Breastfeeding and HIV Transmission
----------------------------------
SAfAIDS FACT SHEET No. 1.98
Material from this fact sheet may be freely reproduced provided this
is not for profit and that the source is clearly acknowledged.
Individual cases of mother-to-child HIV transmission through breast-
feeding were first documented in 1985. By 1992 the level of risk was
more clearly understood, but much is still unknown about the risks
and mechanisms of transmission. It is clear, however, that mothers
with HIV can transmit infection and need advice on what is best for
their babies. The World Health Organization (WHO) and the United Na-
tions Children's Fund (UNICEF) have been slow to support moves to-
wards non-breastfeeding for mothers with HIV in developing countries.
This is because of the real risk that more babies will die of malnu-
trition and diarrhoeal infections than would be saved through avoid-
ing HIV infection. Two considerations are changing this view: the
high levels of maternal HIV in some areas (over 20% of pregnant women
in most of southern Africa, for example) and recognition of the right
of women and families to information on which to make their own deci-
sions.
How Risky is Breastfeeding?
WHO suggests that the risk of HIV transmission from-mother-to-child
is roughly as follows:
- Two-thirds of babies born to mothers with HIV are not infected at
all;
- Of the one-third of babies who are infected, two-thirds are in-
fected in the womb or at birth; one-third are infected through
breastfeeding.
Some studies indicate higher levels of risk, for instance, where
breastfeeding continues for a long time.
Breastfeeding is more risky when:
- the mother acquires HIV infection herself during pregnancy or lac-
tation;
- the mother's nipples are cracked or she has abscesses and other
breast problems;
- she is already symptomatic for HIV-related diseases;
- the baby has sores in the mouth or an inflamed gut.
These factors mean either that the mother has a high viral load in
the milk (or that blood might be present in the milk); or that the
baby's mucosa are more susceptible to infection because of sores and
inflammation (e.g. caused by mixed feeding or formula feeding). The
factor conferring greatest risk is the mother becoming infected her-
self during pregnancy or lactation.
Policy dilemmas
Where maternal HIV infection is high, huge numbers of babies are po-
tentially at risk of infection. The most important strategy must be
trying to reduce maternal infection, trying to protect young women in
particular from becoming infected in the first place. In addition to
this, the number of infected babies can be reduced by:
- increasing reproductive choices for women;
- short-course ZDV (AZT) administered to the mother during late preg-
nancy (a recent Thai study found that short-course ZDV reduced
transmission from 25% to 8% in a non-breastfeeding population);
- certain obstetrical procedures at birth (e.g. avoiding early rup-
ture of membranes);
- administration of vitamin A and other micronutrients to the mother
during pregnancy and lactation;
- mothers with HIV avoiding breastfeeding.
Only changed obstetric practice and micronutrient supplementation,
however, can be effected for all pregnant mothers regardless of HIV
status. These low-cost interventions should be undertaken as a prior-
ity. The other interventions are more costly and require that mothers
know their HIV status. This means they must have access to voluntary
counselling and testing (VCT) which, in turn, requires a substantial
infrastructure linked with existing primary and maternal and child
health facilities. It also means that many social and cultural prob-
lems may arise, for instance if the HIV positive woman is rejected by
her partner or family.
The strategy of avoiding breastfeeding, although an important option
is problematic because, if replacement feeding is undertaken only by
HIV positive mothers, their confidentiality over their HIV status is
automatically lost. If HIV negative mothers also stop breastfeeding,
many babies in poor families will die from malnutrition and diarrhoea
who were at no risk of HIV.
Infant feeding recommendations
The new WHO, UNAIDS and UNICEF policy guideline on breastfeeding is
that all women should:
- be kept optimally informed about the risks of HIV transmission
through breastfeeding;
- have access to VCT to find out their HIV status;
- be supported to undertake safely the option they choose, either
breastfeeding or replacement feeding.
In line with this revised policy, the UN organisations emphasise that
breast milk and breastfeeding remain the desired option for all women
who are HIV negative as well as for all those who do not know their
HIV status. The worst outcome of all would be if fears about HIV
transmission undermine breastfeeding in the general population.
To make replacement feeding an option for the majority of women will
mean ensuring a safe, clean water supply, the knowledge required to
replacement feed safely, and access to a guaranteed supply of re-
placement milk over a period of several months, even up to a year.
The replacement milk could be manufactured formula or modified animal
milk, provided women are educated and supported to dilute it and add
sugar in the required amounts.
If mothers with HIV do breastfeed, the duration of breastfeeding
should be reduced to between 3 and 7 months according to various re-
searchers. The transition to other foods should then be rapidly un-
dertaken to avoid the extra risks of HIV transmission during mixed
feeding.
The comprehensive infant feeding guidelines are being made available
by WHO, UNAIDS and UNICEF to assist governments and health care man-
agers design effective strategies to optimise infant feeding advice
and support in resource-constrained settings.
SAfAIDS Fact Sheet 1.98 is available from:
Southern Africa AIDS Information Dissemination Service (SAfAIDS)
P O Box A509, Avondale,
Harare, Zimbabwe
Tel: +263-4-336193/4
Fax: +263-4-336195
mailto:info@safaids.org.zw
The WHO/UNICEF/UNAIDS statement is available from:
World Health Organisation
CH-1211 Geneva 27,
Switzerland
Tel: +41-22-791-2628
Fax: +41-22-791-4853
http://www.who.ch
--
Send mail for the `AFRO-NETS' conference to `afro-nets@usa.healthnet.org'.
Mail administrative requests to `majordomo@usa.healthnet.org'.
For additional assistance, send mail to: `owner-afro-nets@usa.healthnet.org'.