The State of the World's Children 1998: Focus on Nutrition

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Panel 6

Breastmilk and transmission of HIV

Breastfeeding confers enormous benefits, preventing malnutrition and illness, saving lives and money. It is also, however, one way an HIV-positive mother could transmit the virus to her infant. A child stands the greatest risk - believed to be 20 per cent - of vertical or mother-to-child transmission during the time of late pregnancy and childbirth. There is an additional 14 per cent risk that an infant will become infected through breastmilk.

This risk of infection through breastfeeding needs to be weighed against the great dangers posed by artificial feeding: In communities where sanitation is inadequate and families are poor, death from diarrhoea is 14 times higher in artificially fed infants than in those who are breastfed. If HIV-positive women and those who fear HIV (without actually being infected) were to abandon breastfeeding in large numbers, with out safe and reliable alternatives for feeding their children, the ensuing infant deaths from diarrhoea and respiratory infections could vastly outnumber those from HIV.

The dilemma facing an HIV-positive woman who does not have easy access to safe water, who does not have enough fuel to sterilize feeding bottles and prepare alternatives to breastmilk, or who cannot afford to buy sufficient formula to ensure her child's nutrition is a wrenching one that no mother can solve on her own. Support for women facing this di lem ma is imperative, as the Joint United Nations Programme on HIV/AIDS (UNAIDS) made clear in 1996. The following measures are important starting points:

* Pregnant women should have access to voluntary and confidential counselling and testing to determine their health status. If they are HIV positive, they should receive appropriate treatment to reduce the risk of vertical transmission. If they are HIV negative, health education is vital to help them and their partners remain that way.

* HIV-positive mothers should be informed of the risks of both vertical transmission through breastfeeding and infections associated with artificial feeding in their local environment. Each woman should be assisted by HIV counsellors or health professionals to understand these risks and then make her own decision.

* If an HIV-positive mother has access to adequate breastmilk substitutes that she can prepare safely, then she should consider artificial feeding. Other alternatives include wet-nursing by an HIV-negative woman, which may be acceptable in some cultures. Heat treatment of expressed breast milk (62.5C for 30 minutes) destroys the virus, which may be a good choice for some women.

* When mothers who test positive for HIV choose not to breastfeed but are unable to or cannot afford feeding alternatives, help will be needed from a range of parties, in cluding governmental and partner agencies. Attention must be paid to the needs of the most disadvantaged women, which include improved water and sanitation and attentive family health care.

These measures should be part of an integrated strategy to reduce vertical transmission since breastfeeding is only a small part of the problem. Access to voluntary, confidential testing and counselling is key to any strategy to reduce vertical transmission. Access to a range of prenatal and obstetric care measures associated with reduced transmission risk is also essential.

Studies now in progress will soon give a better understanding of the mechanisms, timing and risks of vertical transmission. It may be possible in a few years to offer all women low-cost, easily delivered services that will minimize or even eliminate the risk of vertical transmission. For now, access to the testing, counselling, information and other services noted above should be high priorities.

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