Breast practice?
Preventing HIV transmission through breast-feeding

The mother-to-child transmission of HIV through breast feeding (MTCT) is a major problem for child health, especially in high HIV prevalence areas, such as sub-Saharan Africa. However, MTCT is preventable: taking issue with WHO recommendations, research suggests that HIV infected mothers should not breast-feed and should offer artificial milk to their infants.

In most developing countries breast-feeding is the normal, safest and culturally accepted method of feeding. Any deviation may result in increased infant mortality, stigmatisation, nutritionally inadequate substitutes, confusion and the undoing of safe motherhood and child health work.

The highest risk of MTCT appears to be in the first few months of life (two-thirds of postnatal transmission), but it remains substantial as long as the mother breast-feeds. Factors that increase risk include:

• advanced clinical disease and reduced immunity caused by depression
• high HIV levels in plasma and breast milk
• breast inflammation, cracked and sore nipples
• oral fungal infection in the child.

Breast inflammation is associated with poor ‘latching on’ to the nipple, which results in the inadequate emptying of milk from the breast. It is less frequent with exclusive breast-feeding (EBF). EBF for the first four to six months is associated with lower HIV transmission than mixed feeding and is promoted by UNICEF for women without safe alternatives. However, in many societies it is normal to discard early lactation milk (thus delaying the onset of feeding) and to give supplements including water (often infected), milk, teas and fruit juices. Working mothers have to adapt to the stresses of maintaining EBF. It requires support from counsellors, families and employers.

The (limited) availability of voluntary counselling and testing (VCT) centres mean that more women may be told that they are HIV-positive. Many are unable to tell their partners because of the threat of strife and possible separation; neither can they undertake breast milk substitution without family consent and support. Thus, many would prefer not to know the test result. Confused messages may cause the mother to give breast and bottle which has higher risks than EBF.

What are the options?

• Commercial infant formulae, preferably by cup and spoon. This is unaffordable for many mothers, facilities for hygienic preparation are inadequate and it requires partner and family support. However, it is the best option and mothers must receive support to undertake it safely. UNICEF has recently been supplying free formulae in some areas but it seems this cannot be sustained.
• EBF for four to six months with provision of a nutritionally adequate complementary food from four to six months. This requires good counselling, support and determination.
• Modified animal milk, diluted with water and with added sugar. This lacks essential micronutrients, e.g. iron, zinc. Giving this formula to infants in the first six months of life is ‘unchartered territory’ and requires research, on growth and nutritional adequacy. However, for many who do not breast feed, it is the only option.
• Research is currently looking at the benefit of giving anteretrovirals to mothers and infants during EBF. Preliminary results suggest this can be successful.

All these strategies require increased funding but, despite new sources of financial support becoming available, governments are unable to support even basic maternal child health services. International agencies provide support for many VCT centres (including HIV tests), infrastructure for prevention programmes, artificial formulae and anteretrovirals. Basic services that may be affordable, such as those that focus on women of child bearing age, will have to be carefully targeted to maximise coverage.

Brian Coulter and Michael Ogundele
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool L3 5QA
UK

l.j.taylor@liverpool.ac.uk

See also:

‘HIV transmission through breast feeding: problems and prevention’, Annals of Tropical Paediatrics: International Child Health 23(2): 91-106, by M.O. Ogundele and J.B.S. Coulter, 2003

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