HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.): SECTION A : HIV IN PREGNANCY: Appropriate interventions to reduce mother-to-child transmission: Modification of infant feeding practice

HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.)

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EXECUTIVE SUMMARY

INTRODUCTION

SECTION A : HIV IN PREGNANCY

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Epidemiology of HIV

Susceptibility of women to HIV infection

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Biological factors

Socio-cultural factors

Effect of pregnancy on the natural history of HIV infection

Effect of HIV infection on pregnancy

Mother-to-child transmission

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Factors affecting mother-to-child transmission of HIV-1

Interventions to prevent mother-to-child transmission of HIV

Appropriate interventions to reduce mother-to-child transmission

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Antiretroviral therapy

Immune therapy

Nutritional interventions

Mode of delivery

Vaginal cleansing

Modification of infant feeding practice

Voluntary HIV counselling and testing in pregnancy

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Testing of antenatal women

Counselling before and after HIV testing in pregnancy

Counselling about pregnancy-related issues

SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN

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Antenatal care

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Obstetrical management

Examination and investigations

Medical treatment during pregnancy

Antiretroviral therapy

Care during labour and delivery

Postpartum care

Care of neonates

SECTION C : INFECTION CONTROL MEASURES

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Universal precautions

Risks of needlestick injuries

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Management of needlestick injuries and other accidental blood exposure

REFERENCES

Modification of infant feeding practice

The increased risk of HIV transmission through breastfeeding is well documented^{237,238,302,303}. Breastfeeding is responsible for a high proportion of mother-to-child transmission in developing countries, where 1 in 7 children born to HIV-positive mother will be infected through breast milk²⁴⁷. Breastfeeding may double the transmission rate^111,238,304 and may be the major determinant for the difference in transmission rates between developed and developing countries. A meta-analysis of studies of transmission through breastfeeding showed the additional risk of transmission through breastfeeding to be between 7 and 22%, and close to 30% for women who are infected during the breastfeeding period²³⁷. Potential modifications of infant feeding practices include complete avoidance of breastfeeding, early cessation, pasteurisation of breast milk, and avoiding breastfeeding in the presence of breast abscesses or cracked nipples^111,305.

The debate on appropriate infant feeding has focused almost exclusively on the risks and benefits of breastfeeding for the infant. Maternal considerations should also be taken into account, although there is a need for further research into the relationship between HIV infection, nutritional status and immune function in breastfeeding mothers. The concerns about the effect of breastfeeding on maternal health in HIV positive women include the potential effects of breastfeeding and resultant weight loss on the immunity and long-term prognosis of the mother. The effects of advanced disease or nutritional deficiencies on the risk of transmission in breast milk and the function of immunologically active components of breast milk from severely immune suppressed or malnourished mothers also need to be considered³⁰⁶. Breast milk could have advantages for those infants already infected with HIV by the time of birth, if there was a way to identify these children.

In developed countries, few HIV positive women will breastfeed³⁰⁷. In resource poor settings, alternatives to breastfeeding may not be feasible for financial, logistical and cultural reasons^126,308,309. Mothers should be given the information on the advantages and disadvantages of breastfeeding and replacement feeding with regard to HIV infection, and encouraged to make a fully informed decision about infant feeding. They should be supported in their decision²⁴⁷.