Hello Iwona
Good to hear of your interest in HIV and
breastfeeding. The risk of postpartum
transmission of the virus is approximately 15%
over two years of breastfeeding. Some sources
suggest that there is a lower risk of
transmission after 6 months (Miotti 1999) some
that it is higher (68% of the total risk) (Iliff
2005) and some that it is constant throughout the
duration of breastfeeding. (Coutsoudis 2004).
Since 1985 HIV-infected mothers in the US have
been advised not to breastfeed their babies, nor
provide their milk for their own or other babies.
(Read) However, as you have noted, there has
been some good research to show that the virus in
breastmilk is inactivated by two methods of
pasteurization which can be easily done at home –
Pretoria pasteurization (Jeffery 2000, 2001,
2004) and flash-heating (Israel-Ballard 2005,
2006, 2007) as you have described. Flash-heating
seems to be slightly more effective and preserves
more of the components of the milk.
From 1992 HIV-infected mothers in resource-poor
settings, particularly in Africa where HIV has
the highest prevalence, were advised to maintain
breastfeeding because the risk of death from not
breastfeeding was deemed to be higher than the
risk of transmission of HIV through breastmilk
(WHO 1992) In 1997 the recommendations were
changed (UNICEF) to suggest that mothers were in
the best position to decide how to feed their
infants, but that when replacements to breastmilk
(formula) were acceptable, feasible, affordable,
sustainable and safe (known as the AFASS
conditions) then mothers were advised not to
breastfeed. (WHO 1998) Over the following decade,
very little monitoring and evaluation of the
effects of this guidance have been recorded and
disseminated outside the research setting.
However, in early 2006 a report was made about
high infant mortality due to formula-feeding in
Botswana, which provides free formula to all
HIV-infected mothers (Creek 2006). Several
additional studies have since been
presented/published showing that while
transmission of HIV may be reduced by
breastfeeding avoidance, infant and young child
mortality is increased so that a) there is no
benefit to overall child survival, and b)
spillover of formula-feeding by uninfected
mothers is occurring. In addition, further
reports show that due to myriad difficulties “HIV
and infant feeding counselling” has seldom been
conducted as intended (Chopra 2007) and has often
caused more harm than good.
Consequently last October at a WHO Technical
Consultation on HIV and Infant Feeding, guidance
for HIV-infected mothers was clarified to
recommend that UNLESS replacement feeding was
AFASS then exclusive breastfeeding should be
recommended for the first six months of life and
that breastfeeding should continue with the
addition of appropriate weaning foods for the
normal 2 years. In addition, infants born
already infected should be breastfed to reduce
opportunistic infections and prolong their lives. (WHO 2006)
Studies published in 1999 and 2001 (Coutsoudis)
and 2005 (Iliff 2005) and earlier this year
(Coovadia 2007) show that when HIV-exposed babies
are exclusively breastfed the risk of postpartum
transmission can be reduced to 0-1.3% at 3 months
and 4% at 6 months. Transmission rates in the
Coutsoudis and Iliff studies for babies
who enjoyed 3 months exclusive breastfeeding
were 5.3% and 5.6% at 15 and 18 months
respectively, showing that the protective effects
of EBF against HIV-transmission appear to extend well beyond its duration.
As others have pointed out, one of the many
anomalies and discrepancies surrounding HIV and
infant feeding has been the difference between
recommendations for the US and other
industrialized countries on the one hand, and
developing countries on the other; the former
based on public health, the latter based on human
rights, but at odds with achievement of the best
child survival outcomes. The consistency is that
both facilitate formula-feeding.
Lastly, a study published just this month
(September) brings the good news that breastfed
African babies in the DREAM study conducted in
Mozambique, Tanzania and Malawi, whose
HIV-infected mothers received highly active
antiretroviral therapy (HAART) from 25 weeks’
gestation until 6 months postpartum showed
cumulative transmission rates at 6 months similar
to those reported in high-income countries (2.2%
vs <2.%), and lower than their formula-fed
counterparts (2.7%). While we have known for
some time that the cost of formula-feeding in the
PMTCT sites may use up 25% - 60% of the entire
budgets, this study also confirms that maternal
treatment with HAART cost the same as infant formula (Palombi 2007).
My list of references is a bit long for a LACTNET
post. Please email me privately if you want them.
Best wishes in your studies,
Pamela Morrison IBCLC
Co-coordinator WABA Breastfeeding and HIV Task Force
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