90 percent of breastfeeding infant-mother pairs to be receiving antiretroviral therapy or prophylaxis by 2015. 23
Antiretroviral drug regimens for pregnant women in 21 African priority Global Plan countries between 2011-2012
Of the 65 percent of women who received ARV treatment for PMTCT in 2012, and the 59 percent in 2011, 24 the proportion of different types of treatment used are shown below.
WHO Infant Feeding Guidelines 2010 and 2013
The 2010 guidelines changed markedly from the 2006 guidelines: from rapidly weaning to gradually weaning from breastmilk, and from no mixed feeding at all to being advised to continue breastfeeding after 6 months and mix-feed whilst taking ARVs. Mixed feeding, or complementary feeding, is defined as breastfeeding and replacement feeding at the same time. 26 Previously, the mix-feed message was confusing, and in South Africa a study found that only 25 percent of mothers exclusively breastfed whereas 75 percent of women used formula or undertook mixed feeding during the first 6 months. 27
The 2006 recommendation of single-dose nevirapine for the infant is no longer recommended. Preventing mother-to-child transmission is much more effective if the mother takes ART and/or the child takes nevirapine for 6 weeks. 28 29
These changes between the 2010 and 2013 guidelines for HIV-positive mothers breastfeeding are summarised in the table below:
|2010 WHO Infant Feeding Guidelines||2013 WHO Infant Feeding Guidelines|
|Mother takes ARVs from 14th week of pregnancy until 1 week after labour, or for an indefinite amount of time if the mother is taking ARVs for their own health||Mother takes ARVs from diagnosis for the rest of her life. Or, national policies can choose to only provide ART to mothers eligible for treatment for their own health, in which case they can stop taking ART one week after cessation of breastfeeding, or one week after labour if not breastfeeding|
|Long ARV regimen during breastfeeding period for either mother and/or infant||Mother takes ARVs throughout breastfeeding period. Infant takes 6 weeks of daily nevirapine (NVP). If using replacement feeding, infant takes 4-6 weeks of daily nevirapine (NVP) or twice-daily zidovudine (AZT)|
|Exclusive breastfeeding for 6 months||Exclusive breastfeeding for 6 months|
|Gradually wean from breastmilk||Gradually wean from breastmilk over a 1 month period|
|Mixed (complementary) feed after 6 months||Mixed (complementary) feed after 6 months until breastfeeding cessation at 12 months or when nutritionally adequate diet is accessible.|
“National or subnational health authorities should decide whether health services will mainly counsel and support mothers known to be infected with HIV to either breastfeed and receive ARV interventions or avoid breastfeeding given their particular context.” 30
If an HIV-positive mother is breastfeeding, she will be advised to exclusively breastfeed for 6 months, that is to feed only breast milk and nothing else. Breast milk provides all of the fluids and nutrients that a young baby requires, so exclusive breastfeeding means that even water can and should be avoided and studies have shown this to be successful. 31 32
Unfortunately, encouraging mothers to practise exclusive breastfeeding is far from easy. In many societies, especially in sub-Saharan Africa, it is normal for a baby to be given water, teas, porridge or other foods as well as breast milk, even during the first few weeks of life. 33 34. In addition, many women are concerned that their breastmilk is not sufficient for their infant, because they are malnourished. 35
A mother may decide to breastfeed exclusively, but may start giving her infant additional fluids because she does not believe she has enough breastmilk. ITPC 36
"The family will offer to buy her formula when she has chosen to breastfeed, they will tell her that breast milk is not enough for the baby, she must also mix it with formula feeding, and she can’t deny that because she hasn’t told them why she chose to exclusively breastfeed her baby so she will just mix feed.” South African health worker 40
When neither infant nor mother are taking an extended course of ARVs, they should be made aware of the dangers of mixed feeding. The risk of HIV transmission rises when mixed feeding due to higher concentrations of HIV in the breast milk as the baby suckles less often. They should also be shown the correct technique for suckling, so as to minimise the likelihood of breast disorders, and should be enabled to seek help should any problems occur, such as mastitis which leads to increased HIV transmission. 41
How and when should babies be weaned?
The longer an HIV positive mother breastfeeds, the more likely she is to infect her baby but this risk has to be weighed against the benefits of breastfeeding. 42
WHO 2013 guidelines state that "the maximum benefit of breastfeeding in preventing mortality from diarrhoea, pneumonia and malnutrition is in the first 12 months of life and that the risk of transmitting HIV to infants through breastfeedng is low in the presence of ARV drugs" 43 At 12 months of age, the baby should be gradually weaned off breastmilk providing there is a nutritionally adequate alternative available.
Women are advised to gradually wean over a period of 1 month, to reduce stress to infants and avoid mortality. 44 45 Rapid weaning can also cause an increase in HIV transmission. 46 By controlling the duration of weaning and allowing ARVs to continue 1 week after breastfeeding has finished, transmission and infant mortality and morbidity are reduced.
When should replacement feeding be recommended?
Replacement feeding is the only 100 percent effective way to prevent mother-to-child transmission of HIV after birth, but the risk of infant mortality from other illnesses such as diarrhoea must be taken into account. The World Health Organization recommends that replacement feeding for women in low- and middle-income countries should only be implemented if the following circumstances are achieved or appropriate, which can be summarised as AFASS:
Breastfeeding is the norm in most cultures, and is generally encouraged by health workers. By choosing not to breastfeed, a mother risks revealing that she is HIV positive, and becoming a target for stigma and discrimination. She must be able to cope with this problem and resist pressure from friends and relatives to breastfeed.
“Many women/couples prepare to try out formula food after receiving counselling on the possibilities of breast milk infecting the infant after birth and information on formula feeds. But the problem crops up when the woman is back home with the extended family who are not aware of the HIV status of the mother or the couple.” Suniti Solomon, Director of YRG Care in Chennai, India 47
A mother who chooses replacement feeding must have adequate time, knowledge, skills and other resources to prepare the replacement food and feed her baby up to twelve times in 24 hours. Boiling water over a charcoal stove, for instance, can take up to fifteen minutes per feed. Unless refrigerated, prepared formula becomes unsafe after just two hours. It is better to feed with a cup rather than a bottle because cups are easier to clean, and because cup feeding promotes greater interaction between the mother and her baby.
Someone has to pay for the ingredients, fuel, water and other equipment needed for replacement feeding. In some countries, the cost of infant formula alone is similar to the minimum urban wage and, unless heavily subsidised, is well beyond the reach of most families. Even in resource-rich countries such as the UK, where water is safe and the majority of women have access to the safest options, socio-economic conditions can create barriers for HIV positive mothers in accessing formula milk. 48
Feeding an infant for the first six months of life requires around 20 kg of formula and regular access to water. Even a brief disruption in supplies may have serious health implications.
Replacement food should be nutritionally sound and free from germs. The water it is mixed with should be boiled, and utensils should be cleaned (preferably boiled) before each use. This means the mother must have access to a reliable supply of safe water and fuel.
Of the five conditions for replacement feeding, safety is often the most critical. Several studies of babies born to HIV-positive mothers in developing countries have tried to determine which type of feeding results in a lower death rate or a higher rate of “HIV-free survival” (the proportion of babies left alive and HIV-negative). These include:
- A randomised trial in Kenya (2001), which concluded that,
infants assigned to be formula fed or breastfed had similar mortality rates and incidence of diarrhea and pneumonia during the first 2 years of life. However, HIV-1-free survival at 2 years was significantly higher in the formula arm.49
- The non-randomised Diatrame Plus study in Côte d'Ivoire (2006), which found
no difference in two-year rates of adverse health outcomes between early weaned breastfed and formula-fed childrenand
mortality rates did not differ significantly between these two groups.50
- The randomised Mashi Study in Botswana (2006), which found that,
Breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both strategies had comparable HIV-free survival at 18 months.51 Rates of HIV-free survival were also similar at 24 months. 52
- A pooled analysis of African studies (2004), which found,
mortality did not differ significantly between ever-breastfed and never-breastfed children [born to HIV-positive mothers], with or without allowance for child infection status.53
Outcomes depend on many local factors, including the conditions in which replacement feeding is provided, and whether breastfeeding is exclusive or mixed (see below). It is worth noting that mothers enrolled in trials usually have access to potable water, extensive education on safe preparation of formula, a reliable supply of formula, and medical care for their infants.
Taken together, these studies demonstrate that replacement feeding can be beneficial, but certainly not in all situations. WHO recommends that counsellors talk with women and assess their individual circumstances before giving guidance about the risks and benefits of different modes of feeding. It is especially important to establish whether the mother has access to clean water and fuel, and whether she has disclosed her HIV status to her partner or family members.
Support for mothers who choose replacement feeding
To prepare replacement foods and feed them to a baby several times per day for many months is challenging, even in the best of circumstances. Mothers who choose replacement feeding need help to succeed. At the bare minimum, this means teaching them how to prepare the food properly, and then asking them to give a demonstration to ensure they understand. Counsellors must emphasise the need for sterile equipment and correct dilution, and the dangers of keeping prepared formula for long periods at room temperature. Mothers should also be taught how to prevent breast engorgement (preferably without using drugs), and how to recognise and treat dehydration.
It might seem obvious that clinics should offer HIV positive mothers a free supply of infant formula. However infant formula is expensive to buy and difficult to distribute. In some settings, providing formula may divert resources from other measures to avert mother-to-child transmission, such as HIV testing or preventive drugs.
If a clinic does choose to provide formula then it must ensure a sustainable supply. Mothers who run out of formula may resort to over-diluting or using inadequate substitutes.
“I rushed to the hospital to get formula and they said it is not available; it had finished. I went home and I did not have anything to give him. I then gave him long life milk. I think 3 weeks expired without formula having arrived.” South African mother, aged 22 54
Feeding guidelines for HIV-positive infants
All children born to HIV-positive mothers should be tested for HIV to determine their status. If an infant is discovered to be HIV positive, mothers are encouraged to exclusively breastfeed for the first 6 months and continue breastfeeding while mixed feeding for up to 2 years. 55
“If infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first 6 months of life and continue breastfeeding as per the recommendations for the general population, that is up to 2 years or beyond" World Health Organization 56
Studies have shown that early cessation of breastfeeding for HIV positive infants can increase mortality compared with an extended breastfeeding period.
The way forward
Without question, breastfeeding should be promoted as ideal for most babies in low- and middle-income countries. But the drive to reinforce breastfeeding should not be a barrier to helping HIV-positive mothers choose the feeding method that is right for them. Policy makers and advocates must avoid unnecessary conflict between preventing HIV infection and improving child health in general.
Ultimately, the only way to end mother-to-child transmission of HIV is to prevent women becoming infected in the first place through education, empowerment and promotion of condoms. For those who do become infected, the 2013 guideline recommendations of providing lifelong ART to all pregnant women is the most effective way to prevent mother-to-child transmission. It also prevents HIV transmission during future pregnancies and to her partner.
Those who test positive face a very difficult decision about how to feed their babies. What they need is accurate information, clear guidance and ongoing support to succeed with their chosen strategies.
Unfortunately, access to high quality counselling is scarce in much of the world, resulting in many mothers making inappropriate feeding decisions. 57 There is a desperate need for more resources and better training of counsellors. Good quality programmes have the potential to save many thousands of infant lives.
Brief history of HIV and infant feeding
Since the mid-1980s, there have been great improvements in our understanding of the risks associated with different types of infant feeding. The timeline below reveals how scientific knowledge, opinions and policies have evolved.
1985: Australian doctors reported the first case of a mother who became infected with HIV shortly after giving birth and whose baby also became infected, presumably through breastfeeding. 58 Later in the year it was announced that HIV had been isolated from breast milk. 59 Soon afterwards, the Centers for Disease Control and Prevention stated that American women with HIV “should be advised against breastfeeding”. 60
1987: Following several more reports of HIV among infants whose mothers became infected while breastfeeding, the WHO convened an expert consultation. The resulting statement suggested screening milk donors for HIV and pasteurising donated milk. It also stated that, “In many cases and, particularly, where the safe and effective use of alternative is not possible, breast-feeding by the biological mother should continue to be the feeding method of choice irrespective of her HIV infection status.” The probability of HIV transmission through breastfeeding was still unknown, but the statement said it was “probably small” as compared with transmission during labour and delivery. 61
1989: The development of a new type of HIV test, called PCR (polymerase chain reaction), made it easier to distinguish between babies infected before or during birth and those infected during infancy. 62 In later years this would enable more accurate estimates of the risk of transmission through breastfeeding, which was still unknown but believed to be low 63. The United Nation’s charity UNICEF said in their report State of the World’s Children 1989 that, “breastfeeding is not a significant means of transmitting AIDS.” In its reports UNICEF – the world’s leading children’s organisation – would continue to downplay the risks of HIV transmission through breastfeeding until the late 1990s. 64
1992: Another WHO consultation concluded that, “Where infectious diseases and malnutrition are the main cause of infant deaths and the infant mortality rate is high, breastfeeding should be the usual advice given to pregnant women including those who are HIV infected”. 65 A few months later, a meta-analysis of studies conducted around the world over the previous four years was published, which estimated a breastfeeding transmission rate of 14 percent from mothers infected before delivery and 29% from mothers infected after delivery. These figures were considerably higher than many had suspected, even though many of the women in the studies had breastfed for just a few weeks. 66
1997-8: The WHO published new infant feeding guidelines, which advised that all mothers should be counselled about possible feeding options and allowed to make their own decisions. Some people interpreted the new guidance as a major policy shift towards promotion of replacement feeding, but the WHO stressed that it still believed breastfeeding was the best choice for many HIV-positive women living in resource-poor areas. 67 UNICEF began supporting mother-to-child transmission programmes in 1998, including the distribution of free infant formula. 68
1999: Preliminary results from a South African study led by Dr Anna Coutsoudis suggested that babies exclusively breastfed for the first three months of life were not much more likely to become infected with HIV than those given replacement food. The highest rate of infection was found among babies given a mixed diet (other foods or liquids as well as breast milk). 69
2001: Following another consultation, the WHO introduced the “AFASS” criteria into their infant feeding guidelines: “when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended”. 70 Later in the year, Coutsoudis’ team published follow-up data that reinforced their earlier findings concerning mixed feeding: “Infants exclusively breastfed for 3 months or more had no excess risk of HIV infection over 6 months than those never breastfed”. 71
2002: UNICEF decided to stop procuring and distributing free infant formula. 72
2005: A team led by Dr Jean Humphrey reported the results of a study in Zimbabwe. Like Coutsoudis’ group, they found that babies given a mixed diet were much more likely to become infected with HIV than those who were exclusively breastfed. 73 A much smaller study conducted by Italian researchers in Uganda contradicted this finding, 74 but its methods and conclusions were strongly criticised by other experts. 75
2007: A study of nearly three thousand mothers in South Africa confirmed that mixed feeding carries a higher risk of HIV infection than exclusive breastfeeding. The team who conducted the research suggested that WHO infant feeding guidelines should be revised in favour of exclusive breastfeeding. 76
2009: Several studies were presented at the International AIDS Society conference in Cape Town that demonstrates that with ARVs, mother-to-child transmission rates can be reduced to around 2 percent. 77 78 79 80 By extending a course of ARVs for either mother or infant, mixed feeding can be practised without the risk of HIV infection to infant. In light of this development, the World Health Organization released new guidelines recommending an extended drug regimen to either mother or infant and mixed feeding. 81
2010: WHO released new guidelines on Antiretroviral therapy for HIV infection in adults and adolescents. The recommendations surrounding breastfeeding changed quite radically from the previous guidelines released in 2006. 82
2013: WHO released a new set of guidelines, widely the same as the 2010 guidelines regarding breastfeeding. These new guidelines recommend all pregnant mothers take ARVs for life (Option B+), or countries may choose Option B where they can test a mother for her eligibility for ARVs after the birth of her child. 83
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