By Jennifer Marcy, MSc, IYCN Project, PATH, and Kiersten Israel-Ballard, MPH, DrPH, IYCN Project, PATH
March 2009
Many countries are introducing a national policy to test all babies who are born to HIV-positive mothers for HIV when they reach six weeks of age. This is a pro-active approach that could save countless lives—it enables early identification of HIV-positive infants so health care providers can offer them appropriate early treatment, care, and support as soon as possible.
It is important, however, to consider the impact of early testing on mothers’ infant feeding decisions and to prepare countries to mitigate that impact before early testing is brought to scale. Anecdotal evidence tells us that many HIV-positive moms choose to immediately stop breastfeeding, once their infants test negative, due to fear of potential future HIV transmission. Health care workers often add pressure by actively encouraging the decision to stop breastfeeding, even when it is not possible for mothers to safely and adequately feed their infants without breastmilk.
This decision can be deadly, particularly in resource-poor areas, where the health risks associated with stopping breastfeeding early often greatly outweigh the risk of subsequent HIV transmission. Recommendations from the World Health Organization reflect those risks, stating that HIV-positive mothers should continue to breastfeed until they can provide a replacement diet that is acceptable, feasible, affordable, sustainable, and safe (known as the AFASS criteria). Appropriate counseling and support to help mothers make informed infant feeding choices is critical in order to minimize unsafe breastfeeding cessation, especially when mothers receive the first HIV test results for their infants, which often occurs as early as two months of age.
One of the dangers of attempting to stop breastfeeding early is that mothers frequently continue to breastfeed while they start feeding their babies other food or fluids—a harmful practice known as mixed feeding. The other foods and fluids may introduce antigens to the infant’s gut that cause inflammation and irritation, resulting in diarrhea and facilitating transmission of HIV. Mixed feeding has been shown to increase the risk of transmission four- to ten-fold compared to breastfeeding exclusively.1,2 This increased risk likely outweighs any potential benefit of early cessation. Thus, to safely stop breastfeeding at two months, mothers must completely avoid mixed feeding by stopping abruptly. There is little evidence demonstrating how to support such mothers or showing that two-month old infants can safely stop breastfeeding so rapidly.
In addition, providing a safe and adequate diet to replace breastmilk’s nutritional and immunological contribution is a tremendous challenge. The risk of HIV transmission must be balanced with the many risks of not breastfeeding. A strong body of evidence shows increased risks of illness and death among formula-fed infants, even in research settings where free formula and support are provided.3,4 Moreover, quantitative and qualitative evidence from studies on early and rapid weaning at four to six months show that morbidity and mortality substantially increase,5,6,7 that HIV-free survival does not improve,8,9 and that mothers experience psychosocial challenges.10 These negative health outcomes are likely to be worse for younger infants, who are even more vulnerable.
Despite such evidence, many health care workers continue to promote early breastfeeding cessation, largely due to a widespread misunderstanding of the actual risk of transmission associated with breastfeeding, which is often greatly overestimated. We recently facilitated several training sessions for health care workers in African countries on infant and young child feeding, and we witnessed some of these misconceptions first-hand. In one country, many health care worker participants believed that more than 50% of infants would be infected with HIV if mothers exclusively breastfed for six months; the actual risk of such transmission is less than 5% (<0.8% per month of breastfeeding).11,12 It is no surprise that this inflated perception of risk leads health care workers to ignore the opposing risks of malnutrition, morbidity, and mortality.
We cannot expect health care workers to remain unbiased or to provide appropriate counseling when there is such a fundamental misunderstanding of the choice to be made. While the structural and social constraints to improving counseling and decision-making are immense, we must do better. We must provide comprehensive training for health care workers and advocate for targeted infant feeding support for women before and after infant testing so that they make infant feeding choices based on correct information and receive support from knowledgeable providers. We must sensitize communities and health care workers to the fact that breastmilk saves babies, even when their mothers are HIV-positive. And we must refocus on the true reason for early infant HIV testing: to identify positive infants so they can immediately obtain the treatment they need and so we can then encourage their mothers to continue breastfeeding for as long as possible. If we fail to do so, we will fail the very mothers and infants our programs intend to serve.
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Steps for post-test counseling (negative infant HIV test result):
- Congratulate the mother on following the program for prevention of mother-to-child transmission of HIV.
- Confirm that the mother is connected to clinical services, has had a recent CD4 test, and is adhering to HAART, if prescribed.
- If the mother is replacement feeding, remind her of the dangers of giving any breastmilk and counsel her on any challenges she is facing.
- If the mother is breastfeeding, reaffirm her choice and explain that breastmilk is the best food for her baby.
- Review the ways to reduce the baby’s risk of HIV from breastmilk.
- Ask if the mother is planning on modifying her feeding choice. If she is, review with her the reasons why she made her original choice and discuss her concerns and challenges. Assess her current situation using AFASS criteria, review the risks and benefits of breastfeeding and replacement feeding, and discuss why it may be dangerous for her to stop breastfeeding now if AFASS criteria are not met.
- Explain that at six months she will introduce complementary foods. At that time, she should come to the clinic to learn how to feed her baby complementary foods and to discuss how long she should continue breastfeeding.
1. Iliff PJ, Piwoz E, Tavengwa NV, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS.2005;19(7):699–708.
2. Coovadia HM, Rollins NC, Bland RM, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort. The Lancet. 2007;369(9567):1107–16.
3. Ibid.
4. Kagaayi J, Gray RH, Brahmbhatt H, et al. Survival of infants born to HIV-positive mothers, by feeding modality, in Rakai, Uganda. PLoS ONE. 2008;3(12):e3877.
5. Onyango C, Mmiro F, Bagenda D, et al. Early Breastfeeding Cessation Among HIV-exposed Negative Infants and Risk of Serious Gastroenteritis: Findings from a Perinatal Prevention Trial in Kampala, Uganda. Presented at: 14th Conference on Retroviruses and Opportunistic Infections, February 25–28, 2007; Los Angeles, California. Available at: http://www.retroconference.org/2007/Abstracts/29008.htm.
6. Kafulafula G, Thigpen M, Hoover D, et al. Post-weaning Gastroenteritis and Mortality in HIV-uninfected African Infants Receiving Antiretroviral Prophylaxis to Prevent MTCT of HIV-1. Presented at: 14th Conference on Retroviruses and Opportunistic Infections, February 25–28, 2007; Los Angeles, California.
7. Thomas T, Masaba R, van Eijk A, et al. Early Weaning Among Infants in Kisumu, Kenya. Presented at: 14th Conference on Retroviruses and Opportunistic Infections, February 25–28, 2007; Los Angeles, California. Available at: http://www.retroconference.org/2007/Abstracts/29105.htm.
8. Thior I, Lockman S, Smeaton LM, et al. Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana. A randomized trial: the Mashi Study. Journal of the American Medical Association. 2006;296(7):794–805.
9. Kuhn L, Aldrovandi GM, Sinkala M, et al. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. The New England Journal of Medicine. 2008;359:130–41.
10. de Paoli MM, Mkwanazi NB, Richter LM, et al. Early cessation of breastfeeding to prevent postnatal transmission of HIV: a recommendation in need of guidance. Acat Paediatrica. 2008;97:1663–68.
11. Coovadia HM, Rollins NC, Bland RM, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort. The Lancet. 2007;369(9567):1107–16.
12. Iliff PJ, Piwoz E, Tavengwa NV, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS. 2005;19(7):699–708.
Date: Mar 6, 2009 | Category: Points of view