Breastfeeding is by far, normally the best way to feed an infant. It is an excellent and readily available source of nutrition, and has immunological properties that help protect the infant (whose immune system is still immature) from potentially deadly infections. In fact, in studies in resource-limited settings where (or when) HIV was not a major problem, breastfeeding out to six months was repeatedly shown to result in better health and survival for babies.
“Exclusive breastfeeding for the first six months is one of the best preventive public health measure for reducing child mortality that we have,” said Dr. Peggy Henderson of WHO’s Department of Child and Adolescent Health and Development, during one of the opening sessions of the conference.
On the basis of such findings, the World Health Organization (WHO) and the United Nations Children’s Funds (UNICEF) developed a Global Strategy for Infant and Young Child Feeding. It recommended exclusive breastfeeding for the first six months and continued breastfeeding up to two years and beyond, with supplemental foods that are nutritionally adequate and safe from age six months, together with related nutrition and support for the mother.
However, when the mother has HIV, there is a significant risk that she can transmit HIV to her infant.
In industrialised countries, HIV-infected mothers can opt for safe and readily available alternatives to breastfeeding (and it also is easier to keep the infant’s home and environment hygienic). With the combination of antenatal antiretroviral therapy (ART or HAART) and breastfeeding avoidance, only about 1-2% of infants of HIV-positive mothers in industrialised countries are infected each year.
Antiretroviral prophylaxis and treatment for the prevention mother-to-child transmission (PMTCT), has also been shown to be quite effective in resource-limited settings, reducing transmission to levels similar to what has been seen in the Global North. However, several studies noted the HIV prevention benefit decreased over time — clearly associated with ongoing breastfeeding. According to a major meta-analysis of breastfeeding studies (the BHITS Group), that risk can be quite substantial in countries where prolonged breastfeeding is common, accounting for 42% of HIV infections in infants and young children in Africa. Overall, an estimated 5–20% of infants born to HIV-infected mothers are infected post-natally.
As a result, WHO and UNICEF amended the guidance in the Global Strategy for Infant and Young Child Feeding. They proposed that women with HIV should completely avoid breastfeeding when replacement feeding is “acceptable, feasible, affordable, sustainable and safe (AFASS).” Women who had no reliable access to formula feeding were not meant to starve their children but to continue breastfeeding until suitable replacement feeding could be obtained.
Over the last few years, the understanding of the risks of HIV transmission from breastfeeding has become more nuanced. Several studies have documented that mixed feeding (giving water or solid foods to the infant) resulted in much higher rates of transmission than if a mother exclusively breastfed.
And so in response, WHO and UNICEF amended their guidance once again to recommend that when replacement feeding wasn’t AFASS that women with HIV exclusively breastfeed for the “first months of life” and that as soon as replacement foods were available, that the infant be weaned abruptly, so as to avoid a prolonged period of mixed feeding (and therefore heightened risk of HIV transmission).
More recently this guidance has been changed yet again (see below).