Normal mixed feeding after six months

As a result of the findings about the protective effects of exclusive breastfeeding during the first six months, concern was expressed about the possible dangers of HIV-transmission during normal mixed feeding after six months. As a result, HIV-positive mothers who elected to breastfeed were advised to practice what was called “early cessation of breastfeeding,” or premature weaning, as soon as practicable. (14, 15)

Subsequent studies have confirmed that after the recommended period of six months’ exclusive breastfeeding, continued partial breastfeeding with the addition of other foods and liquids, as recommended for babies outside the context of HIV, resulted in an extremely low risk of transmission in the 6–12 month period. (16, 17) Further studies from Zambia where maternal ART was initiated in early pregnancy and continued to 12 months postpartum, while infants were exclusively breastfed to six months and continued breastfeeding with complementary feeding from 6–12 months, resulted in postpartum HIV transmission rates of 1–2% at 12 months. (17, 18, 19) Confirmatory results showed that the only postnatal transmissions occurred in one infant at two weeks postpartum (19), which most likely occurred in utero, or in women who were non-adherent to their medications. (20)

What is the risk of not breastfeeding?

In spite of these excellent results, there remains a common assumption that because mothers living with HIV in industrialized countries such as Europe, North America and Australia have access to clean water and safe infant feeding alternatives, breastfeeding avoidance is free from risk. This may in part stem from misleading reporting of research (21) results but in fact, formula-fed babies experience higher rates of morbidity and mortality than their breastfed counterparts, even in industrialized countries. (22, 23, 24, 25, 26, 27, 28)

Current guidance in developed countries

In the industrialized countries of UK, Europe, Australia and Canada, a high percentage of mothers diagnosed as HIV-positive are immigrants from countries of high HIV-prevalence, particularly those in Eastern and Southern Africa. In recognition that their guidance needed to fit the population it was designed to assist, and following extensive consultation, the British HIV Association (BHIVA) published a revised position paper in 2011 stating that although formula-feeding remains the first recommendation for infant feeding in the context of HIV, when an HIV- positive mother with an undetectable viral load wishes to breastfeed, then she should be supported to do so. (29) BHIVA recommends that mothers who choose this option should practice exclusive breastfeeding for the first six months of life while receiving regular monitoring of maternal viral load and infant HIV status.

A similar relaxation of a formerly absolute prohibition of breastfeeding, and accompanying threats of imposition of child safe-guarding measures against mothers who did not comply, has also occurred in the USA. In early 2013, the American Academy of Pediatrics published revised recommendations to support breastfeeding by HIV-positive mothers when mothers are adherent to ART, achieve an undetectable viral load, and practice exclusive breastfeeding for the first six months, and the health of mother and baby are closely monitored and optimised. (30)

Supporting breastfeeding, even in the context of HIV?

Breastfeeding in the context of HIV is best planned meticulously. Antenatally, HIV-positive mothers need to be in touch with their physicians and HIV clinicians. They should discuss with them what they know of up-to-date research findings, including the risks and benefits of different feeding methods, the importance of ART, the duration of therapy, undetectable viral load, and ongoing adherence to their medications. They might also be advised to inform themselves about local and/or national HIV and infant feeding policy and to seek legal representation if there are likely to be any safe-guarding concerns or any threat of coercion to bottle-feed, as is occasionally reported. (31)

If the decision is made to breastfeed, HIV-positive mothers should receive competent and well-informed breastfeeding assistance from a recognized breastfeeding support organization or an International Board Certified Lactation Consultant (IBCLC) before and after birth. Mothers will need practical assistance with latching their baby comfortably to the breast, and ensuring effective breastfeeding. They may need advice and ongoing follow-up to avoid, minimize and quickly resolve any postpartum breast or nipple problems, such as sore nipples, breast engorgement, or symptoms of mastitis. It is important to prevent or treat these kinds of difficulties promptly should they occur, not only to avoid increasing the risk of transmission of postpartum HIV but also so that exclusive breastfeeding can easily be initiated and maintained for the full first six months of their infant’s life. The baby’s HIV status should be tested at birth, and at monthly intervals until three months after breastfeeding ends. (29, 30)