BMJ  2007;334:487-488 (10 March), doi:10.1136/bmj.39135.411563.80

Editorials

Infant feeding and HIV

Avoiding transmission is not enough

Recently, the World Health Organization updated its recommendations of 2000¹ on infant feeding in the context of HIV.² At that time, data had just been published quantifying the risk of infection through breast feeding so avoiding breast feeding was acknowledged as the only effective way of avoiding transmission.³ WHO had also just published a meta-analysis of the mortality risks of not breast feeding, but in non-HIV infected populations.⁴ Considerations of these data resulted in the statement that "When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended."¹ Since the 2000 recommendations, the main emphasis of most national programmes aimed at preventing mother to child transmission of HIV has been to avert transmission of HIV in young infants.

The most difficult challenge has been how to make breast feeding safer in communities with a high prevalence of HIV where breast feeding is the traditional mode of feeding. Remarkably, the dilemma of infant feeding and HIV has split scientific communities and programme managers into opposing camps. Even with the risk of HIV transmission, some maintain that breast feeding may still be the best option for many mothers infected with HIV because of its anti-infective and nutritional advantages.⁵⁶⁷ Others promote commercial infant formula, arguing that the risks of diarrhoea and malnutrition associated with formula feeding are lower in most urban communities, or that the risks of not breast feeding may not be as great for infants born to mothers infected with HIV who, to prevent transmission, choose to give formula milk from birth; it has been suggested that this active decision making and motivation may result in safer preparation and use of formula milk.⁸

In South Africa, formula feeding was reported as a successful intervention with minimal morbidity in an urban transmission prevention programme.⁹ However, this cross sectional study of just 113 infants recorded outcomes only in infants who were still being brought back to the clinics, and data from infants who had already died or had experienced serious morbidity would not have been reported. Recently, two reports have been published from Botswana¹⁰¹¹ that, together with a compelling body of evidence from the literature in children without HIV,⁴¹² emphasise that child survival must be seen as the greater goal; greater even than "just" avoiding HIV infection.

The first is a randomised trial evaluating whether giving zidovudine to infants exposed to HIV while breast feeding resulted in more infants surviving and not being infected with HIV than giving formula milk to infants from birth.¹⁰ It found no significant difference in HIV-free survival rates of infants at 18 months; any gains from reducing transmission by giving formula milk were lost through increased mortality from diarrhoea and malnutrition. At 7 months the infants who were formula fed from birth had almost twice the mortality risk of those who were breast fed (9.3% v 4.9%; P=0.003). Importantly, the data suggested that giving antiretroviral drugs to the mother may reduce transmission of HIV through breast feeding, whereas giving zidovudine to the infant alone seems to have little impact on transmission.

The second report, an investigation conducted by Centers for Disease Control, followed an outbreak of severe diarrhoea and malnutrition across the entire country that, in the first three months of 2006, accounted for 22 470 cases and 470 related deaths in children under 5 years.¹¹ In the same months in 2004 and 2005, there were 8478 and 9166 cases of diarrhoea and 24 and 21 related deaths, respectively. In children admitted with severe diarrhoea, not breast feeding was the biggest risk factor (adjusted odds ratio 50.0; 95% confidence interval 4.5 to 100); this was in spite of 97% mothers having access to piped water sources and most having been part of the HIV transmission prevention programme and therefore counselled on safe replacement feeding practices.

Should we be surprised by these data? In the original randomised trial in Kenya when the risks of postnatal HIV transmission in an African setting were first quantified,³ the risk of mortality associated with formula feeding in the first 6 months of life were similar to those described in the randomised trial in Botswana. By 18 months, however, and in contrast to the recent Botswana study, infants who had been randomised to formula feeding had better HIV-free survival. The mothers in this study also had access to safe water, electricity, and medical care and formula milk was supplied by the study (that is, all the effective conditions deemed necessary in the 2000 WHO recommendations). The irony of these reports is that Botswana arguably has the best primary health infrastructure and provision of water and sanitation in southern Africa. The national HIV transmission prevention programme was the first to promote formula milk as the default feeding option for mothers infected with HIV and it seemed to be successful. As alarming as the report of epidemic diarrhoea and ensuing deaths might be, we should be more concerned about possible longstanding unrecognised mortality related to mothers making inappropriate choices of infant feeding practices when their household circumstances cannot safely support those practices and infants are thereby at high risk of diarrhoeal illness, malnutrition, and death.

The updated WHO report and recommendations,² while generally supportive of the 2000 recommendations,¹ provide greater insight and nuance to the complexity of implementing any theoretical approach in programmes. They acknowledge that exclusive breast feeding has a twofold to fourfold lower risk of transmission than mixed feeding.¹³¹⁴ They recommend that in the absence of safe water, hygiene, and community acceptance exclusive breast feeding should be promoted until the infant is 6 months old rather than just during the first few months of life. The continued risks of serious morbidity and mortality in infants if breast feeding is stopped early at around six months was highlighted stressing the need for continued contact and counselling with mothers during the first months of the infant's life to help guide her decisions about feeding practices after 6 months. Most important, perhaps, was the acknowledgement that the health systems in which transmission prevention programmes are implemented must be able to cope with the diarrhoeal illnesses and malnutrition that are so frequently the consequence of incorrect use of commercial infant formula.²

There is no doubt that breast milk can transmit HIV or that an infant's chances of survival when living in a poor or rural community are greatly decreased by not breast feeding. The challenge is how health systems can, at scale, help individual women, whether infected with HIV or not, appreciate the inherent risks and opportunities of their environment and make good decisions about how to feed their infants. For scientists, the challenge is to study and understand the evidence and not simply follow their hearts and possible prejudices in this crucial component of child survival.

Maternal and Child Health Unit, Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, Congella 4013, South Africa

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. WHO. 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. WHO/RHR/01.28ed. Geneva: WHO, 2001. www.who.int/reproductive-health/publications/new_data_prevention_mtct_hiv/index.html
2. WHO. Consensus statement. WHO HIV and infant feeding technical consultation held on behalf of the inter-agency task team (IATT) on prevention of HIV infections in pregnant women, mothers and their infants. Geneva, October 25-27, 2006. . www.who.int/child-adolescent-health/New_Publications/NUTRITION/consensus_statement.pdf
3. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 2000;283:1167-74.[Abstract/Free Full Text]
4. WHO Collaborative Team. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO collaborative study team on the role of breastfeeding on the prevention of infant mortality. Lancet 2000;355:451-5.[ISI][Medline]
5. Piwoz EG, Ross JS. Use of population-specific infant mortality rates to inform policy decisions regarding HIV and infant feeding. J Nutr 2005;135:1113-9.[Abstract/Free Full Text]
6. Ross JS, Piwoz EG, Habicht JP. Is breastfeeding best for HIV-positive mothers? AIDS 2004;18:363.[CrossRef][ISI][Medline]
7. UNICEF, USAID. HIV and infant feeding: a compilation of programmatic evidence. QAP, University Research Co, LLC (URC), 2004. .www.qaproject.org/strat/sourcedoc.htm
8. Brahmbhatt H, Gray RH. Child mortality associated with reasons for non-breastfeeding and weaning: is breastfeeding best for HIV-positive mothers? AIDS 2003;17:879-85.[CrossRef][ISI][Medline]
9. Hilderbrand K, Goemaere E, Coetzee D. The prevention of mother-to-child HIV transmission programme and infant feeding practices. S Afr Med J 2003;93:779-81.[ISI][Medline]
10. Thior I, Lockman S, Smeaton LM, Shapiro RL, Wester C, Heymann SJ, 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. JAMA 2006;296:794-805.[Abstract/Free Full Text]
11. Creek T, Luo C, Quick T. HIV-exposed children highly affected by deadly outbreak of diarrhea and severe acute malnutrition—Botswana, 2006. The 2006 HIV/AIDS implementers meeting of the president's emergency plan for AIDS relief, Durban, South Africa, Late Breaker Abstract 1, 2006. www.blsmeetings.net/implementhiv2006/TracyCreek_files/frame.htmwww.blsmeetings.net/implementhiv2006/TracyCreek_files/frame.htm
12. Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N, et al. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organ 2005;83:418-26.[ISI][Medline]
13. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005;19:699-708.[ISI][Medline]
14. Coovadia H, Rollins N, Bland R, Little K, Coutsoudis A, Bennish ML, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding: the first six months of life. Lancet 2007 (in press).

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