EDITORIALS

Feeding the infants of HIV-infected mothers

Jose Martines^{I, 1}; Peggy Henderson^II

^ICoordinator, Neonatal and Infant Health, Department of Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland (email: martinesj@who.int)
^IIScientist, Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland

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, or 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. If this feeding option is chosen, health services should ensure that mothers have access to appropriate micronutrients to add to animal milk.

A challenge in dealing with the HIV pandemic is the need to develop policies and guidelines, even though answers to some key questions may not be available. With more women accessing long-term anti-retroviral therapy for their own health, for example, information is needed on whether this therapy will reduce the risk of transmitting HIV through breastfeeding. Operational research such as that reported by Papathakis & Rollins is also much needed so that specific implementation problems can be identified and resolved.

It is imperative that governments and their partners take action now based on available information. The goal of the UN General Assembly Special Session on HIV/AIDS of reducing HIV infections in infants by 20% by 2005 (9) will require specific actions to prevent such infections arising through breastfeeding (10). Also, full support needs to be given to protecting, promoting and supporting breastfeeding for the vast majority of mothers everywhere who are HIV-negative or do not know their serostatus (11). Countries should also ensure that some of the resources available for preventing mother-to-child transmission of HIV are used to orient and train health workers and other counsellors in infant feeding issues. Newly revised WHO guidance (8), the HIV and infant feeding counselling course (6), and other tools should lead to improved support for all women, including those who are HIV-infected, in feeding their infants.

References

1. AIDS epidemic update, 2003. Geneva: UNAIDS; 2003. Available from URL: http://whqlibdoc. who.int/publications/2003/9291733040.pdf

2. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et al. Prevention of mother-to- child HIV transmission in resource-poor countries — translating research into policy and practice. JAMA 2000; 283:1175-82.

3. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000; 355:451-5.

4. VanDerslice J, Popkin B, Briscoe J. Drinking-water quality, sanitation, and breastfeeding: their interactive effects on infant health. Bulletin of the World Health Organization 1994; 72:589-601.

5. New data on the prevention of mother-to-child transmission of HIV and their policy implications: conclusions and recommendations. WHO Technical Consultation on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-Agency Task Team on Mother-to-Child Transmission of HIV, Geneva, 11–13 October 2000. Geneva: World Health Organization; 2001. WHO document WHO/RHR/01.28. Available from: URL: http://whqlibdoc. who.int/hq/2001/WHO_RHR_01.28.pdf

6. WHO/UNAIDS/UNICEF. HIV and infant feeding counselling course. Geneva : World Health Organization; 2000. WHO document WHO/FCH/CAH/00.2-6.

7. HIV and infant feeding: guidelines for decision- makers. WHO/FRH/NUT/CHD/98.1, UNAIDS/98.3, UNICEF/PD/NUT(J)98.1. Geneva: WHO/UNICEF/UNAIDS; June 1998.

8. HIV and infant feeding: guidelines for decision- makers. Geneva: World Health Organization; 2003. WHO/UNICEF/UNFPA/UNAIDS document. Available from: URL: http://www.who.int/child- adolescent-health/publications/NUTRITION/ISBN_92_4_159122_6.htm

9. UN General Assembly Special Session on HIV/AIDS, 25-27 June 2001. Declaration of Commitment on HIV/AIDS. New York: United Nations: 2001. Document number DPI/2229.

10. WHO/UNICEF/UNFPA/UNAIDS/World Bank/UNHCR/WFP/FAO/IAEA. HIV and infant feeding: framework for priority action. Geneva: World Health Organization; 2003. Available from: URL: http://whqlibdoc.who.int/publications/2003/9241590777.pdf

11. Global strategy on infant and young child feeding. Geneva: World Health Organization; 2003. Available from: URL: http://whqlibdoc.who.int/publications/2003/9241562218.pdf

1 Correspondence should be sent to this author.