A series of updates on critical infant and young child feeding issues
The purpose of this issue of Spotlight is to provide decision makers, program
managers, and health workers with guidance on how to support HIV-positive
mothers who choose to breastfeed so that they can minimize the risk of
transmission and protect their own health and the health of their infant. For
many HIV-positive mothers in resource-limited settings, breastfeeding is the
only or the safest infant feeding strategy available.
The greatest threats to child survival in most communities are diarrhea and
respiratory infections. Breastfeeding helps protect against these and other
infections by providing antibodies and other protective factors, minimizing
exposure to pathogens, and ensuring optimum nutrition. Interventions to protect
and promote breastfeeding would prevent an estimated 13 percent of the 10
million deaths of children under five each year, making breastfeeding promotion
one of the most effective child survival interventions available.1 In devising
strategies to reduce mother-to-child transmission of HIV, these wider public
health benefits of breastfeeding must be kept in mind.
Most HIV-infected women do not transmit HIV to their infants. A mother can
transmit HIV to her infant during pregnancy and delivery or through
breastfeeding, but most babies of mothers with HIV are not infected. With no
intervention to reduce transmission, 5–10 percent of infants will be infected
during pregnancy, 10–20 percent during labor and delivery, and 10–20 percent
through breastfeeding if breastfed for 18 to 24 months.2 Using the midpoints of
these ranges, among 100 HIV-infected women, 7 of their infants will be infected
with HIV during pregnancy, another 15 during labor and delivery; and another 15
over the course of about 2 years of breastfeeding. As shown in Figure 1, 63
infants will not become infected with HIV, even if breastfed and without any
intervention in place to prevent transmission.
Promotion and support of optimal infant feeding practices should be part of all
programs for the prevention of mother-to-child transmission (PMTCT) of HIV.
Knowing the mother’s HIV status in pregnancy is the key to infant feeding
counseling. Infant feeding decisions should be based on knowledge of the
mother’s HIV status. Although most countries now offer voluntary and
confidential HIV counseling and testing as part of antenatal services linked to PMTCT programs, actual uptake remains low. The challenge now is to improve these
services and to expand coverage.
Even among mothers known to have HIV, the benefits of breastfeeding may outweigh
the risks of transmission. An HIV-positive mother can avoid postnatal
transmission by replacing breastmilk with commercial infant formula or
home-modified animal milk from birth. However, in many resource
these alternatives may be unavailable or too dangerous due to the risk of death
from malnutrition, diarrhea, pneumonia, and other infections. When replacement
feeding is not “acceptable, feasible, affordable, sustainable, and safe,” the
United Nations agencies recommend exclusive breastfeeding “during the first
months of life.” They recommend that “breastfeeding should be discontinued as
soon as feasible, taking into account local circumstances, the individual
woman’s situation, and the risks of replacement feeding.”
Risk Factors for Postnatal
• Immune/health status
• Plasma viral load
• Breastmilk virus
• Breast inflammation (mastitis, abcess, nipple lesions)
• New HIV infection
• Viral characteristics
• Breastfeeding duration
• Non-exclusive breastfeeding
• Age (first months)
• Lesions in mouth, intestine
• Infant immune response
The risk of HIV transmission through breastfeeding can be reduced.
that contribute to postnatal transmission are listed in the box above. The
HIV-infected mother who chooses to breastfeed can minimize these risks by
guarding her own health, following feeding guidelines, and reassessing the risks
as the infant ages and conditions change. The health provider, community worker,
and program planner can support her and help in the following ways.
Infant Feeding Counseling
Counseling on safer breastfeeding practices should be a major component of
efforts to reduce the risk of HIV transmission and increase child survival.
Provide adequate lactation counseling and support to prevent breast conditions.
Improper positioning and attachment at the breast and infrequent feedings can
cause cracked nipples and mastitis (an inflammation of the breast). A breast
abscess—a localized collection of pus—usually results from untreated mastitis.
Cracked nipples, mastitis, and breast abscess are three conditions associated
with higher transmission of HIV through breastfeeding. Studies suggest that
approximately 11–13 percent of HIV-infected women experience one or more of
these conditions during breastfeeding, often during the early weeks when the
risk of HIV transmission is thought to be greater. Preventable and treatable
breast conditions may be responsible for up to half of HIV transmission through
breastfeeding.4 Counseling on good breastfeeding techniques at the onset of
lactation can help prevent breast problems. In a study in Bangladesh, the
prevalence of severe inflammation of the breast was three times greater in women
who had not received counseling than those who had.5
Counsel women to recognize breast conditions and seek treatment immediately. A
breastfeeding mother with HIV should seek immediate treatment for cracked
nipples, mastitis, and breast abscesses. If she has any of these conditions, she
should express milk frequently from the infected or sore breast and discard it
until the breast is healed.
Counsel on exclusive breastfeeding (feeding only breastmilk, with no other
foods, fluids, or even water). For mothers who are HIV-negative or who do not
know their status, exclusive breastfeeding is universally recommended as the
optimal infant feeding practice for the first 6 months of life. Exclusive
breastfeeding may also help reduce the risk of transmission among HIV-positive
mothers who choose to breastfeed. Several studies are in progress to verify the
results of a study6 in Durban, South Africa showing that infants partially
breastfed before 3 months had higher rates of postnatal transmission compared
with babies who had been exclusively breastfed for at least 3 months.
Assist families with decisions about transitioning from breastfeeding to
replacement feeding (replacing breastmilk with a diet that provides all the
nutrients the child needs). All infants of HIV-positive mothers will eventually
reach an age when the balance of risks favors replacement feeding. Risks change
over time. After the first few months of infancy, the risks associated with the
use of breastmilk substitutes, such as infant formula and animal milk, are
reduced, but the risk of HIV transmission through breastfeeding remains. Data
suggest that breastfeeding after 6 months accounts for about 50 percent or more
of all postnatal transmission. By 6 months the infant is better able to tolerate
undiluted cow’s milk, goat’s milk, and a variety of semi-solid foods, so the
options for replacement feeding become safer, less difficult, and less expensive
than at an earlier age. For these reasons, some health experts recommend that
mothers who choose to breastfeed should transition to replacement feeding at 6
months, a time when the introduction of soft and semi-solid foods should also
The decision about when to stop breastfeeding should be based on an individual
assessment of the health status of both the mother and the infant and the
family’s ability to provide replacement foods. These foods should be appropriate
for the infant’s age, safely prepared, and nutritionally adequate to ensure
child growth and good health and development. Health providers and community
workers can teach parents how to prepare replacement milks safely and help them
address attitudes in the community toward women who do not breastfeed.
Antiretroviral Treatment and Prophylaxis
Antiretroviral treatment to keep HIV-infected mothers healthy may be one of the
most important ways of preventing postnatal HIV transmission.
Treat the mother with a combination of antiretroviral (ARV) drugs. If available
and clinically indicated,7 highly active antiretroviral therapy should be used
to treat the mother to delay disease progression. In a study in West Africa,8
postnatal transmission (measured from 6 weeks through 24 months in breastfeeding
infants) was 22 percent in mothers with baseline CD4* counts below 500/mm3 but
only 2 percent among women with higher baseline CD4 counts. Both viral load and
CD4 count are independently associated with the risk of transmission through
breastfeeding. The World Health Organization recommends that if mothers taking ARV treatments to delay disease progression choose to breastfeed, they should
continue their ARV regimen even though the effects on infant health and on
transmission through breastfeeding have not yet been evaluated.9
Provide antiretroviral prophylaxis for PMTCT. In situations where combination
therapy is either not indicated or not available, prophylactic therapy with
antiretroviral drugs taken by the mother and infant about the time of delivery
reduces the risk of perinatal transmission. Several regimens are approved for
this purpose. The regimen most commonly used in resource-limited settings
involves 200mg of nevirapine given orally to the mother at delivery and 2mg/kg
given to the neonate within 72 hours. Trials are currently underway to evaluate
the safety and efficacy of antiretroviral regimens taken by the mother and/or
infant after delivery to prevent transmission through breastfeeding. Although
preliminary results are encouraging, no regimens for postpartum antiretroviral
prophylaxis have yet been approved.
Counseling on safer sex should be a component of PMTCT programs. The risk of
transmission through breastfeeding is higher if the mother is newly infected
Promote safer sex to prevent infection of women who are not HIV infected. The
higher risk of transmission through breastfeeding among newly infected mothers
is thought to be due to the high level of virus in the mother after infection
but before her immune system begins to fight the infection. Uninfected mothers
can protect themselves and their breastfeeding infants from infection by
practicing safe sex.
Supporting Nutritional Interventions
Nutritional interventions for the HIV-infected mother may improve her health and
quality of life, provide additional nutrients to support pregnancy and
lactation, and meet the increased energy needs resulting from the HIV infection.
Counsel the mother and her family on the importance of nutritional support and
care. Nutritional care and support may be the only treatment to which the HIV
positive mother has access. Reduced appetite, poor nutrient absorption, and
physiological changes can lead to weight loss and malnutrition in HIV-infected
people. Nutritional requirements are known to increase as a result of HIV
infection and should be met by increased intakes of nutritious foods.
Asymptomatic HIV infection increases energy needs by an estimated 10 percent,
and symptomatic infections increase requirements by up to 30 percent.
Some micronutrient supplements have been shown to improve the survival of
HIV-infected adults with more advanced infection. Although adequate
micronutrient intake is best achieved through an adequate diet, multiple
micronutrient supplements may be needed in pregnancy and lactation in some
settings. Due to concerns about the possible negative effects of certain
micronutrients in excess of requirements, WHO currently recommends that intake
by HIV-infected women not exceed “recommended daily allowance” levels.
Lactation also increases nutritional requirements. To support lactation and
maintain maternal reserves, breastfeeding mothers (whether infected or not)
should consume the equivalent of about one extra meal (650 Kcal) per day.
Normally, mothers are hungrier and thirstier during lactation and will satisfy
this need if food and drink are available. HIV-infected mothers with reduced
appetites can be encouraged to eat well by ensuring that food is available,
appetizing, and nutritious.
Together the interventions outlined in this document can increase child survival
and enable families to take positive actions to protect the health of both
mother and child.
* CD4 cells are a component of the immune system attacked by HIV. Low CD4 counts
are therefore both an indicator and a functional consequence of advanced HIV
Acknowledgment: This issue of Spotlight draws upon a paper4 and presentations by
Ellen Piwoz, SARA Project and Jay Ross, LINKAGES Project.
1 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS and the Bellagio Child
Survival Study Group. How many child deaths can we prevent this year? Lancet
2 De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, Alnwick DJ,
Rogers M, Shaffer N. Prevention of mother-to-child HIV transmission in
resource-poor countries: translating research into policy and practice. JAMA
3 WHO. New data on the prevention of mother-to-child transmission of HIV and
their policy implications. Conclusions and recommendations. WHO technical
consultation on behalf of the UNFPA/UNICEF/WHO/ UNAIDS Inter-Agency Task Team on
Mother-to-Child Transmission of HIV. Geneva, 11-13 October 2000. Geneva: World
Health Organization, 2001, WHO/RHR/ 01.28.
4 Piwoz E, Ross J, Humphrey J. HIV transmission during breastfeeding: knowledge,
gaps and challenges for the future. In: Advances in Experimental Medicine and
Biology. Protecting infants through human milk: advancing the scientific
evidence base. USA: Kluwer Publishing, (in press).
5 Flores M, Filteau S. Effect of lactation counselling on subclinical mastitis
among Bangladeshi women. Ann Trop Paediatr 2002;22:85-88.
6 Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai W-Y, Coovadia HM. Method of
feeding and transmission of HIV-1 from mothers to children by 15 months of age:
prospective cohort study from Durban, South Africa. AIDS 2001;15:379-387.
7 WHO. Scaling up antiretroviral therapy in resourcelimited settings – 2003
Revision (DRAFT). Geneva: World Health Organization, 2003.
8 Leroy V, Karon JM, Alioum A, Ekpini ER, Meda N, Greenberg AE, Msellati P,
Hudgens M, Dabis F, Wiktor SZ. Twenty-four month efficacy of a maternal
short course zidovudine regimen to prevent mother-to-child transmission of HIV-1
in West Africa: West Africa PMTCT Study Group AIDS 2002;16:631-641.
9 WHO. Antiretroviral drugs and the prevention of mother-to-child transmission
of HIV infection in resource- constrained settings. Recommendations for use,
2004 Revision (DRAFT: 7 January 2004). Geneva: World Health Organization, 2004.
10 Dunn DT, Newell ML, Ades AE, Peckham C. Risk of human immunodeficiency virus
type 1 transmission through breastfeeding. Lancet 1992;340:585-588.
Spotlight: PMTCT: Reducing Mother-to-Child Transmission of HIV among Women who
Breastfeed is a publication by LINKAGES: Breastfeeding, LAM, Related
Complementary Feeding, and Maternal Nutrition Program, and was made possible
through support provided to the Academy for Educational Development (AED) by the
Bureau for Global Health of the United States Agency for International
Development (USAID), under the terms of Cooperative Agreement No. HRN-A-00-
97-00007-00. The opinions expressed herein are those of the author(s) and do not
necessarily reflect the views of USAID or AED. April 2004