HIV transmission through breastfeeding: problems and prevention.

The greatest burden of HIV infection in women and their children is disproportionately borne by the poorest countries, especially in sub-Saharan Africa. Breastfeeding is a major health-promoting factor for infants and children in developing countries but the risk of mother-to-child transmission (MTCT) of HIV by this route is challenging traditional practices and health policies in low-resource countries. Maternal and infant factors contributing to the risk of MTCT through breastfeeding are still poorly understood and not well researched. Factors identified include: advanced clinical stages of infection in the mother; high maternal plasma HIV-1 load; presence of mastitis; and infant oral thrush. In many developing countries, international agencies are providing support and recommendations for preventing MTCT of HIV-1 by breastfeeding. Preventive strategies supported by WHO/UNICEF and charitable agencies in some sentinel centres in sub-Saharan Africa include routine antenatal voluntary counselling and testing (VCT), PCR testing of infants of seropositive mothers at 6 weeks of age, various combinations of a shortened period (3-6 mths) of exclusive breastfeeding, perinatal administration of antiretrovirals (ARV) such as nevirapine and provision of affordable and safe infant replacement feeds (presently given free by UNICEF in some centres). Many problems, however, have hindered effective implementation of these interventions. In many poor communities, even where VCT facilities are available, acceptance of HIV testing is low because there is fear of stigmatisation by the spouse, family or community and compliance with complex drug regimens is therefore poor. Other problems include the exorbitant cost of antiretroviral drugs, inadequately resourced health care systems and unavailability or poor acceptance of safe breast-milk alternatives. The rate of mixed feeding is high and so the risk of MTCT is increased. Continued promotion of exclusive breastfeeding for at least 6 months, irrespective of HIV status, followed by a properly prepared, high energy, nutritious complementary diet, with the possibility of early weaning to an animal milk formula, still appears to be the most appropriate option for the poor in countries with high levels of MTCT not deriving any benefit from the above strategies. While a longer period of breastfeeding would probably increase the risk of MTCT in vulnerable communities, a shorter duration would certainly increase infant morbidity and mortality. Results of investigations of the efficacy of ARV for protecting the infants of HIV-infected mothers during the breastfeeding period are awaited.