Cover Image
close this bookNew Data on the Prevention of Mother-to-Child Transmission of HIV and Their Policy Implications (UNAIDS, 2001, 24 p.)
close this folderConclusions and recommendations regarding infant feeding
View the documentRisks of breastfeeding and replacement feeding
View the documentCessation of breastfeeding
View the documentInfant feeding counselling
View the documentBreast health
View the documentMaternal health

Risks of breastfeeding and replacement feeding

The benefits of breastfeeding are greatest in the first six months of life (optimal nutrition, reduced morbidity and mortality due to infections other than HIV, and delayed return of fertility).26-34

Exclusive breastfeeding during the first 4-6 months of life carries greater benefits than mixed feeding with respect to morbidity and mortality from infectious diseases other than HIV.27,29,35,36

Although breastfeeding no longer provides all nutritional requirements after six months, breastfeeding continues to offer protection against serious infections and to provide significant nutrition to the infant (half or more of nutritional requirements in the second six months of life, and up to one third in the second year).37

Replacement feeding carries an increased risk of morbidity and mortality associated with malnutrition and associated with infectious disease other than HIV. This is especially high in the first 6 months of life and decreases thereafter. The risk and feasibility of replacement feeding are affected by the local environment and the individual woman’s situation.38-41

Breastfeeding is associated with a significant additional risk of HIV transmission from mother to child as compared to non-breastfeeding. This risk depends on clinical factors and may vary according to pattern and duration of breastfeeding. In untreated women who continue breastfeeding after the first year, the absolute risk of transmission through breastfeeding is 10-20%.42-45

The risk of MTCT of HIV through breastfeeding appears to be greatest during the first months of infant life but persists as long as breastfeeding continues. Half of the breastfeeding-related infections may occur after 6 months with continued breastfeeding into the second year of life.9,44,45

There is evidence from one study that exclusive breastfeeding in the first 3 months of life may carry a lower risk of HIV transmission than mixed feeding.46

Recommendations:

· 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.

· To minimize HIV transmission risk, 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).

· When HIV-infected mothers choose not to breastfeed from birth or stop breastfeeding later, they should be provided with specific guidance and support for at least the first 2 years of the child’s life to ensure adequate replacement feeding. Programmes should strive to improve conditions that will make replacement feeding safer for HIV-infected mothers and families.

Cessation of breastfeeding

There are concerns about the possible increased risk of HIV transmission with mixed feeding during the transition period between exclusive breastfeeding and complete cessation of breastfeeding. Indirect evidence on the risk of HIV transmission through mixed feeding, suggests that keeping the period of transition as short as possible may reduce the risk.

Shortening this transition period however may have negative nutritional consequences for the infant, psychological consequences for the infant and the mother, and expose the mother to the risk of breast pathology which may increase the risk of HIV transmission if cessation of breastfeeding is not abrupt.

The best duration for this transition is not known and may vary according to the age of the infant and/or the environment.

Recommendation: HIV-infected mothers who breastfeed should be provided with specific guidance and support when they cease breastfeeding to avoid harmful nutritional and psychological consequences and to maintain breast health.

Infant feeding counselling

Infant feeding counselling has been shown to be more effective than simple advice for promoting exclusive breastfeeding in a general setting.47-50 Good counselling may also assist HIV-infected women to select and adhere to safer infant feeding options, such as exclusive breastfeeding or complete avoidance of breastfeeding, which may be uncommon in their environment. Effective counselling may reduce some of the breast health problems which may increase the risk of transmission.

Many women find that receiving information on a range of infant feeding options is not sufficient to enable them to choose and they seek specific guidance. Skilled counselling can provide this guidance to help HIV-infected women make a choice that is appropriate for their situation to which they are more likely to adhere. The options discussed during counselling need to be selected according to local feasibility and acceptability.

The level of understanding of infant feeding in the context of MTCT in the general population is very limited, thus complicating efforts to counsel women effectively.

The number of people trained in infant feeding counselling is few relative to the need and expected demand for this information and support.

Recommendations:

· 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.

· Assessments should be conducted locally to identify the range of feeding options that are acceptable, feasible, affordable, sustainable and safe in a particular context.

· Information and education on mother-to-child transmission of HIV should be urgently directed to the general public, affected communities and families.

· Adequate numbers of people who can counsel HIV-infected women on infant feeding should be trained, deployed, supervised and supported. Such support should include updated training as new information and recommendations emerge.

Breast health

There is some evidence that breast conditions including mastitis, breast abscess, and nipple fissure may increase the risk of HIV transmission through breastfeeding, but the extent of this association is not well quantified.51-53

Recommendation: HIV-infected women who breastfeed should be assisted to ensure that they use a good breastfeeding technique to prevent these conditions, which should be treated promptly if they occur.

Maternal health

In one trial, the risk of dying in the first 2 years after delivery was greater among HIV-infected women who were randomized to breastfeeding than among those who were randomized to formula feeding.54 This result has yet to be confirmed by other research.

Women who do not breastfeed or stop breastfeeding early are at greater risk of becoming pregnant.

Recommendation: HIV-infected women should have access to information, follow-up clinical care and support, including family planning services and nutritional support. Family planning services are particularly important for HIV-infected women who are not breastfeeding.

Regimens of proven efficacy (randomized controlled clinical trials)


Antepartum

Intrapartum

Postpartum/postnatal

Study

Drug

14-28 wks

28-36 wks

>36 wks

Labour

1 wk PP

1-6 wks PP

ACTG 076

ZDV



Infant

Harvard Thai

ZDV




Infant

Harvard Thai

ZDV




Infant


Harvard Thai

ZDV




Infant

Harvard Thai

ZDV




Infant


DITRAME

ZDV




Mother


CDC

ZDV





PETRA Arm A

ZDV + 3TC




Mother and Infant


PETRA Arm B

ZDV + 3TC



Mother and Infant


HIVNET/SAINT

NVP



Infant