|Cambodia. Two women review a brochure on AIDS awareness and prevention they were just given by health workers from the provincial hospital, part of the Provincial AIDS Secretariat.|
Breastfeeding and HIV transmission
Infant and young child feeding in the context of HIV poses signifcant challenges due to the risk of transmission of the virus via breastfeeding. Prior to the 2010 guidelines on HIV and infant feeding, avoidance or early cessation of beastfeeding seemed logical or appropriate. However, the repercussions for the halth and survival of the infants were serious, with studies howing much higher mortality rates due to diarrhoea, malnutrition and other diseases in non-breastfed children. The 2010 recommendations are based on evidence of positive outcomes for HIV-free survival through provision of ARVs to breastfed HIV-exposed infants. Thus the focus is now firmly on ensuring HIV-free survival, not just on preventing transmission. The 2010 UN guidelines provide a much clearer pathway towards this goal.
Breastfeeding carries significant health benefits for infants and young children and is an essential child survival intervention. Without intervention, about 35% of HIV-positive pregnant women will pass on the infection to their babies during pregnancy, delivery and post-natally through breastfeeding. Without preventive interventions, about 10-20 per cent of infants born to infected mothers will contract the virus through breastmilk if breastfed for two years. The risk of postnatal HIV transmission after 6 weeks of age is estimated at around 1% per month of breastfeeding (WHO 2006).
Several other factors affect the risk of transmission, including the “viral load” or amount of virus in the mother’s body (highest right after infection and when AIDS develops; a very sick mother is eight times more likely to transmit HIV to her infant than a healthy mother), the duration of breastfeeding (the longer the period, the greater the risk, as transmission is cumulative), and the condition of the breasts (whether there are sores around the nipples).
The method of infant feeding is clearly associated with the risk of transmission through breastmilk. Exclusive breastfeeding for the first six months is associated with a 3-4 fold lower risk of HIV transmission as compared to mixed feeding (mixed feeding means the infant receives both breastmilk and any other food or liquid including water, non-human milk and formula before 6 months of age). One study found that only about 4% of exclusively breastfed infants became infected with HIV between 6 weeks and 6 months, even in the absence of ARVs (WHO 2007). It is believed that mixed feeding in the first six months carries a greater risk of transmission because the other liquids and foods given to the baby alongside the breastmilk can damage the already delicate and permeable gut wall of the small infant and allow the virus to be transmitted more easily. Mixed feeding also poses the same risks of contamination and diarrhea as artificial feeding, diminishing the chances of survival.
Unfortunately mixed feeding is still the norm for many infants less than six months old in many countries with high HIV prevalence. Exclusive breastfeeding rates among children <6 months of age in two-thirds of developing countries with trend data have increased between 1998-2008, but are still quite low at 33% in sub-Saharan Africa. Thus HIV transmission through breastfeeding can be reduced if HIV-positive women breastfeed exclusively for six months rather than practising mixed feeding. Public health programs for protection, promotion and support of breastfeeding can have major benefits for HIV-positive women and their children, as well as for the population in general. With the new recommendations, it is postulated that an HIV-infected woman who takes ARVs and mix-feeds may still have a higher rate of transmission than a mother who exclusively breastfeeds and takes ARVs: the transmission risk is shifted downwards for all breastfeeding mothers but the pattern of higher risk remains for the mixed-fed infants. Therefore continued emphasis needs to be placed on discouraging mixed feeding in the first six months.
The risk of HIV-infection has to be compared with the risk of morbidity and mortality due to not breastfeeding. In general, babies who do not breastfeed are more than 14 times more likely to die from diarrhoea or respiratory infections than babies who are exclusively breastfed in the first six months (Lancet Nutrition Series 2008).
The 2010 UN Guidelines on HIV and infant feeding
Significant programmatic experience and researchand evidence regarding HIV and infant feeding have accumulated since the recommendations on HIV and infant feeding were last revised in 2006. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or the HIV-exposed infant can significantly reduce the risk of post-natal transmission of HIV through breastfeeding. With the provision of ARVs, breastfeeding is made dramatically safer and the "balance of risks" between breastfeeding and replacement feeding is fundamentally changed. A major additional benefit of the new guidelines is that the mother's health is also protected for a greater proportion of HIV-infected women. This new evidence sigificantly transforms the landscape in which decisions on infant feeding methods are made by individual mothers, health providers, national health authorities and international development partners.
This evidence is the basis fo the 2010 UN recommendations on prevention of mother to child transmission (PMTCT) of HIV and on infant feeding n the context of HIV. These recommendations highlight that the overall risk of mother to child transmission of HIV can be reduced to less than 5% in breastfeeding populations (from a background risk of around 35%) and to less than 2% in non-breastfeeding populations (from a background risk of around 25%) (WHO 2010, Rapid Advice on PMTCT version 2). A 2011 systematic review reports that the risk of transmission can be reduced to 1-2% when ARVs are provided (Siegfried et al 2011).
The evidence has major implications for how women living with HIV might feed their infants and how health workers should counsel these mothers. The 2010 guidelines recommend that the national authorities in each country should decide which infant feeding practice and interventions - i.e. breastfeeding with an ARV intervention or avoidance of all breasfeeding - should be promoted and supported as a single national public health recommendation by their maternal and child health services. This differs from the previous approach in which health workers were expected to individually counsel all HIV-infected mothers about the various infant feeding options, and it was for mothers to decide which option they would choose. The national recommendation will depend on various local conditions such as HIV prevalence, child mortality, undernutrition, health services, etc.
Recommending a single option within a national health framework does not remove the need for skilled counseling and support to be available to pregnant women and mothers. Tha nature and content of the counseling and support that are required has shifted away from the previous principle of counseling on the balance of risks and the different options the mother can choose from. Rather, the counseling focuses on conveying the national public health policy the Government has decided to adopt and helping the mother to feed her baby and take the ARVs according to this policy. The counselors should also be able to provide additional information on the alternative options: individual rights should not be forfeited in the course of public health approaches.
Where national authrities have selected a policy of breastfeeding and ARVs, mothers known to be HIV-infected are now recommended to breastfeed their infants until at least 12 months of age, with exclusive breastfeeding for the first six months. The ARVs should continue to be provided, either to the mother or to the infant depending on which PMTCT protocol the country has selected, until one week after all breastfeeding has ceased.
The recommendation that replacement feeding should not be used unless is it acceptable, feasible, affordable, sustainable and safe (AFASS) remains, but the acronym is replaced by more common, everyday language and terms. It was believed that more carefully defining the environmental conditions that make replacement feeding a safe or unsafe option for HIV-exposed infants will enhance mothers' understanding and practices and improve HIV-free survival of infants. It was considered that such language would better guide health workers regarding what to assess and communicate to mothers who were considering if their home conditions would support replacement feeding. The concept of AFASS had proven difficult to translate into practical counseling messages.
Recognizing that ARVs will not be rolled out everywhere immediately, guidance is given in the 2010 document on what to do in their absence. Every effort should be made to accelerate access to ARVs for both maternal health and PMTCT. While ARV interventions are being scaled up, national health authorities should not be deterred from recommending that HIV-infected mothers should breastfeed, as the most appropriate infant feeding practice in their setting even when ARVs are not yet available. An implementation and communication challenge will be to prevent the misconception that HIV-infected mothers should only breastfeed if they have ARVs.
Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding, so that the infant receives the full nutritional and life-saving benefits breastmilk affords.
UNICEF Policy and Action
The 2010 recommendations highlight the opportunity for investing in effective infant and young child counseling and communication interventions that will improve IYCF practices by both HIV-infected and uninfected mothers. Improving practices for all would significantly reduce the risk of undernutrition, illness and death and help countries achieve international development goals. The most recent contribution to the tools to guide implementation of the 2010 guidelines is the joint UN updated Framework For Priority Action, issued in 2012.
UNICEF is supporting countries to design and implement comprehensive and effective infant and young child feeding policies and strategies, based on the principles outlined in its 2011 Programming Guide on Infant and Young Child Feeding. Working with WHO and many other partners, UNICEF assists governments in HIV-affected countries to set appropriate national policy on HIV and infant feeding based on local conditions and the latest UN guidance, to ensure the policy and strategy are widely disseminated and to build capacity to implement it, including updating of relevant national protocols, guidelines, training materials and counseling cards. The UNICEF Community IYCF Counseling Package contains a series of counseling cards based on the 2010 guidelines. UNICEF also contributes to the better integration of HIV and nutrition services, generation of programmatic knowledge, including documentation of lessons learned from implementation experience and formative research on various issues, such as the reasons behind different trends in exclusive breastfeeding rates in HIV-affected countries.