Series L, Number 14
Issues in World Health

CONTENTS

Home (Key Points)

Breastfeeding Gains and Goals
Table 1. Breastfeeding Practices Improving
Web Table 1. Early Initiation of Breastfeeding Over Time
Web Table 2. Exclusive Breastfeeding Over Time
Web Table 3. Breastfeeding at Two Years
Table 2. Breastfeeding Common but Not Usually Optimal
Web Figure 1. Most Infants Breastfed Initially
Web Figure 2. Levels of Breastfeeding Vary Widely

Comprehensive Strategies Needed

Spotlight: Madagascar’s Comprehensive Approach Improves Breastfeeding

Breastfeeding Increases Women’s Contraceptive Options
Table 3. When Breastfeeding Mothers Can Begin a Family Planning Method After Childbirth Compared with Mothers Not Breastfeeding

Centerspread: Breastfeeding Is Best
Figure 1. Better Breastfeeding Reduces Diarrhea

Women with HIV Face Crucial Breastfeeding Decisions
Figure 2. Estimated Risk of HIV Infection in Infants and Young Children

Bibliography

Credits

• Counseling Aid: When Can a Woman Use LAM?
• Counseling Aid: HIV and Infant Feeding Counseling Flow Chart

• Box: Taking Ten Steps to Successful Breastfeeding
• Table: When Breastfeeding Mothers Can Begin a Family Planning Method

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Women with HIV Face Crucial Breastfeeding Decisions

A mother living with HIV faces a difficult decision- whether to breastfeed, in order to give her infant important nutrients and protection from potentially deadly diseases, or not to breastfeed, to avoid the risk of transmitting HIV through breastmilk.

From a public health perspective, preventing HIV transmission through breastfeeding is crucial. Transmission through breastfeeding is estimated to account for one-fourth to one-half of infant HIV infections, depending on the duration of breastfeeding (54, 259) (see Figure 2).

HIV also can be transmitted from an infected mother to her child during pregnancy or delivery. Among 100 children born to mothers with HIV who do not receive antiretroviral treatment, an estimated 15 to 25 children will become infected with HIV during gestation and delivery. If mothers with HIV breastfeed their infants up to six months of age, an additional 5 to 10 of these 100 children would become infected. If breastfeeding lasts between 18 and 24 months, 15 to 20 of these children would be infected through breastmilk (259).

On average, among babies born uninfected and who are breastfed by untreated mothers with HIV, 16% will become infected when breastfeeding continues for two years (32, 54, 63, 96, 105, 156). Shorter and exclusive breastfeeding minimizes the risk (see 'Shorter breastfeeding poses less risk.'). Studies are underway to assess whether treating mothers and their breastfeeding babies with antiretroviral therapy will reduce HIV transmission through breastmilk (see 'Seek antiretroviral treament.').

Balancing the Risks

Weighed against the risks of breastfeeding for infants of women with HIV are the risks and consequences of not breastfeeding. In developing countries diarrheal and respiratory diseases are common and often fatal to infants-and considerably more common and deadly for infants who are not breastfed than for those who are. Infants who do not breastfeed miss the early immunological protection conveyed by breastmilk, and they risk malnutrition and exposure to contaminated water. It is estimated that over half of deaths among young children can be attributed to malnutrition (38). Breastfeeding could prevent many of these deaths-especially exclusive breastfeeding, because it promotes greater gains in weight during infancy (pp. 12-13).

Women with HIV and their health care providers need to weigh the various risks and consequences in deciding whether to breastfeed and, if so, when to begin replacement feeding. Currently, infants cannot be reliably tested for HIV early enough to influence a mother's feeding decision. Instead, the weighing of risks and consequences often depends on the circumstances that a woman with HIV faces:

• Can she obtain safe replacement food for her infant? A mother or family must be able to afford replacement food and also have the utensils and skills to prepare it correctly and hygienically.
• Can she adequately care for her own health while nursing? It is important that women with HIV maintain adequate nutrition since HIV infection progresses more rapidly among women who are undernourished. Nursing mothers with HIV also must care for their breasts to prevent problems such as mastitis, which increase the chance that breastfeeding will pass HIV to their babies (see 'Maintain good health.').
• Can she win the support of her family and community for replacement feeding instead of breastfeeding? In some places not breastfeeding amounts to acknowledging that you are infected with HIV and exposes women to the social stigma and censure that many HIV-infected people face.

In contrast, one issue that does not have to concern women with HIV is that breastfeeding does not harm their own health and does not place them at a higher risk of death while breastfeeding (33, 49, 115, 125, 201).

While safe and nutritious alternatives to breastmilk would eliminate the risk of HIV transmission, such alternatives often are unavailable, unaffordable, or culturally unacceptable (see 'What Do Experts Advise?'). In areas with high infant and child mortality rates and without appropriate alternatives to breastmilk, not breastfeeding is more dangerous to the child of a woman with HIV than breastfeeding-particularly because most children breastfed by HIV-positive mothers do not become infected. A study that assessed the risks of different feeding strategies through a simulation model found that in areas of poverty and poor hygiene-such as much of sub-Saharan Africa-the risk of death associated with replacement feeding considerably exceeds the risk of HIV transmission (and death) associated with six months of breastfeeding (191). The study estimated that, compared with replacement feeding, any breastfeeding by HIV-infected mothers during the first six months would result in 68 HIV infections but 100 fewer deaths from other causes per 1,000 live births.

HIV Transmission Through Breastfeeding Can Be Reduced

The risk of HIV infection varies substantially depending on the pattern and duration of breastfeeding.

Shorter breastfeeding poses less risk. Even a few weeks or months of breastfeeding provides infants with nutrition and protection against illness. Women with HIV can breastfeed to provide these benefits and then stop breastfeeding early to reduce the chances of infecting their infants. The risk of HIV transmission is cumulative-that is, the longer the child is breastfed, the greater the chances of infection (32, 65). Research findings are mixed, however, as to whether the risk in the first weeks of breastfeeding is higher than in later months (32, 50, 67, 96, 132, 150, 156).

Exclusive breastfeeding is less risky than mixed feeding. Introducing other food while still breastfeeding increases the likelihood of HIV transmission (96). A recent study in Zimbabwe, involving more than 4,000 HIV-positive mothers and their infants, found that exclusive breastfeeding in the first months of an infant's life is safer than early introduction of other food. Compared with infants who were exclusively breastfed for the first three months, infants who were mixed-fed were 4 times more likely to have acquired HIV at 6 months. Infants who were exclusively breastfeeding in the first months of life were better off later, too, when replacement food was given along with breastmilk. Compared to these babies, infants who were mixed-fed early were 3.8 times more likely to have acquired HIV at 12 months and 2.6 times more likely at 18 months (96). This study confirms earlier findings (50).

It is not clear why mixed feeding is less safe than exclusive breastfeeding. It is thought that other foods disturb the intestinal lining of infants in the first months of life, allowing HIV to pass more easily into the bloodstream (37, 213). In any case, the intestines of young infants are highly permeable, which enables them to absorb immunoglobulins and gain other passive immunity from breastmilk (116). Breastfeeding facilitates faster closure of the intestinal gaps, whereas foods other than breastmilk can inflame and damage intestinal cells (37, 249).

The Zimbabwe study also found that even predominant breastfeeding-that is, giving only liquids such as water, tea, or juice in addition to breastmilk-increased risk of HIV transmission. Compared with infants who were exclusively breastfed, infants who were predominately breastfed for the first three months of life were 2.6 times more likely to have acquired HIV by 12 months of age (96).

What Do Experts Advise?

WHO and other UN agencies advise that HIV-positive mothers avoid breastfeeding if replacement feeding meets five essential criteria-affordable, feasible, acceptable, sustainable, and safe (often referred to as the AFASS criteria, for the first letter of each of the criteria). Otherwise- and this would apply for the great majority in developing countries-HIV-positive mothers should breastfeed exclusively for their infants' first months of life and stop breastfeeding if replacement feeding can meet the five criteria or when breastmilk alone is no longer adequate (259). The greater risk of early mixed feeding means that infants of mothers with HIV need to stop breastfeeding all at once, rather than gradually, when they switch to replacement feeding.

Where replacement food for infants can meet the five essential criteria, as in much of the developed world, the decision is clear:Women should avoid breastfeeding if they have HIV and give only appropriate replacement foods. In much of the developing world, however, the decision is more difficult. Safe replacement feeding usually cannot be readily obtained. Most families cannot afford to purchase, prepare, or properly store commercial formula. Homemade breastmilk substitutes must be carefully measured and should be prepared and stored under sterile conditions, which is often difficult or impossible. Common traditional substitutes for breastmilk, such as rice water, do not provide enough nutrition. All of these factors make replacement feeding difficult or dangerous.

What Providers and Mothers Can Do

Ultimately, every HIV-positive mother's decision whether to breastfeed is her own individual decision. For their part, health care providers should take responsibility for making sure she has adequate accurate information to make that decision, and they should provide support for the decision that she makes. In particular, they can help women weigh the risks of breastfeeding and of replacement feeding.

WHO, UNICEF, and other international health organizations suggest a number of ways that providers can advise and encourage women with HIV to make informed decisions about breastfeeding and can counsel HIV-negative women or those who do not know their HIV status to avoid infection and seek testing (119, 136, 167, 259). Their advice includes the following:

Avoid HIV infection. If a woman is HIV-negative or she does not know her HIV status, she needs to protect herself against HIV infection and, if at risk, she and her sexual partner should consistently use condoms. Recent research suggests that her chances of acquiring HIV may be greater in pregnancy than at other times. A large study in Rakai, Uganda, reports that pregnant women have a 2.3 times greater risk of acquiring HIV than women who are not pregnant and not breastfeeding and almost 1.8 times greater risk than breastfeeding women (81).

Avoiding HIV infection while breastfeeding is especially important for the sake of the infant's health. If a woman becomes infected with HIV in the time she is breastfeeding, the risk of transmitting HIV to her infant is more than twice the risk among women infected before giving birth (63, 65, 240).

Get HIV testing and counseling. When women know their HIV-infection status and are counseled, they can make more informed decisions about infant feeding and about how to protect their own health. HIV transmission through breastmilk is more likely among mothers with higher levels of HIV in breastmilk (67, 104, 193, 202) or in maternal plasma (75, 132, 202). High levels of the virus typically occur when the immune system begins to fail. High levels also occur in primary HIV infection-the first phase of infection, when the virus replicates quickly before the immune system develops antibodies to respond (110). Unfortunately, the most widely available tests cannot detect HIV infection this early.

The strength of an HIV-infected person's immune system and the severity of the HIV infection are reflected in the CD4+ cell count, also referred to as the T4 cell count. The CD4+ cell count declines when the HIV virus is replicating quickly, signaling advanced disease. Thus mothers with lower CD4+ cell counts are at greater risk of transmitting the virus through breastfeeding (32, 65, 96, 132).

Many women are reluctant to get tested for HIV. Some fear being stigmatized and condemned by their community if their infection becomes known. Others feel that testing is pointless because they cannot obtain treatment or access to good reproductive health services. Improving the quality of treatment and counseling available to mothers with HIV can help overcome such reluctance (106). Providers can counsel women that knowing their HIV status is important to making informed decisions about their own health and about the health of their infants. Also, providers can encourage a woman to seek testing together with her spouse or partner as a way to overcome some of these barriers.

Maintain good health. Women with HIV and women of unknown HIV status who are nursing should pay extra care and attention to their breast health. Mastitis, breast abscess, and nipple lesions increase the risk of HIV transmission through breastfeeding (65, 67, 104, 202, 250). To help avoid these problems, health care providers can give nursing mothers advice and support on positioning the baby and latching on and recommend frequent feeding from both breasts. Caring for the infant's oral health is also important. Oral thrush (a fungal infection of the mouth) in infants appears to increase HIV transmission through breastfeeding (65). Providers can teach mothers to identify and seek treatment for breast problems or infant thrush.

Health care providers can help women to maintain adequate nutrition. When women are well-nourished, HIV progresses less rapidly. For example, a study in Tanzania found that HIV progressed less rapidly among mothers given supplements of vitamins B, C, and E than among mothers who were given a placebo (68). In Zimbabwe, a study found that HIV transmission through breastfeeding decreased as mother's upper-arm circumference increased (arm circumference is an indicator of nutritional status) (96).

Improving mother's nutrition to reduce the rate of disease progression benefits both the mother and her infant. A study in Zambia found that HIV-free infants born to women with advanced HIV are 2.9 times more likely to die and 2.3 times more likely to be hospitalized than HIV-free infants born to women with less advanced HIV infections (124). Also, when HIV progresses less rapidly, levels of HIV in the mother's body remain lower, and thus the likelihood that HIV will pass to the baby during breastfeeding is less (32, 65, 132).

Consider a range of infant feeding options. Counseling a woman on the healthiest choices for her situation and on replacement feeding methods can enable her to make informed decisions (259) (see 'HIV and Infant Feeding Counseling Flow Chart').

For women who breastfeed: If a woman with HIV decides to breastfeed her newborn, she has several options.

• Exclusive breastfeeding. Exclusive breastfeeding for the first months of life-and avoiding mixed feeding-is usually the best way to increase the safety of breastfeeding, while giving infants the ideal nutrition and immunologic protection provided by breastmilk. Exclusive breastfeeding is recommended for HIV-positive women when replacement feeding does not meet the five essential criteria. Breastfeeding should be stopped if and when all these criteria can be met or when exclusive breastfeeding is no longer nutritionally adequate. Stopping breastfeeding early is recommended so that the amount of time an infant is exposed to HIV transmission through breastfeeding is short. Also, mothers should stop breastfeeding all at once, rather than gradually, since mixed feeding poses greater risk.
• Expressing and heat-treating breastmilk. Women can express breastmilk either manually or with a breast pump. Expressed breastmilk can be either flash heated or else pasteurized and then cooled to kill HIV and the cells that carry it. Flash-heating is heating breastmilk in a water bath (that is, a double-boiler) until the water begins to boil, and then removing the milk from the water bath and heat source (42). A simple and inexpensive home pasteurization method, Pretoria Pasteurization, involves boiling a pan of water, removing it from the heat source, immediately placing a covered jar of breastmilk in the water and leaving it there for 20 minutes (103). In laboratory tests both flash heating and pasteurization have been shown to deactivate HIV (99). Heat treatment destroys some breastmilk components, but it is still better for infants than commercial formulas or animal milk.
• Wet-nursing. Allowing a family member or someone else to nurse the baby is acceptable in some cultures when the infant's mother is too ill or does not have enough breastmilk (94, 276). Wet nurses may not be safe, however. Cases of HIV transmission from wet nurses with undiagnosed HIV infection have been reported (206). Wet-nursing should be considered only when the prospective wet nurse tests HIV-negative and remains so during the feeding period.

For women who can choose replacement feeding: If replacement feeding can meet the five essential criteria, a woman with HIV may decide to avoid breastfeeding altogether. In this case she can consider several options, each of which has specific risks and benefits:

• Commercial formulas. Commercial infant formulas are an option if they are affordable and there will be reliable supplies, as well as clean water, fuel, utensils, preparation skills, and time to prepare foods correctly and hygienically. Liquid commercial formulas based on modified animal milk or soy protein are closest in nutrient composition to breastmilk, but they lack essential fatty acids, hormones, immune cells, and other factors present in breastmilk. Commercial formulas also come in powdered form. Although these are often more affordable than liquid formula, they are not always hygienic. Many contain contaminants and, occasionally, some contain bacteria dangerous to young infants (266).
• Home-modified animal milk. Milk from cows or goats is often readily available in either fresh or powdered form and can cost less than commercial formula. It is not fit for infants less than six months of age, however, unless it is properly modified. It must be diluted with clean boiled water to increase the fluid content and mixed with sugar to improve the energy content (259). Also, animal milk does not provide enough of certain minerals and vitamins (173). Supplementing animal milk with these micronutrients is essential but can be costly and thus beyond the reach of many people.

Seek antiretroviral treatment. Antiretroviral (ARV) drugs given to HIV-positive women during pregnancy and delivery and/or to infants during delivery and the first weeks of breastfeeding help treat their infection and can reduce the risk of HIV infection in their infants (263). Short courses of a single ARV and of combinations of ARV drugs such as zidovudine, lamivudine, and nevirapine reduce the risk of HIV transmission during pregnancy and labor (143, 224) as well as during the first weeks postpartum (71, 133, 218). Many clinical trials have assessed these drugs for safety and effectiveness and found that they both decrease replication of HIV in the mother and help protect the infant during and after exposure to the virus (248). Efavirenz, which is used in some ARV combinations, should not be given to pregnant women because it interferes with fetal central nervous system development (262).

A number of clinical trials are underway or planned to assess whether these drugs can reduce HIV transmission through breastfeeding beyond the first weeks postpartum. Some drug regimens involve treating the mother both during late pregnancy and breastfeeding in order to reduce the amount of virus in her breastmilk (74). Others involve giving ARVs to uninfected breastfed infants to reduce the chances of infection through breastfeeding (74).

Clinical trials are planned or underway in Ethiopia, India, and Uganda to treat uninfected infants during their first six weeks of life. Studies in Botswana, Rwanda, Tanzania, Uganda, South Africa, and Zimbabwe will treat infants for their first six months of life. Also, the clinical trial in Botswana, as well as clinical trials in Burkina Faso, Kenya, Malawi, and Tanzania, will treat mothers with highly active antiretroviral therapy (HAART) up to six months postpartum to attempt to reduce transmission during breastfeeding (74). In a subset of women and infants from the Botswana trial, nevarapine concentrations in breastfeeding infants of mothers who received this ARV for nearly four months postpartum reached levels that can inhibit HIV infection (204).

Another option being explored is directly treating breastmilk with microbicides-agents that kill HIV. Initial studies suggest that the microbicide sodium dodecyl sulfate (SDS) holds promise. Adding a small amount of SDS to breastmilk kills all HIV without harming breastmilk (237).

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Programs to prevent mother-to-child transmission of HIV are expanding, but they still have little coverage at this point (165). In the countries most affected by AIDS, an estimated 10% of pregnant women are currently offered services to prevent HIV transmission during pregnancy and childbirth (107). One strategy not sufficiently emphasized is avoiding unwanted pregnancies among women with HIV. In public health terms, avoiding unwanted pregnancies would be the single action that would most reduce the number of infants infected with HIV (261). Rather, most programs focus on antiretro-viral treatment, preventing HIV infection among parents-to-be, and on ensuring safe delivery practices. HIV-positive pregnant women also learn how to reduce the risk of passing HIV infection to their infants and how to most safely feed their infants such as by exclusively breastfeeding for the first months of life (119).