Infant feeding in the context of HIV
Biological, behavioural and contextual rationale
Infant feeding in the context of HIV is complex because of the major influence that feeding practices and nutrition have on child survival. The HIV virus can be transmitted from mothers known to be HIV-infected to infants during the course of pregnancy, child birth, and through breastfeeding. Globally, about 370 000 infants become infected with HIV every year (1) and about 91% of these new infections occur in sub-Saharan Africa (2). Depending on the availability of interventions to reduce HIV transmission during pregnancy and delivery, HIV transmission through breastfeeding is responsible for between 30% and 60% of all HIV infections in children (3). Women with more advanced HIV disease or who have just become infected are more likely to transmit the virus.
If an HIV-infected mother breastfeeds her infants for two years without receiving any antiretroviral drugs (ARVs) then 14–20% of infants will become infected (3). However, in many resource-limited settings, infants who do not breastfeed are up to six times more likely to die from malnutrition, pneumonia and diarrhoeal disease (4, 5). The dilemma in settings where child mortality due to these conditions is relatively commonplace, such as sub-Saharan Africa, has been to balance the risk of infants being infected with HIV through breastfeeding, with the risk of death from other causes if infants are not breastfed. HIV-free survival is the term used to describe survival of infants while remaining HIV-uninfected.
In the past, health workers were expected to individually counsel all HIV-infected mothers about the various infant feeding options such as breastfeeding or formula feeding. It was then for the mothers to decide between the options and for health services to support them in their choices. However, health workers did not have sufficient time or training to effectively communicate and guide these decisions, and mothers had difficulty with the complexities of balancing the risks, or were under a range of pressures from other people at home or in the community. As a result, mothers' infant feeding practices were often inappropriate for their home circumstances and infants were at high risk of mortality and HIV transmission (6, 7).
In 2009 and 2010, several research studies reported new findings that ARVs can dramatically reduce the risk of HIV transmission through breastfeeding to 1–2% over a 12 month period (8–10). ARVs can either be given to mothers or to their infants during the period of breastfeeding so that it is now possible for infants to breastfeed with little risk of acquiring HIV while also being protected from other major causes of child mortality.
The efficacy of ARV interventions to prevent transmission through breastfeeding has transformed the landscape in which national recommendations can be made (11). National health authorities are now recommended to endorse one approach, that is, either breastfeed with ARVs (to either the mother or infant), or avoid all breastfeeding. This decision should be made after a careful review of the HIV epidemic in that country and a review of the main causes of childhood death other than HIV. In countries and regions such as Brazil, Thailand or Europe, where the risk of death from serious infectious diseases to infants is very low, HIV-infected mothers will probably continue to provide replacement feeds. In countries where, for example, safe water is not consistently available and other conditions are not supportive of safe replacement feeding, then breastfeeding with ARV protection will give infants the best chance of HIV-free survival. In these countries, it is recommended that HIV-infected mothers should breastfeed their infants until 12 months of age and only then consider stopping. In the first six months of life, mothers should exclusively breastfeed and then introduce complementary foods. The only real difference now for women who are HIV-uninfected or whose HIV status is unknown, is that they should continue breastfeeding until 24 months and beyond instead of possibly stopping after 12 months.
In addition to the benefits for individual infants, it is now possible to simplify communication messages and strategies to improve infant feeding practices for all infants living in HIV-affected communities.
References
1. UNAIDS report on the global AIDS epidemic 2010. Geneva, UNAIDS, 2010 (http://www.unaids.org/globalreport/Global_report.htm, accessed 21 February 2011).
2. WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Geneva, World Health Organization, 2010 (http://www.who.int/hiv/pub/2010progressreport/en/, accessed 21 February 2011).
3. Breastfeeding and HIV International Transmission Study Group. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. Journal of Infectious Diseases, 2004, 189(12):2154–66.
4. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. The Lancet, 2000, 355(9202):451–5.
5. Homsy J et al. Breastfeeding, mother-to-child HIV transmission, and mortality among infants born to HIV-Infected women on highly active antiretroviral therapy in rural Uganda. Journal of Acquired Immune Deficiency Syndrome, 2010, 53(1):28–35.
6. Doherty T et al. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS, 2007, 21(13):1791–7.
7. Kuhn L et al. Differential effects of early weaning for HIV-free survival of children born to HIV-infected mothers by severity of maternal disease. PLoS.ONE, 2009, 4(6):e6059.
8. Shapiro RL et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. New England Journal of Medicine, 2010, 362(24):2282–94.
9. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. Lancet Infectious Diseases, 2011.
10. Chasela CS et al. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. New England Journal of Medicine, 2010, 362(24):2271–81.
11. Guidelines on HIV and infant feeding, 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Geneva, World Health Organization, 2010 (http://www.who.int/child_adolescent_health/documents/en/, accessed 21 February 2011).