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HIV and infant feeding

 

Overview of HIV and infant feeding

Introduction

For most babies, breastfeeding is without question the best way to be fed. Breast milk provides all of the nutrients needed during the first few months of life; it is usually readily available and free. Breastfeeding strengthens the emotional bond between mother and child and, because of its contraceptive effect, helps to control the spacing of pregnancies.

What is more, breast milk contains agents that help to protect against common childhood illnesses such as diarrhoea and respiratory infections. Even in rich countries, breastfed babies are less likely to become ill than those given replacement foods.¹ In other parts of the world, where there is little access to clean water, sanitation and health services, not breastfeeding can greatly increase the risks of disease and death.^{2 3}

Unfortunately, breastfeeding can also transmit HIV. Among women who are infected with HIV and receive no antiretroviral treatment or other interventions, breastfeeding for two or more years can double the rate of mother-to-child transmission to around 40% (the rest of the transmission occurs during pregnancy, labour and delivery). In Africa, between one third and one half of infant HIV infections are due to breastfeeding.⁴

When a mother has HIV, the dangers of not breastfeeding must be balanced against the threat of HIV transmission. This results in a painful dilemma for millions of women in developing countries, for whom there are no easy options.

Advice for HIV-positive mothers in developed countries

For HIV-positive women in well-resourced countries the advice from national health agencies is straightforward: they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding. 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.”⁵

In some countries, including the UK and the USA, there is a possibility that HIV-positive mothers who choose to breastfeed may be prevented from doing so, or may be charged with child endangerment if they persist.

Advice for HIV-positive mothers in developing countries

In countries with fewer resources, where replacement feeding can be much more hazardous, the recommendations for infant feeding usually depend on a mother's individual situation. Although there is some variation in national and local policies, most are influenced by the guidance published by the World Health Organisation (WHO). According to the latest version of this guidance:

“When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life.”⁶

This means that some mothers should be advised to breastfeed and others should be encouraged to give replacement foods instead, depending on personal circumstances. The final decision, however, should be down to the mother:

“All HIV-infected mothers should receive counselling, which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. Whatever a mother decides, she should be supported in her choice.”⁷

In developing countries there are many factors that determine what advice a mother should receive, and how easy it will be for her to carry out her chosen feeding method. The most important issues are outlined in the rest of this page.

Replacement feeding

What is replacement feeding?

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. 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.

When should replacement feeding be recommended?

Replacement feeding is the only 100% effective way to prevent mother-to-child transmission of HIV after birth. This benefit, however, must be weighed against practical difficulties and the threat from other illnesses, which is increased by not breastfeeding. According to the WHO, the necessary conditions for replacement feeding can be summarised as follows.

Acceptability: 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, India⁸

Feasibility: 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.

Affordability: 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.

Sustainability: 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.

Safety: 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.”⁹
• 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 children,” and “mortality rates did not differ significantly between these two groups.”¹⁰
• 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.”¹¹ Rates of HIV-free survival were also similar at 24 months.¹²
• 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.”¹³
• A mathematical simulation based on previously reported rates of HIV transmission and infant death (2004), which concluded that, “Compared with artificial feeding, breastfeeding during the first 6 months by HIV-positive mothers increases HIV-free survival by 32 per 1000 live births. After 6 months … replacement feeding appears to be safer.”¹⁴

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.

“‘Safe’ cannot be assumed: new programs should verify that formula saves lives in their context before widespread implementation” - Conclusion of a CDC investigation of infant feeding in Botswana, 2006¹⁵

 

The 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.

The United Nations Children's Fund, UNICEF, began distributing free infant formula to governments in 1998, to be given to HIV positive mothers who wanted to avoid breastfeeding but could not afford to do so. UNICEF decided to abandon the scheme four years later after deciding it was unhelpful. The charity found that formula was often given to women who were incapable of preparing it safely, while most of those who had the resources to practise safe replacement feeding could also afford to purchase formula. Furthermore UNICEF was concerned that the provision of free formula was leading to “spillover” (as discussed below).

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 22¹⁶

Breastfeeding

What is exclusive breastfeeding?

If an HIV-positive mother chooses to breastfeed then there are several things she can do to lower the chances of her baby becoming infected. The first of these is exclusive breastfeeding. Four major studies have shown that mixed feeding – giving other foods or liquids as well as breast milk – should be avoided because it substantially increases the chances of HIV transmission and death.^{17 18 19 20} Breast milk provides all of the fluids and nutrients that a young baby requires, so even water can and should be avoided.

Although it is not fully understood why mixed feeding leads to such a high risk of HIV transmission, it is thought likely that the extra foods and liquids damage the infant’s immature digestive system, making it easier for HIV in breast milk to enter the tissues. In addition, mixed feeding may introduce harmful germs, and may reduce gut acidity, making it easier for infections to take hold. Mixed feeding is therefore never advisable during the first few months of a baby’s life, regardless of the mother’s HIV status.

Difficulties in promoting exclusive breastfeeding

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.^{21 22} Researchers have found that a lot of mothers who choose exclusive breastfeeding have difficulty complying, especially when there is pressure from partners and relatives to follow traditional practices.^{23 24 25}

“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 worker²⁶

Nevertheless, high rates of exclusive breastfeeding may be achievable in some settings where mothers are provided intensive counselling, education and support services.²⁷

Support for mothers who choose breastfeeding

Those who choose to breastfeed should be made aware of the dangers of mixed feeding. 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. Cessation of breastfeeding should be discussed and planned for in advance.

If a mother has cracked nipples or mastitis (a type of breast inflammation), or if her baby has infections or sores in its mouth, then the risk of HIV transmission is probably increased.²⁸ It is therefore important that women are taught how to breastfeed correctly, and are able to access health care to clear up any ailments.

Another factor believed to influence HIV transmission rates is the concentration of virus in a mother’s breast milk, which is known as the “viral load”. The highest viral loads are found in two groups of women: those who have been recently infected, and those who have been infected for a long time and are progressing to AIDS. Antiretroviral drugs reduce viral load, and there is some evidence that they may lower the chances of HIV transmission, though this has yet to be conclusively proven.²⁹

The WHO recommends that all mothers should have access to ongoing care and assistance, including family planning services and nutritional support.

How and when should babies be weaned?

The longer an HIV-positive mother breastfeeds, the more likely she is to infect her baby.³⁰ For this reason the WHO recommends that:

“breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV and malnutrition).”

It is acknowledged that early cessation of breastfeeding is not feasible and safe without a reliable supply of replacement food; in some cases, breastfeeding may have to continue beyond six months.

Because rapid weaning (taking just a few days to move from breast milk to other foods) minimises the period of mixed feeding, it may reduce the risk of HIV transmission. However some studies suggest that rapid weaning may increase the likelihood of severe diarrhoea among infants, and the effect on transmission rates is uncertain.^{31 32} Further research is needed to establish whether the benefits of rapid weaning outweigh the risks. What is clear is that mothers need additional support during weaning, including the provision of micronutrient supplements if necessary.

Feeding with safer breast milk

Ideally, an HIV-positive mother would like to provide her baby with the advantages of breastfeeding without the threat of HIV transmission. A possible solution for some women is to employ a wet nurse who is known to be HIV negative and is willing to ensure she remains that way throughout the time she is breastfeeding. The wet nurse must also accept the risk that the baby, if already infected with HIV, may transmit the virus to her. This risk is unknown, but a few such cases are suspected to have occurred.³³

Another possible solution is to obtain donated breast milk, for example from milk banks, which are widespread in some countries such as Brazil. If the milk has been properly pasteurised then it carries no significant threat of HIV infection.³⁴

An HIV-positive mother can improve the safety of her own breast milk by expressing it into a container and submitting it to either flash-heating or Pretoria pasteurisation. Flash-heating is achieved by placing the covered container in a pot of water and heating until the water bubbles, then removing the container and letting it cool. Pretoria pasteurisation involves boiling a small pot of water, removing it from the heat, immersing the container, covering the pan and leaving it to cool for 20 minutes. Both of these methods, if performed correctly, destroy HIV while preserving much of the goodness of the milk.^{35 36} However they are time consuming and require a lot of fuel. Some women may choose to compromise by using one of these methods only during weaning, when the risk of HIV transmission is likely to be greatest.

“Spillover”

Many organisations have spent years promoting breastfeeding and trying to counter marketing campaigns run by infant formula companies. Since the discovery that HIV could be transmitted through breastfeeding, there have been concerns that the provision of replacement feeding to HIV-positive mothers could have “spillover” effects on the rest of the community, causing uninfected mothers to avoid breastfeeding and thus endanger their babies. Another worry is that support for breastfeeding programmes may decline because of concerns about HIV transmission, and because resources are being shifted towards HIV prevention. There is evidence that both of these things have already happened in some countries.^{37 38}

The potential dangers of spillover are very real and efforts should be made to avert them, in particular through implementing the International Code of Marketing of Breast-milk Substitutes, which controls how infant formula is promoted.³⁹ Yet it is also important to ensure that excessive fear of spillover does not prevent policy makers taking sufficient action to assist HIV-positive mothers.

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.⁴⁰ Later in the year it was announced that HIV had been isolated from breast milk.⁴¹ Soon afterwards, the Centers for Disease Control and Prevention stated that American women with HIV “should be advised against breastfeeding.”⁴²

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.⁴³

1989: The development of a new type of HIV test, called PCR, made it easier to distinguish between babies infected before or during birth and those infected during infancy.⁴⁴ 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.⁴⁵ 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.⁴⁶

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.”⁴⁷ 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% 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.⁴⁸

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.⁴⁹ UNICEF began supporting mother-to-child transmission programmes in 1998, including the distribution of free infant formula.⁵⁰

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).⁵¹

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.”⁵² 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.”⁵³

2002: UNICEF decided to stop procuring and distributing free infant formula.⁵⁴

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.⁵⁵ A much smaller study conducted by Italian researchers in Uganda contradicted this finding,⁵⁶ but its methods and conclusions were strongly criticised by other experts.⁵⁷

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.⁵⁸

The way forward

Without question, breastfeeding should be promoted as ideal for most babies. 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. All women need access to HIV testing and counselling, but this is especially true for pregnant women and new mothers.

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.⁵⁹ 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.

AVERT is campaigning for better services to prevent mother-to-child HIV transmission around the world through our Stop AIDS in Children campaign.

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