Mother-Child Transmission of HIV
LEAVEN Volume 35, No. 1, February-March 1999, pp. 3-5
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time
Breastfeeding promotion is important to counter the erosion of breastfeeding practices among the vast majority of infants who are not at risk.
An economist from the World Bank refers to the transmission of HIV through breastfeeding as the "triple minority." The minority of a population are HIV positive; of those who are HIV positive, the minority transmit HIV to their children; of those who do transmit HIV to their children, the minority do so through breastfeeding.
Risks before or during Delivery
The scientific community tells us that HIV passes to the infant before or during delivery in 20 percent of infants born to HIV-infected women. This rate of transmission is thought to be affected by maternal health and nutrition, other infectious disease prevalence, viremia (presence of viruses in the blood) and rate of elective cesarean section. In a community where the prevalence of HIV in pregnant women is extremely high (20 percent) and 20 percent of infants are infected before or during delivery, about 4 percent of all infants in the community would be infected before or during delivery (20 percent of population x 20 percent of infant infection before or during delivery = 4 percent transmission rate).
Risks during Breastfeeding
We are also told that HIV passes via breastfeeding to about 14 percent of infants born to HIV-infected women. This rate of transmission is thought to be influenced by breastfeeding patterns, maternal viremia, malaria and timing of the infection. In the same community where the prevalence of HIV in pregnant women is 20 percent and 14 percent of infants are infected by breastfeeding, about 3 percent of all infants in the community would be infected through breastfeeding (20 percent of population x 14 percent of infant infection through breastfeeding = 2.8 percent transmission rate through breastfeeding).
For the 93 percent of infants worldwide who are not HIV positive, there is a danger that public information about the risks of transmission of HIV in breast milk could cause an overall reduction in breastfeeding. The effects of a reduction in breastfeeding practices could be disastrous for child health and survival, for birth spacing and for women's health. Breastfeeding promotion is important where HIV is prevalent to counter the possible erosion of breastfeeding practices among the vast majority of infants who are not at risk.
The following questions are adapted from The LINKAGES FAQ Sheet: Frequently Asked Questions on Breastfeeding and HIV/AIDS, revised October 1998.
Q. Should mothers with HIV choose not to breastfeed?
A. IF a mother knows she is infected (in most settings, testing for HIV is unavailable; less than 5 percent of HIV-infected individuals have access to reliable HIV testing), IF breast milk substitutes are affordable and can be fed safely, and IF adequate health care is available and affordable, then it might seem logical for a mother with HIV to choose not to breastfeed.
Unfortunately, alternatives to breastfeeding are often neither affordable nor safe. In many countries, where the cost of locally available formula exceeds the average household's income, families cannot buy sufficient supplies of breast milk substitutes, leading to overdilution, underfeeding or substitution with dangerous alternatives. In the 50 poorest developing countries, infant mortality averages over 100 deaths per thousand live births. Artificial feeding roughly triples the risk of infant death in such environments, where most infants' deaths are due to infectious diseases such as diarrhea and pneumonia, where hygiene and sanitation are often poor and where access to adequate health care is limited. In these conditions, breastfeeding may be the safest feeding option even when the mother is HIV positive. Support for this option is seen in research that shows that breastfeeding appears to slow the progression of the disease (Ryder 1991; Tozzi 1990). A study of both HIV-positive and HIV-negative mothers identified a factor in human milk that inhibits the binding of HIV to specific receptor sites on human T-cells in the laboratory, thus potentially inhibiting the virus from taking hold in the baby (Newburg 1992, 1995).
Q. If a mother with HIV breastfeeds, how can she reduce the risk of transmission?
A. Many experts believe that the safest way to breastfeed in the first six months is to do so exclusively, without adding any other foods or fluids to the infant's diet. Such additions are not needed and may cause gut infections that could increase the risk of HIV transmission.
There is evidence that the risk of transmission continues as long as the infant is breastfed. The risk of death due to replacement feeding is greatest in the first few months and becomes lower later on. Some mothers may choose to stop breastfeeding early and introduce breast milk substitutes as soon as an available replacement method becomes safer. The optimal time for introducing substitutes is not known and varies with the situation.
Q. What if the mother is not infected?
A. Breastfeeding should continue to be encouraged among women who are not infected. Breastfeeding remains one of the most effective strategies to improve the health and chances of survival of both the mother and child. It provides a complete and hygienic source of the infant's fluid and nutritional requirements through the first six months of life, as well as growth factors and antibacterial and antiviral agents that protect the infant from disease for up to two years and more. Breastfeeding also contributes to child spacing and women's long-term health.
The best way to protect children from HIV is to help women avoid HIV infection.
Q. What are the current international recommendations on breastfeeding and HIV?
A. In May 1997, a policy statement was issued by UNAIDS, the United Nations system's joint program on HIV/AIDS, whose sponsors include the World Health Organization and UNICEF. The statement emphasizes supporting breastfeeding in all populations; improving access to HIV counseling and testing; providing information to empower parents to make fully informed decisions; reducing women's vulnerability to HIV infection; and preventing commercial pressures to provide artificial feeding. It also recommends weighing the rates of illness and death from infectious diseases and the availability of safe alternatives to breastfeeding against the risk of HIV transmission when recommending feeding practices. The policy emphasizes the need for women to make their own choices based on the best available information.
Subsequently, in 1995, the UN agencies published guidelines for policy makers and for health care managers to help countries implement this policy. Several groups are planning pilot projects in many countries to offer voluntary counseling and testing as a part of antenatal services. Pregnant women who test positive for HIV will receive counseling on infant feeding options. To fully understand the positive and negative effects of these efforts on feeding practices and infant health in the general population, it is important for them to be adequately monitored and evaluated.
The International Code of Marketing of Breastmilk Substitutes was introduced by the World Health Organization in 1981 to counter negative effects of the introduction of breast milk substitutes in developing countries. The Code's provisions should continue to be promoted and observed. The effects of a general reduction in breastfeeding practices would be disastrous for child health and survival.
A selected council appointed by the LLLI Professional Advisory Board is reviewing the issue of mother-child transmission of HIV. After their work is completed, the LLLI Public Relations Department will update their media release statement on HIV.
Maryanne Stone-Jimenez, a Leader for 17 years, served as Coordinator of Leader Accreditation (CLA) and Regional Administrator of Leader Accreditation (RALA) for Latin America. She was Country Director of the LLLI Child Survival Project in Guatemala. In 1997 she moved with her husband, Roberto, and daughter, Rosana, from Guatemala to Washington DC to join the LINKAGES Project as LLLI representative. Roberto and Maryanne have three children: Michelle is studying in Montreal, Marty works and studies in Guatemala and Rosana is a high school senior.
For Further Reading
Dunn D., Newell M., Ades A., et al. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet 1992; 340:585-88.
Ekpini, E., Wiktor, S., Satten, G., et al. Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Cote d'Ivoire. Lancet 1997; 349:1054-59.
Khun, L.. Stein. Z. Infant survival, HIV infection, and feeding alternatives in less-developed countries. Am J Public Health 1997;87:926-31.
LINKAGES: Breastfeeding, LAM, Complementary Feeding and Maternal Nutrition Program The LINKAGES FAQ Sheet: Frequently Asked Questions on Breastfeeding and HIV/AIDS, revised October 1998.
Mohrbacher, N., Stock, J. BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLLI, 1997.
Nduati, R., John, G., Richardson, B, et al. Human immunodeficiency virus type 1-infected cells in breast milk: Association with immunosuppression and vitamin A deficiency. J of Infect Dis 1995; l72:1461-68.
Newburg, D. et al. Human milk glycosaminoglycans inhibit HIV glycoprotein gpl20 binding to its host cell CD4 receptor. J Nutr 1995;125:419-24.
Newburg, D. et al. A human milk factor inhibits the binding of HIV to the CD4 receptor. Pediatr Res 1992; 3(1):22-28.
Nicoll, A., Newell, M., Van Pragg E., et al. Infant feeding policy and practice in the presence of HIV-1 infection. AIDS 1995; 9:107-19.
Preble, E., Piwoz, E. HIV and Infant Feeding: A Chronology of Research and Policy Advances and Their Implications for Programs. Joint publication of the LINKAGES and Support for Analysis and Research in Africa (SARA) Projects. Washington, DC: Academy for Educational Development, 1998.
Ryder, R. et al. Evidence from Zaire that breast-feeding by HIV-1 seropositive mothers is not a major route for perinatal HIV-1 transmission but does decrease morbidity. AIDS 1990; 5(6):709-14.
Semba, R., Miotti, P., Chiphangwi, J., et al. Maternal vitamin A deficiency and mother-to-child transmission of HIV-1. Lancet 1994; 343:1593-97.
Tozzi, A. et al. Does breast-feeding delay progression to AIDS in HIV-infected children? AIDS 1990; 4:1293-1304.
UNAIDS. HIV and Infant Feeding. http://www.us.unaids.org/highband/document/epidemio/infant.html
WHO. Recommendations on the safe and effective use of short-course ZDV for prevention of mother-to-child transmission of HIV. Wkly Epid Rec 1998; 73:313-20.
WHO/UNAIDS/UNICEF. HIV and Infant Feeding: Guidelines for Decision-Makers. Geneva World Health Organization, 1998.
WHO/UNAIDS/UNICEF. HIV and Infant Feeding: A Guide for Health Care Managers and Supervisors. Geneva World Health Organization, 1998.