Q: What are UNICEF’s nutritional priorities concerning HIV/AIDS?

The majority of our work thus far has been focusing on reducing the transmission of HIV from mother to child through breastfeeding. However, with the crisis in Southern Africa, we are paying much more attention to the nutrition, care and support of those who are HIV positive or affected by HIV/AIDS such as orphans and children living in households where family members have HIV.

Q: What is UNICEF’s recommendation for HIV-positive mothers?

Our challenge is to balance the risk of transmitting HIV with the dangers of not breastfeeding and then to counsel the mother on all of her options. Very roughly, 30 to 40 per cent of infants with HIV-positive mothers become infected. Of these, 10 to 15 per cent are infected through breastfeeding. (This percentage may vary, depending on whether the mother was taking antiretroviral drugs to reduce transmission.) At the same time, non-breastfed infants have a six times greater chance of dying from infectious diseases in the first few months than breastfed infants.

Generally, if replacement feeding is acceptable, feasible, affordable, safe and sustainable, then we will recommend it. However, we find in most of the places where we work, this is not the case. There may be taboos about alternative feeding. The mother may have no access to clean water to safely prepare formula or cow’s milk. She may not have enough money to buy replacement food, or, even if it is free, she may live too far away from the supply to guarantee continued access. Thus, when these five essential conditions do not exist, we recommend breastfeeding, at least for the first few months until the mother can give other foods. From six months on, the mother can start introducing porridge and blended family foods.

Q: What factors have an impact on the risk of transmission through breastfeeding?

The virus can be passed to the child in pregnancy, delivery and through breastfeeding. An important factor with breastfeeding is the viral load: a mother with a more advanced disease has more virus in her body and in her breastmilk which increases the probability of transmission. Duration of breastfeeding is important because the risk of transmission is continuous, the longer a mother breastfeeds, the greater the chance she will pass on the virus. Sores on the nipples and breast infections may increase the likelihood. Finally, a study in South Africa has shown that exclusivity of breastfeeding may protect against transmission, compared with a combination of breastmilk and other foods.
 
Q: What process is used to determine the best feeding option for individual HIV-positive mothers?

Ideally, we like to have a continuous support system, with several counselling sessions before and after the child is born, to answer any questions or resolve any doubts. We go through a checklist with the mother: “How would you normally feed your child? What kind of access to resources do you have? What kind of replacement foods would be acceptable?” In most cases, breastfeeding, formula and cow’s milk are the three available options. Sometimes there are alternatives like wet nursing, milk banks or expressing and heat treating breastmilk.

Q: What nutritional programming does UNICEF have for those infected with, or affected by, HIV?

First, we are trying to help countries develop national guidelines on nutrition and infant feeding, with a segment on HIV. The next step is to assist with the nutritional counselling of those with HIV/AIDS, a group with greater nutritional requirements. We are also providing food to people affected by the crisis in Southern Africa, specifically targeting families affected by HIV/AIDS.

The crisis in Southern Africa has shown how far the coping mechanisms of communities and extended families have deteriorated due to HIV. At one point most could survive the periodic droughts or floods. Today, many have spent their extra resources on health care, on funerals, on taking care of orphans. Now they need basics: food, blankets, soap and money for schooling.

Q: What are some of the challenges going forward?

One of the biggest problems is the stigma around HIV/AIDS – or perhaps even the fear of stigma. Nobody wants to be known as being HIV positive. Many mothers will try to hide it or they may worry about the reaction of neighbours, family members or husbands. HIV-positive people are a normal group of the population with special needs who require support, not blame or finger pointing. As long as stigma persists, our job is going to be difficult.