Nutrition

HIV and Infant Feeding

© UNICEF/HQ00-0136/Noorani

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 carries significant health benefits for infants and young children and is an essential child survival intervention.  Without intervention, about 40% 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).

The type of infant feeding is clearly associated with the risk of transmission through breast milk.  Exclusive breastfeeding for up to six months is associated with a 3-4 fold decreased risk of HIV transmission as compared to mixed feeding. 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 more virus to be transmitted. 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. Thus HIV transmission through breastfeeding can be reduced if HIV-positive women breastfeed exclusively for six months rather than practicing mixed feeding. Public health programs for protection, promotion and support of breastfeeding can have major benefits for HIV-positive women and their children.

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).
Exclusive breastfeeding rates among children <6 months of age in the developing world have increased between 1996-2006, but is still quite low at 30% in sub-Saharan Africa. Some countries with high HIV burden such as South Africa and Kenya currently have very low rates at 7% and 13% respectively.

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 six times more likely to die from diarrhoea or respiratory infections than babies who do breastfeed (WHO-Lancet 2000). Moreover, breastfeeding provides complete nutrition and strengthens a baby's immune system, as well as the stimulation necessary for good psychosocial and neurological development, and contributes to birth spacing.

Replacement feeding from birth can eliminate postnatal transmission through breastfeeding. However for replacement feeding to be acceptable, feasible, affordable, sustainable and safe (the “AFASS” criteria), minimal conditions need to be in place such as access to clean water, regular postnatal follow-up and nutritional counseling in addition to an uninterrupted supply of formula.  Research from settings in Southern Africa where antiretroviral prophylaxis and free infant formula were provided indicate high rates of mortality in the first months of life among formula-fed children born to HIV-positive women, and that HIV-free survival at 18 months (children alive and free of HIV-infection at 18 months of age) is similar among formula-fed and breastfed infants.

For many women in developing countries, their situations are further complicated by poverty or social pressures. A mother may lack access to clean water needed to safely prepare breastmilk substitutes. Alternatives may be prohibitively expensive or she may live too far away from the supply to have continuous access. Finally, there may be taboos or stigma about alternative feeding. Fearing marginalization, many women may not wish to share their HIV status with their partners, family or community.
This is further compounded by the fact that the vast majority of HIV+ women in developing country settings do not know their HIV status.

UN Guidance and UNICEF Policy and Action

The most appropriate infant feeding option for an HIV-infected mother depends on her individual circumstances and involves a balancing of risks. She must have the information she needs to make an informed decision and all the services and support to help her implement that decision.
UNICEF and other UN agencies recommend exclusive breastfeeding for HIV-infected women for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) before that time. Such conditions are rare in much of the developing world. However, if they do exist, it is recommended that HIV-infected women avoid breastfeeding. If formula feeding is still not acceptable, feasible, affordable, sustainable and safe at the age of six months, continuation of breastfeeding with additional complementary foods is recommended along with regular assessment of both mother and baby. Breastfeeding should stop once a nutritionally adequate and safe diet without breastmilk can be provided.

Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding.
Initial evidence from research studies in developing countries suggests that mother-to-child transmission of HIV is reduced if mothers receive highly active antiretroviral therapy (HAART) during pregnancy and lactation (whether or not indicated for their own health). However, pending further evidence on impact of this intervention for the mother (if HAART is not indicated for her own health) and child, this is currently not recommended as a public health approach solely for Prevention of Mother To Child Transmission (PMTCT). New guidance is expected to be forthcoming in the near future.

Governments and donors should greatly increase their commitment and ability to implement the Global Strategy for Infant and Young Child Feeding and the UN HIV and Infant Feeding Framework for Priority Action. Together these strategies seek to prevent post-natal HIV infections, improve overall child survival rates and move the world closer to achieving the health-related MDGs.

UNICEF is supporting Governments and other stakeholders to promote and support breastfeeding in the wider community. Active support is provided to HIV-infected mothers who choose to exclusively breastfeed and measures are taken to make formula feeding safer for HIV-infected women who choose that option. National programmes are supported to provide all HIV-exposed infants and their mothers with a full package of health-related interventions, with strong links to HIV prevention, treatment and care services. Every effort is made to protect children who test negative for HIV after delivery from infection, particularly during breastfeeding. Whether the child is breast or formula fed, health services endeavour to monitor all HIV-exposed infants and offer infant feeding counseling and support, particularly at key moments such as the diagnosis of the HIV status of the infant and at six months of age, when complementary feeding can begin.

Knowing one’s HIV status is crucial to making choices about feeding, so support for voluntary and confidential testing is a priority. However, the most important means of preventing mother to child transmission is basic HIV prevention education. Efforts to protect young mothers from infection are critical, and UNICEF supports a wide range of education programmes at the local level to educate women and girls of the risks.