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
<mailto:[log in to unmask]>[log in to unmask]

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