HIV and the global context of infant feeding

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Investing in improving infant feeding practices in the context of HIV, the WHO believes that “Governments, other stakeholders and donors should greatly increase their commitment and resources for implementation of the Global strategy for infant and young child feeding.”

Regulations on how or whether someone with HIV should breastfeed their child vary between countries.1 In their publication ‘HIV and Infant Feeding’, the WHO have made specific recommendations to minimise maternal transmission of HIV to her offspring. Recognizing that every nation has unique responsibilities and circumstances to consider, the WHO recommends that “national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an antiretroviral intervention to reduce transmission or avoidance of all breastfeeding, will be primarily promoted and supported by Maternal and Child Health services.”

As the strategy that will most likely give infants the greatest chance of HIV-free survival, each country’s health authority2 will decide whether to principally counsel and support parents known to be HIV-infected to either breastfeed and receive ARV interventions, –or– avoid all breastfeeding.3

The WHO recommends “mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.”

Furthermore, “when mothers known to be HIV-infected decide to stop breastfeeding at any time, infants should be provided with safe and adequate replacement feeds to enable normal growth and development.”

For infants less than six months of age, alternatives to breastfeeding include:

  • Commercial infant formula milk as long as home conditions (outlined below) are fulfilled,4
  • Expressed, heat-treated breast milk (see below).

“Home-modified animal milk is not recommended as a replacement food in the first six months of life.”5

Those known to be HIV-infected may consider expressing and heat-treating breast milk as a temporary feeding strategy:

  • In special circumstances such as when the infant is born with low birth weight or is otherwise ill in the neonatal period and unable to breastfeed;
  • When the parent is unwell and temporarily unable to breastfeed or has a temporary breast health problem such as mastitis;
  • To assist parents to stop breastfeeding;
  • If antiretroviral drugs are temporarily not available.

In ‘HIV and Infant Feeding,’ the WHO supports heat-treating for temporary feeding6 during an emergency and when no other safe options are available. In a 2008 training package the CDC also stated that “HIV is killed by heating the milk and ends the risk of transmitting HIV through breast milk.” It may be argued that, if a recipient receives milk from a donor of unknown HIV status, heat-treating the breastmilk is a viable short term solution.7)

Currently, there is no clear evidence on whether heat-treating breastmilk should be used as a permanent solution.

Please see ‘How can breastmilk be pasteurized at home?’ for more information on heat-treating.

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  1. “The [WHO] noted that governments of highly resourced countries in which infant and child mortality rates were low, largely due to low rates of serious infectious diseases and malnutrition, recommend that HIV-infected mothers avoid all breastfeeding. In some of these countries, infants have been removed from mothers who have wanted to breastfeed even when the mother is on ARV treatment. Authorities in these countries have taken the position that the pursuit of breastfeeding under these circumstances constitutes a form of abuse or neglect. [bold –ed.] []
  2. “This decision should be based on international recommendations and consideration of the: socio-economic and cultural contexts of the populations served by maternal and child health services; availability and quality of health services; local epidemiology including HIV prevalence among pregnant women; and, main causes of maternal and child under-nutrition and infant and child mortality.” []
  3. “The systematic reviews also reported improved HIV-free survival in HIV-exposed infants when breastfed in similar settings, especially exclusive breastfeeding, compared with mixed feeding or replacement feeding (16–17).” [bold –ed.] []
  4. Conditions needed to safely formula feed: Parents known to be HIV-infected should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status, when specific conditions are met: safe water and sanitation are assured at the household level and in the community, and, the parent, or other caregiver, can reliably provide sufficient infant formula milk to support normal growth and development of the infant; and, the parent or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhea and malnutrition; and the parent or caregiver can, in the first six months, exclusively give infant formula milk; and, the family is supportive of this practice; and the parent or caregiver can access health care that offers comprehensive child health services. []
  5. This is not specific to HIV positive parents. []
  6. Per Kiersten Israel-Ballard: “In practice, the term ‘In the interim’ unfortunately will encompass many HIV+ mothers who are waiting for ARVs.” []
  7. Per ‘HIV and Infant Feeding’: “Laboratory evidence demonstrates that heat treatment of expressed breast milk from HIV-infected mothers, if correctly done, inactivates HIV (42–44) […] heat treatment of expressed breast milk from mothers known to be HIV-infected could be considered as a potential approach to safely providing breast milk to their exposed infants.” (See Grade profile 6, Annex 4. []

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