Definition of the Prevention Area
HIV can be transmitted from a mother to her child during pregnancy or delivery. When a mother is HIV infected, her baby can also be infected through breastfeeding. Several interventions reduce the risk of transmission in the first two phases. Until recently, there was uncertainty regarding appropriate and healthy options for feeding infants of mothers living with HIV.
The 2010 World Health Organization (WHO) Guidelines on HIV and infant feeding have changed this landscape dramatically. The benefits of breastfeeding can now be achieved by mothers living with HIV, with a very low risk of transmitting HIV to the infant when breastfeeding is combined with maternal or infant antiretroviral (ARV) interventions. This avoids the risks associated with formula feeding and attains the ultimate goal of "HIV-free survival" for more infants.
Epidemiological Justification for the Prevention Area
Without interventions to prevent mother-to-child transmission, an estimated one-third of infants born to mothers living with HIV will become infected. Breastfeeding is responsible for 30 to 60 percent of the infections among children with HIV.
Mothers with high viral loads or low CD4 cell counts are most likely to transmit the virus during breastfeeding. Antiretroviral treatment before pregnancy or during early pregnancy and continuing postnatally can cut the risk of mother-to-child transmission by at least 75 percent. Other risk factors include mixed feeding (giving formula or other substances in addition to breast milk) in the first 6 months, various breast pathologies (such as mastitis, abscesses, or nipple lesions), and poor maternal nutrition.
Core Programmatic Components
The major programmatic options include promoting breastfeeding or formula feeding. Unfortunately, in regions with poor sanitation, unclean water used to mix formula has caused serious illness and deaths among formula-fed infants, who are more likely than breastfed infants to die from diarrhea, malnutrition, and serious infections. Alternatives such as heat treating expressed breast milk or providing breast milk from HIV-uninfected wet nurses are not practical in most resource-limited settings.
The 2010 WHO Guidelines advise national authorities to advocate a single infant feeding practice based on local conditions (socioeconomic and cultural contexts; availability and quality of health services; local epidemiology including HIV; the primary causes of infant and child mortality; and maternal and child undernutrition). Breastfeeding with antiretroviral (ARV) treatment/prophylaxis or avoidance of all breastfeeding are optimal choices. Most governments are expected to opt for breastfeeding with ARV treatment/prophylaxis. In resource-limited countries that have opted for breastfeeding as the primary option, exclusive breastfeeding for the first 6 months should be promoted even if ARV treatment or prophylaxis are not yet accessible; breastfeeding is not conditional on ARV treatment or prophylaxis.
Major messages in the 2010 WHO Guidelines for countries that opt for breastfeeding are:
- "Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status)should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life."
- "If infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first six months of life and continue breastfeeding as per the recommendations for the general population, that is, up to two years or beyond."
WHO also promotes counseling and support for infant feeding and informed choice on the part of the mother. Support should not be contingent on whether a mother's choice aligns with national recommendations.
The absence of comprehensive and widely accessible postnatal care (including infant feeding) has been a major gap in PMTCT programs overall. These new WHO recommendations urgently need to be implemented in order to achieve the ultimate goal of "HIV-free survival" of infants.
Current Status of Implementation Experience
Cultural barriers, financial and manpower constraints, and other obstacles made it difficult to implement maternal, newborn, and child health and PMTCT programs recommended by WHO in 2006. In many cases, counseling and support for women were inadequate. The stigma associated with HIV compromised the ability of women to breastfeed, and the cost and complexity of using formula created further barriers to implementation.
Successful implementation of the 2010 WHO Guidelines will require several steps: national guidelines and policies related to HIV and infant feeding will need to be changed; training curricula altered; new training provided for health workers; and efforts to secure community support reinforced.
Finally, efforts to widely promote breastfeeding for all mothers—which have been compromised in recent years due to fears about HIV transmission—will need to be reinvigorated.