Introduction
Transmitting the HI-virus from an HIV-infected mother to her child (MTCT) is one of the three major ways of transmitting HIV. This can happen during pregnancy or during birth, but also after birth when the mother breastfeeds her infant. It is roughly estimated that 700 000 children become infected with HIV each year and of these an estimated 300 000 become infected through breastfeeding for longer that six months¹.

In June 2007, Durban hosted the 3rd South African AIDS Conference. The measure in which breastfeeding can contribute to MTCT was hotly debated.

The advantages of breastfeeding
According to Rebecca Denison² breastfeeding has many advantages. It is a natural first food for babies and it provides energy and nutrition that the infant needs for the first months of life. It also serves as a protection from diseases, in particular infections. Breastfeeding is a natural form of contraception, since women that breastfeed are likely not to fall pregnant. This helps spacing her children. But, an HIV-infected mother that breastfeeds run the risk of infecting her child with HIV, especially if the breastfeeding continues far longer than six months.

What are the available options?

Replacement/Formula Feeding
This involves replacing the breast milk with formula. There are disadvantages to using formula:

• If formula is made with dirty water it can infect the baby too
• It might be served in a bottle or cup that is not sterilised or at least clean

The abovementioned can expose the infant to dangerous bacteria and is therefore not the ideal solution. It seems realistic to deem formula in developing countries as a risk. A very good example is a study carried out in Botswana³. The recent outbreak of diarrhoea and increase of infant mortality in formula fed babies in that country can therefore be seen as a direct result of poor public health programmes⁴.

It seems that formula should be the best option simply based on the fact that there is not HIV presence. In this regard the World Health Organisation has devised a set of criteria for using formula⁵. Formula can only be successful when it is:

• Acceptable to the mother - it needs to be culturally acceptable for her not to breastfeed
• Feasible – the mother must have water available in the middle of the night to feed the baby
• Affordable - either the government provides it for free or at a subsidised price, or the mother and her family can afford to purchase it without jeopardising the family’s finances
• Sustainable – there should be formula available at all times.
• Safe – the water has to be safe or she has to be able to make the water safe. There has to be generally good hygienic conditions.

Mixed feeding
Mixed feeding implies feeding the baby breast milk and formula. This is the most risky form of feeding. The HI-virus in the breast milk finds it easier to get in and infect the baby, since the formula irritates the lining of the baby’s stomach. In a South African study of HIV-positive women and their babies, 36% of babies who received mixed feeding were reported infected compared to about 25% of those who were exclusively breastfed⁶.

Exclusive breastfeeding for only six months
It is now generally agreed upon that exclusive breastfeeding is the much safer option, provided that the mother wean the baby after six months. Some researchers doubt whether mothers will be able to breastfeed exclusively. A study in Uganda showed that of the 60 mothers who breastfed, only six were in fact able to breastfeed exclusively⁷.  

Dr Coovadia raises another interesting point⁸. In South Africa, the budget for supplying formula, accounts for 30% of the budget for Prevention of Mother to Child Transmission. Shouldn’t we rather use this amount of money to educate our mothers on exclusive breastfeeding? Furthermore, they experience many other problems with the supply of formula, such as having a constant supply available at all times at every medical facility. He further reiterates, “If you choose breastfeeding, you would of course have HIV infection. You would have about 300 000 (infected babies) per year in the world. But if you avoided breastfeeding, the mortality would be about 1,5 billion per year. So on the balance of probabilities for poor women in the developing world, there is no other choice than to breastfeed their infants”⁹.

Boiling of breast milk
A study by the South African Medical Research Council has found that boiling breast milk can help prevent the transmission of HIV. When boiling breast milk at 56° - 63°C for twenty minutes, 80% of the nutrients and antibodies found in the milk will be preserved¹⁰.

The role of ART
There are no conclusive results from studies which can determine the effects of HIV-positive mothers using antiretroviral drugs that are breastfeeding. However, it is expected to have a positive outcome and it would be interesting to know for certain.

Conclusion
It does seem that ‘breast still remains to be the best’. There are overwhelming research results showing that exclusive breastfeeding for six months have a lower transmission rate than mixed feeding. It also seems wise not to use formula in developing countries, but wise in developed countries. Cultural barriers may play its part in determining a successful outcome in developing countries too. Therefore it might be recommended to look at each individual’s circumstances in determining the particular way that infant should be fed.

Visit www.afroaidsinfo.org to read more articles in the AfroAIDSinfo dedicated section on women or e-mail us at afroaidsinfo@mrc.ac.za.

Sources

• Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML, 31 March 2007. Mother-to-child-transmission of HIV-1 infection during exclusive breastfeeding in the first six months of life: an intervention cohort study. The Lancet 369(9567):1107-1116.
• Denison R, HIV and Breastfeeding: What’s a mother to do? February 2002 http://www.aidsmap.com/content/treat/art13590.htm Viewed on 5 July 2007
• http://www.sciencedirect.com/science
• Swart T, Infant feeding policy debated at the Conference on Retroviruses and Opportunistic Infections. 13 March 2007 http://www.aidsmap.com/cms1191021.asp Viewed on 5 July 2007
• Ibid
• Denison R, HIV and Breastfeeding: What’s a mother to do? February 2002 http://www.aidsmap.com/content/treat/art13590.htm Viewed on 5 July 2007
• Ibid
• Swart T, Infant feeding policy debated at the Conference on Retroviruses and Opportunistic Infections. 13 March 2007 http://www.aidsmap.com/cms1191021.asp Viewed on 5 July 2007
• Ibid
• http://www.mrc.ac.za//maternal/highlights.htm

Author: Pieter Visser and Dumisani Wambi
E-mail: afroaidsinfo@mrc.ac.za
Date: July 2007