Preventing HIV Transmission to Infants Through Breastfeeding: The Key for Child Survival
22 May, 2007 03:34 pm
Protecting against HIV transmission, exclusive breastfeeding is a critical intervention for child survival. For the majority of women in sub Saharan Africa who do not have all the resources and support to safely formula feed, the option of exclusive breastfeeding offers a very high chance of the infant surviving and also being HIV uninfected.
• 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.
Experience in implementing these recommendations in different high HIV prevalent areas of sub Saharan Africa has been extremely variable. In some relatively well resourced communities actively supported by NGOs, it has been possible to safely offer replacement feeding namely, commercial infant formula. Elsewhere however, the avoidance of breastfeeding in order to avoid all risk of HIV transmission to the infant has been accompanied by significantly higher rates of death amongst the infants born to HIV positive mothers. These children died from infections other than HIV such as diarrhoea, pneumonia as well as malnutrition, all of which breastfeeding very effectively protects against in other settings. The difficulty was that counsellors were unable to offer that ‘specific guidance and support’ to HIV positive women to enable them make the appropriate and wisest decision for their circumstance. They could not determine whether all the conditions necessary to make the use of replacement feeding acceptable (to other members of the family of local community), feasible (making fresh batches of formula milk 5-8 times per day), affordable (for at least 6 months), sustainable (willing to follow all the steps to make formula milk safer) and safe (having access to clean water and sanitation) were present. As a result women made inappropriate choices and their infants died.
At the WHO meeting in 2000, data was presented which suggested that exclusive breastfeeding, where the infant received breastmilk without any other water, milks or foods such as porridge for the first months of life, was associated with a lower rate of HIV transmission than when the infant was breastfed and any of these other fluids or foods were also given. Results of a study conducted in northern KwaZulu Natal and funded by the Wellcome Trust (UK) were recently reported. HIV infected women were supported to exclusively breastfeed and the number of infections occurring in the infants were measured. Over 2000 mothers were visited at their homes every week and information about the way in which they fed their infants was captured. Blood samples were collected from a simple finger prick every month and tested to determine the HIV status of the infant. The study reported that exclusive breastfeeding reduced the risk of HIV transmission by about half compared to when formula milk was given with breastmilk and by more than ten times compared to when solid foods such as porridge were also given. This would, perhaps, seem counterintuitive. One might expect that if more breastmilk was given then more HIV virus would be presented to the infant and more would become infected. There are several ways by which exclusive breastfeeding might in fact be protective and so explain these results.
Exclusive breastfeeding protects the integrity of the lining of the gut, and as with intact skin, an intact gut epithelium could effectively protect against the HIV virus gaining entry to the blood system. Conversely, the ingestion of foreign proteins such as cows’ milk protein as found in formula milk, might stimulate the large numbers of immune receptors that ordinarily line the gut and thereby facilitate virus adherence to the gut and entry into the underlying tissues. Exclusive breastfeeding is also associated with a lower amount of HIV virus in the milk compared to when the mother mix breastfeeds. When mothers mix breastfeed the breast is not entirely emptied of all milk and the residual milk triggers a low level of inflammation that results in higher levels of virus in the milk. Finally breastmilk naturally contains several anti-HIV substances that can inhibit virus growth. While more breastmilk will present more virus, it also equates to more of these substances reaching the infant.
The importance of these data cannot be overstated. For in addition to protecting against HIV transmission, exclusive breastfeeding is a critical intervention for child survival. For the majority of women in sub Saharan Africa who do not have all the resources and support to safely formula feed, the option of exclusive breastfeeding offers a very high chance of the infant surviving and also being HIV uninfected.
The question remains how best to support women to make the best choice for their circumstance. It is possible now to say with confidence that exclusive breast feeding has a major advantage over mixed breastfeeding in terms of HIV transmission and over replacement feeds in terms of surviving the common fatal infections of early childhood. In the light of this study WHO changed their recommendations this year to reflect these findings. The overall paradigm for decision making has changed to acknowledge that overall child survival and not just avoiding HIV transmission is the over-arching goal. For most women in Southern Africa where clean water, electricity and fridges are not always available, exclusive breastfeeding offers the best chance of her child surviving without HIV infection.
Rollins NC. Infant feeding and HIV: Avoiding transmission is not enough. BMJ 2007;334:487-488
Coovadia HM, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 2007,