Breastfeeding by HIV-positive mothers: Damned if they do, Damned if they don’t

The issue of breastfeeding by HIV-positive mothers in developing countries and other resource-poor settings presents a quandary to health providers, researchers, public health officials, and policy-makers, as well as to the mothers themselves. Every year, approximately 530,000 infants and children become infected with HIV.[i] In countries most affected by HIV/AIDS, the under-5 mortality attributable to HIV may be as high as 30 per 1000, as is the case for Botswana, Namibia, Swaziland, Zambia, and Zimbabwe. In sub-Saharan Africa, HIV-attributable deaths for those under 5 comprised 7.7% of under-5 deaths in 1999.[ii] Most instances of HIV infection in infants and children occur as a result of mother-to-child transmission (MTCT),[iii] which may occur during pregnancy, labor and delivery, or breastfeeding.[iv] The risk of MTCT with breastfeeding is 30-45%, up to two years after delivery. This number is reduced to 16-23% with peripartum antiretroviral treatment[v] (ART).

Given such high MTCT rates through breastfeeding, the best route for HIV-positive mothers to take is to avoid breastfeeding their children altogether. However, in resource-poor settings, most families do not have the means or the knowledge to carry out replacement feeding feasibly and safely. To illustrate, infant formula may easily be mixed with contaminated water in these areas,[vi] bringing about increased risk of infection by life-threatening diseases other than HIV. These include diarrhea and respiratory disease. In fact, approximately 20% of child deaths in the world are due diarrhea.[vii] Furthermore, protection against diarrhea is about 6-fold for breastfed infants versus formula-fed infants in the first six months of life; while protection against acute respiratory infection is about 2.5-fold.[viii]

Mothers in these communities are also more likely to be illiterate and unable to the read the directions for mixing proper proportions of water and formula. Even those who are aware of the proper proportions may be apt to dilute the infant formula in an attempt at cost savings.6 Either way, children in these situations are underfed as a result of infant formula use. Breastfeeding, on the other hand, provides all of an infant’s required nutrients until about 6 months of age and is an important source of nutrients thereafter,3 ensuring proper growth and development for the child. Thus, it is important for mothers to breastfeed in resource-poor settings where child malnutrition is prevalent. Finally, breastmilk boosts infants’ immune systems, providing them with a number of antibodies and other essential agents.[ix]

The benefits and dangers of breastfeeding by HIV-positive women pose a difficult dilemma. In 2006, WHO, UNICEF, UNFPA, and UNAIDS came together to form an inter-agency task team (IATT) on prevention of HIV infections in pregnant women, mothers, and their infants. After a review of relevant studies and programs, the IATT determined that in resource-poor settings where safe replacement feeding is not feasible and sustainable, the benefits of exclusive breastfeeding by HIV-positive mothers far outweigh the risk of MTCT in the first six months of life.3

One will undoubtedly find horrendous health disparities prevalent in studies of and work in global health. But this author finds the issue of breastfeeding by HIV-positive women in resource-poor settings particularly abominable. The idea that a mother must choose between probable infection and even death of her child by HIV or another infectious disease is unthinkable. Further, that young children must be put at great risk for morbidity or mortality due to diarrhea or malnutrition in order to avoid HIV by MTCT is difficult to stomach. No one is deserving of HIV or any other disease, the least of whom are infants and children. Needless to say, the author of this blog believes that much more attention and resources must be focused on HIV-positive mothers in resource-poor settings, as well as on their children.

Given the child mortality attributable to HIV and to diarrheal diseases and how these two are related through breastfeeding by HIV-positive mothers, it is imperative that global health efforts target HIV-positive mothers, particularly in developing countries. The issue encapsulates a multitude of global health problems—contaminated water, lack of proper sanitation systems, undernutrition, to name a few. These are longer-term issues to be addressed. More immediately, pregnant women who have HIV should be targeted for ART. As discussed above, the risk of MTCT decreases when the mothers undergo ART while pregnant and while breastfeeding. However, it is still best for HIV-positive mothers to choose replacement feeding when it feasible and can be done safely. Thus, global health efforts and resources should be put into research and development of programs for safe and feasible replacement feeding for infants and children of HIV-positive women in resource-poor settings. Such programs may consist of education on proper replacement feeding, distribution of potable water, and subsidies for the purchase of infant formula. Given the importance of healthy children to the future of their societies and economies, such programs would prove a cost-effective investment, producing a wealth of returns. Indeed, breastfeeding by HIV-positive mothers and its implications on mortality and global burden of disease make it an exceedingly important issue to be addressed by the global health community.

[i] UNAIDS (2006). AIDS epidemic update. Geneva, Switzerland: UNAIDS.
[ii] Walker N, Schwartlander B, Byce J (2002). Meeting international goals in child survival and HIV/AIDS. The Lancet, 360, 284-289.
[iii] WHO, UNICEF, UNFPA, UNAIDS (2006). HIV and infant feeding: New evidence and programmatic experience. Geneva, Switzerland: WHO.
[iv] WHO, UNICEF, UNFPA, UNAIDS, World Bank, UNHCR, WRP, FAO, IAEA (2003) Hive and infant feeding: Framework for priority action. Geneva, Switzerland: WHO.
[v] Gaillard P, Fowler MG, Dabis F, Coovadia H, van der Horst C, van Rompay K, Ruff A, Taha T, Thomas T, de Vincenzi I, Newell ML (2004). Use of antiretroviral drugs to prevent HIV-1 transmission through breast-feeding: From animal studies to randomized clinical trials. Journal of acquired immune deficiency syndromes, 35(2), 178-187.
[vi] Anderson GC (1989). The Nestle affair. Science, 244(4906), 844-845.
[vii] Skolnik R (2008). Essentials of global health. Sudbury, MA: Jones and Bartlett Publishers.
[viii] WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality (2000). The Lancet, 355(9209), 451-455.
[ix] Mead MN (2008). Contaminants in human milk: Weighing the risks against the benefits of breastfeeding. Environmental Health Perspectives, 116(10), 427-434.