Breastfeeding is vital for the health, survival and development of children and women everywhere.

Mother to child transmission of HIV can take place during pregnancy, at delivery and postnatally through breastfeeding, but it is difficult to establish with any certainty the relative contribution of each event.

Ground-breaking research from South Africa* presents the first evidence of the impact of exclusive breastfeeding on vertical transmission. Results indicate that exclusive breastfeeding would exert a protective effect on the infant's gut lining minimizing the risk of HIV transmission via the gut wall.

When exclusive breastfeeding is not practised during the early months of infancy i.e. other foods and fluids are given, damage to the gut surfaces by various means can occur. The damaged mucosal surfaces are then more vulnerable to infection, allergens or physical trauma and thus could allow passage of the HIV across the membrane and into the body tissues.

Researchers, Coutsoudis et al., using a rigorous definition of exclusive breastfeeding concluded that when breastfeeding is exclusive from birth, it does not appear to transmit HIV from an infected mother to her uninfected infant. This prospective cohort study found that transmission rates among those exclusively breastfed from birth were lower at three months than among those not breastfed at all and much lower than those breastfed but not exclusively. Although the difference for those not breastfed was not significant, the authors stated that this "raises the possibility that virus acquired during delivery could have been neutralized by immune factors present in breastmilk but not in formula feeds,"

• Coutsoudis, A et al. Influence of Infant Feeding Patterns on Early Mother to Child Transmission of HIV-1 in Durban South Africa: a prospective cohort study. The Lancet, Aug. 7, 1999.

Researchers have identified a simple, affordable drug regimen that is highly effective in preventing HIV infection in infants of mothers with the disease.

A joint Uganda-U.S. study* has found a highly effective and safe drug regimen for preventing transmission of HIV from an infected mother to her newborn that is more affordable and practical than any other examined to date. Interim results from the study, sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), demonstrate that a single oral dose of the antiretroviral drug Nevirapine (NVP) given to an HIV- infected woman in labour and another to her baby within three days of birth reduces the transmission rate by half compared to a similar short course of AZT. If implemented widely in developing countries, this intervention potentially could prevent some 300,000 to 400,000 newborns per year from beginning life infected with HIV.

• Musoke P. et al a phase 1-2 study of the safety and pharmakinetics of Nevirapine in HIV-1 infected pregnant women and their neonates. AIDS March 11:13, 479-86, 1999.

Because of the difference in HIV prevalence and level of appropriate resources existing between countries, no single policy or guideline is applicable globally. For this reason policies must be developed regionally to suite local situations.

Developing policy dealing with the challenge of HIV requires special consideration:

• Prevention of infection with HIV through the education of the public is of paramount importance.
• Women have the right of access to voluntary and confidential counselling and testing for HIV.
• It is the mothers right to decide how she will feed her child with the fullest possible information on which to base her decision.
• When examining options for replacement feeding for infants of mothers that are infected with HIV and have decided not to breast-feed, priority should be given to alternatives that are available and sustainable at the local level.
• Implementation of the International Code of Marketing of Breast milk Substitutes and subsequent, relevant WHA Resolutions is paramount to prevent the spill-over of artificial feeding to the majority of infants for whom breastfeeding is vital, and to ensure that both health care practices and women's choices are not influenced by commercial pressures.

Strategies designed to prevent HIV transmission through the adoption of formula feeding may reduce the life expectancy of infants more than the risk of HIV. The threat of the disease should not be used to validate the promotion of breastmilk substitutes to the public.

In conclusion:
Prevention of HIV transmission, must be part of a comprehensive approach aimed at keeping the best interests of the mother and baby foremost. This requires strengthening of the maternity and family planning services, with increased antenatal care; counselling and voluntary and confidential testing for HIV; possible use of antiretroviral drugs which allow continued breastfeeding; and safe alternatives to breastfeeding where necessary.

Further independent research to verify the Coutsoudis conclusions is necessary. In addition research in breast milk options for example, heat-treated breast milk or banked breast milk is needed.

The results of the Coutsoudis study should be given serious consideration by UNAIDS/WHO/UNICEF in the continued implementation of the guidelines on infant feeding and HIV. In cases where replacement feeding is necessary, measures must be in place to ensure that

• There are no donations of free and low-cost supplies within any part of the health care system (WHA 47.15)
• Free and low-cost supplies donated outside the institution are provided for as long as the infant concerned requires them (article 6.7), for at least six months.
• The use of generic labelling is mandatory to avoid exploitation of emergency situations for marketing purposes. (IBFAN has designed a generic label for use in these circumstances.)
• A cup not a bottle is recommended for feeding.
• Mothers are taught how to use the formula correctly and there is adequate clean water or means of sterilizing it.
• Formula is not recommended for children older than six months where conditions are not hygienic. Instead appropriate complimentary foods are encouraged.

Every effort must be made to provide health education and information which stresses the substantial benefits which breastfeeding provides to both children and mothers, and also the increased risks of artificial feeding to child health and its contribution to child mortality.

It is the role of the health worker to provide complete and accurate information and unbiased support so that the woman infected with HIV can make choices which she and her family can live with.

References
HIV and Infant Feeding - WHO/UNICEF/UNAIDS 1997

IBFAN European Meeting, Malta September 1997.

"HIV and Infant Feeding" - P. Kisanga, IBFAN Africa News, June 1998.

Guidelines on HIV and Infant Feeding - UNICEF/UNAIDS/WHO 1998:

Code Implementation Regional Seminar, Nairobi Kenya 3-12 August 1998.

Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: A prospective cohort study. (Coutsoudis A., Pillay K., Spooer E., Kukn L., and Coovadia HM.)
Musoke P. et al. A phase 1-2 study of the safety and pharmakinetics of Nevirapine in HIV-1 infected pregnant women and their neonates. AIDS March 11:13, 479-86, 1999.

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