21 September 2008

Breast Feeding and HIV Transmission in Infants: A WHO Policy Change

Each year 200,000 infants are infected with HIV virus from their mother’s breast milk. Because of the high risk of passing on a fatal disease by HIV positive mothers who nurse their babies, the World Health Organization and other agencies have recommended that these mothers not breastfeed, “if replacement feeding is acceptable, feasible, affordable, sustainable and safe.” Pretreatment of the HIV positive mother with a single antenatal dose of the antiretroviral nevirapine is also recommended, which reduces prenatal HIV transmission by 50%, and gives some protection to the nursing infant for 4-6 weeks postpartum. In the resource poor environment of many developing countries early exclusive breastfeeding is critical to infant survival. Early formula feeding or mixed feeding (breast milk + formula and or cereal products) exposes the vulnerable infant to a markedly increased risk of diarrhea and other infections, and results in a high mortality rate. Clinical studies have also shown that mixed feeding also results in a four times or greater rate of HIV acquisition in comparison to those infants who are exclusively breastfed. This unfortunate set of circumstances places health workers and agencies on the horns of a serious dilemma. Does the baby die from AIDS or from diarrhea? WHO recommended in 2000 that mothers in developing countries exclusively breastfeed to 4 or 5 months, then abruptly stop nursing and switch to formula and cereal. This approach has been challenged by recent clinical research. The final report of a long-term study in Zambia recently appeared in the New England Journal of Medicine. (1). This study showed that there was no benefit in HIV-free survival to 24 months among infants of HIV infected mothers who were encouraged to stop breastfeeding abruptly at 4 months as compared with infants of mothers who continued breast feeding for a median of 16 months.

This study and others recently completed have caused the World Health Organization to revise its developing countries recommendations to include

  1. Extension of the time of exclusive breastfeeding to 6 months.
  2. Continuation of breastfeeding with addition of complementary foods, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, (2)

A recent NEJM editorial on HIV and breastfeeding, (3), points out that this important issue is far from settled. Further research is indicated, including more extended use of antiretroviral therapy, and further efforts to tailor breastfeeding options to obtain optimal HIV free survival.

  1. Kuhn, L., Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia, NEJM 2008; 359:130-141.
  2. WHO, UNICEF, UNAIDS, UNFPA. HIVAND Infant Feeding: Update. Geneva WHO, 2007
  3. Gray, G. E. Breast Feeding, Antiretroviral Prophylaxis and HIV. NEJM 2008; 359:189-191.

Reported by Roger Boe MD. UMVIM Medical Consultant.

No comments:

Post a Comment