From JAIDS: Journal of Acquired Immune Deficiency Syndromes
Jean H. Humphrey, ScD
In developing countries, breast-feeding is both the cornerstone of child survival and the cause of about one-third of all infant HIV infections.
Moreover, the same economic and development inequities that make breast-feeding so critical to infant survival in these settings also make formula feeding inAccessible, unFeasible, unAffordable, unSustainable, and unSafe (ie, not AFASS) for most families.
This poignant dilemma has resulted in emotive and sometimes polarizing debate within the public health community as we have wrestled to quantify these competing risks, test interventions to reduce them, and modify policy as our understanding improves.
Four articles in this issue of the Journal of Acquired Immune Deficiency Syndromes shed new light on this issue. To appreciate their design and findings, it is helpful to contextualize them within the rapidly evolving science and policy of HIV and infant feeding.
2006 HIV and Infant Feeding Policy
In October 2006, when HIV and infant feeding policy was again revised; new evidence included an additional evidence that early exclusive breast-feeding is protective against postnatal transmission compared with mixed feeding, findings from 2 randomized trials in which infection-free survival was comparable between infants randomized to formula or breast-feeding from birth and between infants randomized at 4 months of age to continued breast-feeding or abrupt breast-feeding cessation ; and preliminary findings from the 4 studies published in this issue of the Journal of Acquired Immune Deficiency Syndromes.
Reflecting these new data, the 2000 policy which had stated, "When replacement feeding is AFASS, avoidance of all breastfeeding by HIV-infected mothers is recommended…
Otherwise, exclusive breastfeeding is recommended during the first months of life," was rewritten to read "Exclusive breastfeeding is recommended for HIV-infected women for the first six months of life unless replacement feeding is AFASS for them…. When replacement feeding is AFASS, avoidance of all breastfeeding by HIV-infected women is recommended."
The 2006 guidance also specified that breast-feeding should continue beyond 6 months if a replacement feeding is still not AFASS.
Thus, even though replacement feeding remains the best option for HIV-infected women in situations with plentiful nutritious foods and breastmilk substitutes, good sanitation, clean water, cooking fuel, accessible quality health care delivered by a well-functioning health care system, high levels of female education, low rates of underlying infant mortality, and broad social support; and even though there are examples of successful replacement feeding in Africa,[34–36] this subtle shift (in nuance more than substance) in the recommendations reflected the participants' sentiments that:
For the large majority of HIV-exposed infants, exclusive breast-feeding for the first 6 months of life, and continued breast-feeding after that for some yet undetermined duration, will provide the greatest chance of infection-free survival.
Ironically, the HIV epidemic may be the best thing that ever happened to breast-feeding.
It is difficult to imagine an experiment that could provide more compelling momentum for breast-feeding promotion than the natural one the HIV epidemic has provided: an incurable disease that infects up to 30%-40% of antenatal women in some African countries and is transmitted to infants through breast-feeding leads UN agencies and governments to promote and even freely provide formula for exposed infants. Moreover, scores of these infants are already under surveillance by scientists measuring and documenting numerous indices of infant health. In short, the HIV epidemic and our efforts to ameliorate its effect on children provided an ethical opportunity to observe what happens when large number of infants living in conditions of poverty are not breast-fed.
If these observations lead to stronger breast-feeding policy and programming that in turn reduce the 1.4 million child deaths occurring each year due to suboptimal breast-feeding, we will have created one of the epidemic's very few silver linings.