Feeding the infants of HIV-infected mothers

Abstract

Mother-to-child transmission is the predominant route of human immunodeficiency virus (HIV) infection in young children. In 2003, an estimated 2.5 million children under 15 years of age were living with HIV/AIDS, 700 000 were newly infected, and 500 000 died (1). HIV may be transmitted during pregnancy, labour and delivery, of by breastfeeding. About 5-20% of infants born to HIV-positive women acquire the infection through breastfeeding, and this mode may be responsible for 30-50% of HIV infections in infants and young children in Africa (2). Eliminating the risk of HIV transmission by stopping breastfeeding exposes children to different risks: increased exposure to other life-threatening infections, especially in the first year of life (3); and malnutrition if replacement feeding is inadequate. The relative risks of morbidity and mortality associated with replacement feeding vary with the environment and individual circumstances (4). Recognizing this and the right of mothers to a fully informed decision, WHO recommends that all HIV-infected mothers receive counselling, which includes general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the one most suitable for their situation. When replacement feeding is acceptable, feasible, affordable, sustainable and safe, HIV-infected mothers should avoid all breastfeeding. Otherwise, exclusive breastfeeding is recommended during the first months of life, with the time of stopping being determined by individual circumstances (5). WHO/UNICEF/UNAIDS developed a course on HIV and infant feeding in 2000 (6), based on policy guidance published in 1998 (7). The course is aimed at developing the skills of health care providers and providing practical information to mothers on issues such as the risks of transmission and infectious disease mortality and the options for replacement feeding. Home-modified animal milk is one such option. The paper by Papathakis & Rollins published in this issue of the Bulletin (pp. 164-171) examines the appropriateness of this in South Africa. It raises several important issues: from nutrient adequacy, to the cost and time required for preparation. The authors identify the unavailability of appropriate micronutrient supplements as an important constraint. New guidance promoted by WHO (8) notes that nutritional adequacy is difficult to achieve with home-modified animal milk, even with the addition of micronutrient supplements, when it is given during the entire first six months of life. …