For most babies, breastfeeding is without question the best way to be fed, but unfortunately breastfeeding can also transmit HIV. Breast milk provides all of the nutrients needed during the first few months of life, and it also contains agents that help to protect against common childhood illnesses such as diarrhoea and respiratory infections.
Even in rich countries, breastfed babies are less likely to become ill than those given replacement foods.In other parts of the world, where there is little access to clean water, sanitation and health services, not breastfeeding can greatly increase the risks of disease and death.
However, among women who are infected with HIV and receiving no antiretroviral treatment or other interventions, breastfeeding for two or more years can double the rate of mother-to-child transmission to around 40% (the rest of the transmission occurs during pregnancy, labour and delivery).
When a mother has HIV, the dangers of not breastfeeding must be balanced against the risk of HIVtransmission. This results in a painful dilemma for millions of women in developing countries, for whom there are no easy options.
Advice for HIV-positive mothers in developed countries
For HIV-positive women in well-resourced countries the advice from national health agencies is straightforward: they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding. Replacement feeding means giving a baby commercial infant formula (prepared from powder and boiling water) or home-modified animal milk (boiled with added water, sugar and micronutrients) instead of breast milk. Nevertheless the UK Department of Health advises that:
“Under exceptional circumstances, and after seeking expert professional advice on reducing the risk of transmission of HIV through breastfeeding, a highly informed and motivated mother might be assisted to breastfeed.”
In some countries, including the UK and the USA, there is a possibility that HIV-positive mothers who choose to breastfeed may be prevented from doing so, or may be charged with child endangerment if they persist.
Advice for HIV-positive mothers in developing countries
In countries with fewer resources, where replacement feeding can be much more hazardous, the recommendations for infant feeding usually depend on a mother's individual situation. Although there is some variation in national and local policies, most are influenced by the guidance published by the World Health Organisation (WHO). According to the latest version of this guidance:
“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 of life.”
This means that some mothers should be advised to breastfeed and others should be encouraged to give replacement foods instead, depending on personal circumstances. The final decision, however, should be down to the mother:
“All HIV-infected mothers should receive counselling, which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. Whatever a mother decides, she should be supported in her choice.”
If an HIV -positive mother chooses to breastfeed, then something which can help her baby from becoming infected with HIV is exclusive breastfeeding, that is feeding only breast milk and nothing else. Breast milk provides all of the fluids and nutrients that a young baby requires, so exclusive breastfeeding means that even water can and should be avoided. Four major studies have shown that mixed feeding – giving other foods or liquids as well as breast milk – should be avoided because it substantially increases the chances of HIV transmission and death.
Although it is not fully understood why mixed feeding leads to such a high risk of HIV transmission, it is thought likely that the extra foods and liquids damage the infant’s immature digestive system, making it easier for HIV in breast milk to enter the tissues. In addition, mixed feeding may introduce harmful germs, and may reduce gut acidity, making it easier for infections to take hold.