HIV and Infant Feeding
Supporting mothers to make informed choices
Von Lída Lhotská / IBFAN
The HIV/AIDS pandemic and the fact that HIV can be transmitted via breastfeeding have brought about one of the most painful dilemmas of the last two decades in the field of public health. Suddenly, breastfeeding, so well known and appreciated for saving lives and improving overall health prospects of babies and their mothers everywhere in the world, came to be regarded as a culprit. Because it could transmit a virus for which there was no cure, it seemed that all its myriad benefits were temporarily forgotten.
It has been estimated that, without any intervention with antiretroviral drugs, the rate of the additional transmission of HIV through breastfeeding might be between 10 and 20% if a baby were to be breastfed for two years. It is interesting to note that exactly the same transmission rate was attributed to the approximately 24-hour period of labour and delivery, making it the single time point of greatest risk. The transmission rate during pregnancy was determined to be 5-10%.
The calculation of 10-20% HIV transmission rate through breastfeeding was based on the data from cohorts of breastfed children. However, throughout the 1990s breastfeeding experts tried to alert the HIV/AIDS research and public health community that it was vital to specify the pattern of breastfeeding practiced by HIV-infected women.
Patterns of breastfeeding
There was some evidence that exclusive breastfeeding was important for maturation of the intestinal mucosa because the introduction of infant formula or any other fluid, or substance that was not breastmilk, to young infants might cause micro bleeding of the gut or other negative effects. This was likely to facilitate the virus to get across the baby’s gut wall. They were saying that breastfeeding practices (exclusive versus predominant or partial) could be an important determining factor for the rates of HIV transmission.
Yet, in most studies concerned with HIV transmission from mothers to babies, this information was not collected and even where it had been, this was often without using the standard WHO definitions for breastfeeding patterns. Exclusive breastfeeding was not defined as nothing but breastmilk with the exception of drops or syrups consisting of vitamins, mineral supplements or essential medical drugs. Commonly non-milk liquids and solid foods (such as cereal-based gruels) were allowed in the definition of exclusive breastfeeding, whereas WHO definitions would have categorised this type of feeding as “partial breastfeeding” or “mixed feeding”.
The first analysis looking closely at the possible impact of different patterns of breastfeeding on HIV transmission was a randomised controlled trial (RCT) in South Africa. The main focus of this study had been to look at the impact of the antenatal Vitamin A supplementation on perinatal transmission, but the authors had also looked at feeding patterns and published the results in 1999 (1). The researchers compared the cumulative rates of HIV transmission in infants exclusively or partially breastfed (to three months). The rates of infection were similar at birth, but partially breastfed infants had higher rates of postnatal transmission at three, six, and up to 15 months of age when compared with exclusively breastfed babies.
Cumulative probability of HIV infection remained similar among those children never breastfed and exclusively breastfed up to six months. No transmission of HIV (beyond perinatal acquisition) was observed if mothers did not breastfeed.
Until recently, this data had stirred controversy because of the observational nature of the study and also because for years the research was not replicated. However, the findings alerted the research community to the need for making a distinction between different patterns of breastfeeding when trying to understand better why HIV transmission through breastfeeding occurred in some mother/baby couples but not in others.
Nonetheless, by the millennium, the data was not yet there. As the world continued to grapple with the dilemma of how to advise mothers, the protection, promotion and support of breastfeeding was already dwindling. The advent of, at first long and then short, regimens of antiretroviral prophylaxis, which could cut back HIV transmission during pregnancy and delivery, became the focus of the international debate as were programme efforts on how to reduce HIV transmission once the baby was born.
Should HIV-positive women in developing countries be advised to use exclusive infant formula feeding, especially in cases when they could receive HIV prophylaxis, so that the gains in terms of reduced transmission at birth would not be lost due to subsequent transmission via breastfeeding? Or should they rather be told to breastfeed because there might be no possibility for them to make up artificial feeds safely?
The dilemma was reflected not only at programme level but also, understandably, at policy level. With evolving knowledge about HIV transmission from mothers to babies, the technical agencies in the UN system (mainly WHO and UNICEF), went through, in the last 15 years, policy development processes which resulted in a series of subsequent policy statements and recommendations.
The first UN Consensus statement on HIV and breastfeeding dates back to 1992 (2). It noted the impressive nutritional, immunological, psychological and child-spacing qualities of breastfeeding. It also noted that not breastfeeding was a major contributory factor in the 1.5 million annual infant deaths from diarrhoeal and respiratory infections. But the statement also noted the need to weigh the baby's risk of HIV infection through breastfeeding against its risk of dying of other causes if denied breastfeeding.
The final recommendations were based on the epidemiological indicators of settings in which HIV-positive women might live. In settings where infectious diseases were the primary cause of death during the first year of life, HIV-positive women were to be advised to breastfeed. In settings where this was not the case, mothers were to be advised not to breastfeed.
The interpretation of this policy came under serious scrutiny once the UN system started looking through human rights lenses at the implications of such blanket rules. In 1997, applying principles derived from key human rights instruments such as the Convention on Elimination of all Forms of Discrimination Against Women (1979) and the Convention on the Rights of the Child (1989), a new Policy Statement was issued by UNICEF, UNAIDS, WHO, the lead agencies in this area. (3)
This policy squarely put the right to make informed choices about infant feeding methods into the hands of the mother. It stated:
"Because both parents have a responsibility for the health and welfare of their children, and because the infant feeding method chosen has health and financial implications for the entire family, mothers and fathers should be encouraged to reach a decision together on this matter. However, it is the mothers who are in the best position to decide whether to breastfeed, particularly when they alone may know their HIV status and wish to exercise their right to keep that information confidential".
Following this statement, a set of guidelines (4), which explained which infant feeding options might be available for the mother to choose, was developed. The options included: breastfeeding by the mother; by a wet nurse (known not be HIV positive); modified breast milk (e.g. donated pasteurised breastmilk); complete replacement feeding (i.e. no breastmilk at all) with either commercial or homemade infant formula.
In 2000, based on additional research data, the recommendations were further refined (5) to say:
"When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise exclusive breastfeeding is recommended during the first months."
The new recommendation on exclusive breastfeeding was not based on the South African study (1) and possible preventive effect on HIV transmission, but on the known benefits of protection against infectious diseases such as diarrhoea and pneumonia.
After all, it had been well documented that breastfed babies had a much greater chance of survival when compared with their artificially fed counterparts. WHO analysis (6) of data from several studies showed this with absolute clarity. The relative risk of death in the first two months of life was shown to be six times greater for artificially fed babies than for those who were breastfed. The risk continued to be elevated even in the second year of the babies' lives. In terms of effectiveness, breastfeeding has been ranked as the number one intervention for child survival with the potential of preventing 13-15% of child deaths in low-income countries (7).
Replacement Feeding – only if AFASS!
Acceptable, feasible, affordable, sustainable and safe replacement feeding has become known as AFASS. The UN has made it clear, that when one of these five conditions is not in place, replacement feeding is likely to carry a great risk for the baby.
At first sight the five conditions may seem easy to disentangle, yet they are quite complex:
Acceptable: The mother is under no social or cultural pressure not to use replacement feeding, she is supported by the family and community in carrying out this practice or able to cope with pressure from her family and friends to breastfeed, and she can deal with possible stigma attached to being seen with replacement food.
Feasible: The mother (or family) has adequate time, knowledge, skills and other resources to prepare the replacement food and feed the infant up to 12 times in 24 hours.
Affordable: The mother and family, with community or health-system support if necessary, can pay the cost of purchasing/producing, preparing and using replacement feeding, including all ingredients, fuel, clean water, soap and equipment, without compromising the health and nutrition of the family. This concept also includes access to medical care if necessary for diarrhoea and the cost of such care.
Sustainable: Availability of a continuous and uninterrupted supply and dependable system of distribution for all ingredients and products needed for safe replacement feeding, for as long as the infant needs it, up to one year of age or longer.
Safe: Replacement foods are correctly and hygienically prepared and stored, and fed in nutritionally adequate quantities, with clean hands and using clean utensils, preferably by cup.
The key to enable HIV-positive mothers to make the best possible decisions about feeding their babies is the provision of skilled counselling which includes full information on the pros and cons of infant feeding options and is free from commercial pressures. And equally importantly, mothers must be supported to carry out their decision after it has been made.
Current UN recommendations
The 2000 UN recommendation have been in place for six years but meanwhile an additional body of evidence has been accumulated. In October 2006, a WHO Technical Consultation adopted the following refined and clarified recommendations (8).
HIV-negative women or HIV status unknown: Exclusive breastfeeding for six months and continued breastfeeding for two years or beyond.
HIV-positive women: Exclusive breastfeeding for six months unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS). The most appropriate infant feeding option for an HIV-exposed infant depends on individual circumstances, including consideration of health services, counselling and support.
This recommendation now unifies the duration of exclusive breastfeeding by HIV-positive women with that for the general population, thus helping to tackle some of the confusion caused by the previous double standard – i.e. six months which clashed with “during the first months”.
The basis for the recommendations
A number of studies contributed to this important refinement of the recommendations of which three are presented for illustration:
An investigation by the Centre for Disease Control (CDC) in Botswana, where an outbreak of severe diarrhoea and a sharp increase in malnutrition and infectious diseases, led to a dramatic increase in deaths among children under five years (9). Not breastfeeding and poor growth before illness were the two biggest risk factors. This country appeared to fulfil all five AFASS criteria so that all HIV-positive women were advised to artificially feed and received free infant formula. However, in late 2005, early 2006, heavy rains affected water quality. The resulting epidemic highlighted the vulnerability of infants and young children on replacement feeding.
Consequently, CDC suggested that the “safe” component of “AFASS”; should be empirically demonstrated and not assumed. Any programs contemplating the use of infant formula should verify that this could save lives in the particular context before the launch of widespread distribution.
Also from Botswana the ‘Mushi’ Study (mushi means milk) (10) showed that in the context in which the study was conducted, any gains from the reduction of HIV transmission through free formula distribution were lost because of increased mortality from infections such as diarrhoea and pneumonia.
Professor Hoosen M. Coovadia and his colleagues carried out a meticulous prospective study in South Africa. This provided the long awaited evidence on the effect of exclusive breastfeeding versus mixed feeding on HIV transmission (11). This research confirmed the finding of the earlier study (1): that infants exclusively breastfed by their HIV positive mothers have a lower risk of HIV transmission than those who are mixed fed. Moreover, the type of mixed feeding also matters: infants exposed to a mix of breastfeeding with infant formula feeding had double the risk of HIV transmission than those breastfed exclusively; the addition of solid foods to breastfeeding raised the risk eleven fold.
What do the new 2007 recommendations imply?
First and foremost the recommendations will be of little help unless skilled, unbiased counselling by well trained health workers, sensitive to the individual’s situation, is available to HIV-positive mothers. They may have only discovered their status through recent HIV testing which should always be voluntary and confidential. These women need support long before the birth of their baby. They need good antenatal care to facilitate their infant feeding decisions. Continued support is necessary so that mothers can practice their chosen infant feeding option. In the light of the evidence, including new programmatic data, to improve the chances of a child’s HIV free survival, HIV-positive mothers appear to have two principal infant feeding options: either six months of exclusive breastfeeding or complete replacement feeding. However, the other infant feeding options remain open for discussion if the mother is interested. For example, in places where there are properly managed human milk banks, or in situations when a mother can manage home-pasteurisation of her own breastmilk (feasible and proven to eliminate the HIV virus), women might opt for one of these choices perhaps for the early months when infant vulnerability to infection is greatest. When or if a child is found to have his or her own HIV infection (not merely the mother’s transferred antibodies) the mother may be strongly encouraged to breastfeed into the second year of her child's life. HIV-positive children who are breastfed have better survival outcomes, later start of AIDS and lower rates of pneumonia and less chronic diarrhoea. (12)
These examples illustrate that it is crucial to emphasize that a mother's decision is not necessarily a “once and for all” decision. The mother must be helped to re-assess her situation continuously and to adjust her feeding option if possible or necessary.
To ensure that HIV-positive mothers do receive all the support they need for their difficult decision, there are some policy imperatives that must be fulfilled. They are encapsulated in the HIV and Infant Feeding: Framework for policy action. (13) This Framework, developed by eight UN agencies plus the World Bank, was adopted in 2004 and 2006 by the highest decision-making body in public health, the World Health Assembly (WHA). It highlights five priority areas for governments:
- Develop or revise a comprehensive national infant and young child feeding policy which includes HIV and Infant Feeding.
- Implement and enforce the International Code of Marketing of Breastmilk Substitutes and WHA resolutions.
- Intensify efforts to protect, promote and support appropriate infant and young child feeding practices in general, while recognizing HIV as one of the exceptionally difficult circumstances.
- Provide adequate support to HIV-positive women to enable them to select the best feeding option for themselves and their babies, and to successfully carry out their infant feeding decisions.
- Support research on HIV and infant feeding, including operations research, learning, monitoring and evaluation at all levels, and disseminate findings.
The first and third priorities emphasise the need for strong national commitment which should result in a coordinated, comprehensive approach. HIV and infant feeding should not be singled out but be addressed within a policy that facilitates exclusive breastfeeding for six months, followed by nutritious complementary feeding with continued breastfeeding for two years and beyond, for the general population. Exclusive breastfeeding is not a common practice in many countries. Unless society as a whole embraces this practice, it will be forever difficult for HIV-positive mothers to make it happen. Scaling up of the Baby-Friendly Hospital Initiative (launched by WHO and UNICEF in 1991) is highlighted as an important opportunity to address HIV and infant feeding.
The second priority area recognizes the need for both breastfed and artificially fed babies, their parents, families and all caregivers to be protected from commercial pressures. The International Code (14), adopted by WHA in 1981 aims to "contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution."
In the context of HIV the Code is often misunderstood. It neither compels women to breastfeed nor prohibits the use of breastmilk substitutes, including infant formula. It aims to take commercial pressures out of the infant feeding arena to ensure that decisions about products are based on impartial, scientific and factual information which will protect the child’s health. The Code also protects all health professionals and scientists who might be vulnerable to commercial pressures and conflicts of interest in their working lives. Moreover the Code protects company personnel whose incomes must not depend on sales of breastmilk substitutes. Over the past 26 years, WHA has clarified and amplified the Code through numerous subsequent resolutions, which have equal status to the Code.
Some of the key elements under the forth priority have been addressed in this article. It is important to mention that this priority area calls for improved follow up, supervision and support of health workers in order to sustain their skills both in health care and quality counselling, and also to prevent burn-out.
The final, fifth, priority area reminds us that there is still much need for further research, both at basic and operational level. The world has clearly made some progress in this difficult and complex area, but the work needs to continue to improve the survival for children born to HIV-positive mothers, and to protect breastfeeding for the majority of children who would benefit from it.
The following quotation from Professor Hoosen Coovadia of the University of Natal in South Africa summarizes the challenge:
"Breastfeeding enhances motherhood as love nourishes the family. It is the key to a healthy life for infants and children. Breastfeeding has withstood many threats to its survival through its evolutionary history. It is our responsibility now to ensure that breastfeeding continues to be fostered, promoted and protected for all women through the HIV crisis. We can achieve this goal and preserve this basic right by increasing the means through which breastfeeding becomes safe for HIV-positive women through the AIDS pandemic."
* Lída Lhotská, Ph.D. in applied anthropology, is the Regional Coordinator for Geneva Infant Feeding Association (IBFAN-GIFA) Europe, based in Geneva, with overall responsibility for IBFAN European network coordination and two thematic areas: Infant feeding in emergencies and HIV and infant feeding (since 2001). In the period 1994 to 2001 she worked as a Senior Advisor, Infant Feeding and Care, Nutrition Section, UNICEF, New York. Contact: firstname.lastname@example.org. IBFAN - the International Baby Food Action Network - consists of public interest groups working around the world to reduce infant and young child morbidity and mortality. Contact: www.ibfan.org
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14. The International Code of Marketing of Breastmilk Substitutes, WHO, 1981