AVERT - AVERTing HIV and AIDS

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%1.

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.

Advice for HIV-positive mothers in high-income countries

Even in high income countries, breastfed babies are less likely to become ill than those given replacement foods2 3. 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.

While some HIV positive mothers in high income countries may wish to breastfeed their child 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. Replacement (sometimes known as formula) feeding is the only infant feeding method that does not expose an infant to HIV and in regions of the world where clean water and facilities are available; it is usually promoted as the only option.

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.  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 4

Advice for HIV-positive mothers in low and middle-income countries

For HIV positive women in low and middle income countries, advice on infant feeding differs from high income countries to reflect the fact there are limited resources and infrastructure. It is known that where there is little access to clean water, sanitation and health services, that not breastfeeding can greatly increase the risks of disease and even the death of the baby. So as most HIV positive women in these countries cannot safely formula feed their infants breastfeeding is the only realistic option available

The latest (2010) guidance produced by the WHO, and increasingly followed by individual countries, is that in order to reduce the risk of the baby becoming infected, mothers, or their infant(s), are advised to take a course of antiretroviral drugs throughout the breastfeeding period5. While both mother and infant will take a course of antiretroviral drugs, who takes the longer course of ARVs is a decision for the national body but either option have a very high success rate6. Mothers are also advised to exclusively breastfeed their infant for 6 months and after time, introduce other food substances while continuing to breastfeed for up to a year.

"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 7

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%8 9 10 11. But there must be 100% adherence to taking the drugs correctly or else there is a risk that the baby will become infected with HIV12 or will become resistant to the medication13 14 15. 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.

In countries where it is not possible for HIV positive women to access a regular supply of antiretroviral drugs, it is recommended that in general they follow the previous recommendations from the WHO.

When ARVs are not immediately available, the recommendations included in the 2006 HIV and Infant Feeding Update still provide useful guidance for mothers and health workers. - World Health Organization 16

Many HIV positive women will not be able to obtain an extended course of ARV drugs that not only includes the period when they are pregnant, but also includes the breastfeeding period. In 2008, 660,000 HIV positive pregnant women received ARVs to prevent mother to child transmission but nearly 60% of these women only received single dose nevirapine or an intermittent regimen17. So many women will still face a dilemma about whether, and in exactly what circumstances, they should breastfeed.

Antiretroviral drug regimens for pregnant women in low and middle income countries in 2008

ARV regimens for pregnant women in low and middle income countries

Author:World Health Organization18

WHO Infant Feeding Guidelines 2006 and 2010

In 2006 the WHO recommended that HIV positive mothers exclusively breastfeed their infants for 6 months and then rapidly wean. After weaning, mothers were advised to begin giving replacement feeding such as biscuits, soft foods and milk but an emphasis was placed on the dangers of mixed feeding. Mixed feeding, or complementary feeding, is defined as breastfeeding and replacement feeding at the same time and was believed to increase HIV transmission. It was also advised that replacement feeding could take place where it was “acceptable, feasible, affordable, sustainable and safe”, although it was not clear what this meant in practice.

This 2006 advice was replaced in 2010 to reflect the fact that HIV positive women were confused about feeding methods and mixed feeding continued to be widespread19. In South Africa, a study found that only 25% of mothers exclusively breastfed whereas 75% of women used formula or undertook mixed feeding during the first 6 months20. As extended breastfeeding and mixed feeding is only safe when antiretroviral drugs are taken, there is now an emphasis on using antiretroviral drugs to prevent the baby becoming infected as well as an emphasis on breastfeeding.

These changes are summarised in the table below:

2006 WHO Infant Feeding Guidelines 2010 WHO Infant Feeding Guidelines
Mother takes ARVs from 28th 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 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.
Short ARV regimen during breastfeeding period for either mother and/or infant Long ARV regimen during breastfeeding period for either mother and/or infant
Exclusive breastfeeding for 6 months Exclusive breastfeeding for 6 months
Rapidly wean from breastmilk Gradually wean from breastmilk
No mixed feeding Mixed (complementary) feed after 6 months
Not recommended to breastfeed after 6 months Recommended to breastfeed and mix feed in conjunction with ARVs
"Breastfeeding, which is essential for child survival has posed an enormous dilemma for mothers living with HIV. Now, WHO says mothers may safely breastfeed provided that they or their infants receive ARV drugs during the breastfeeding period. This has been shown to give infants the best chance to be protected from HIV transmission in settings where breastfeeding is the best option." - WHO 21

Exclusive breastfeeding

A young baby breastfeeding in Delhi, India

A young baby breastfeeding in Delhi, India

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 successful22 23.

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 life24 25. In addition, many women are concerned that their breastmilk is not sufficient for their infant, because they are malnourished26.

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 27

There can also be issues of stigma and pressures from family28 29 30.

"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 worker31

When neither infant nor mother are taking an extended course for ARVs, they 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, such as mastitis which leads to increased HIV transmission32.

How and when should babies be weaned?

The longer an HIV positive mother breastfeeds, the more likely she is to infect her baby33 but this risk has to be weighed against the benefits of breastfeeding. Before interventions were introduced it was necessary to rapidly wean so that the baby was not exposed to mixed feeding for too long.

For this reason the WHO, in their 2006 guidelines, recommended 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)”34.

Due to the high risk of diarrhoea among infants and the benefit of ARVs, women are advised under the 2010 recommendations to gradually wean to reduce stress to infants and avoid mortality35 36. Rapid weaning can also cause an increase in HIV transmission37. 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% 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:

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, India38
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, India39
An HIV-positive Ukrainian mother practises cup feeding her infant

An HIV-positive Ukrainian mother practises cup feeding her infant

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. 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.

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.”40
  • 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.”41
  • 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.”42 Rates of HIV-free survival were also similar at 24 months.43
  • 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.”44

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 2245

Feeding practices 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.

“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 46

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. 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 decisions47. 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 breastfeeding48. Later in the year it was announced that HIV had been isolated from breast milk49. Soon afterwards, the Centers for Disease Control and Prevention stated that American women with HIV “should be advised against breastfeeding”50.

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.51

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 infancy52. In later years this would enable more accurate estimates of the risk of transmission through breastfeeding, which was still unknown but believed to be low53. 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 1990s54.

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.”55. 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 weeks56.

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 areas57. UNICEF began supporting mother-to-child transmission programmes in 1998, including the distribution of free infant formula58.

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)59.

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”60. 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”61.

2002: UNICEF decided to stop procuring and distributing free infant formula62.

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 breastfed63. A much smaller study conducted by Italian researchers in Uganda contradicted this finding,64 but its methods and conclusions were strongly criticised by other experts65.

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 breastfeeding66.

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%67 68 69 70. By extending a course of ARVs for ether mother or infant, mix 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 mix feeding71.

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Last updated July 28, 2010