HIV Prevention

Here are the 2009 WHO guidelines on HIV and breastfeeding.

WHO. 2009. Rapid advice: revised WHO principles and recommendations on infant feeding in the context of HIV – November 2009. Geneva.
http://www.who.int/child_adolescent_health/documents/9789241598873/en/index.html

I am pasting text from 2 sections. The guidelines advise that HIV positive mothers " breastfeed and receive ARV interventions,1
or
avoid all breastfeeding". The document recognizes that ART reduce the risk of HIV transmission while allowing for the general health benefits of breastfeeding for the infant. A section below discusses that most, but not all, studies have found that breast feeding is not harmful to the mother but there seems to be some debate surrounding this question. There is also a section discussing what to do when ART is not available (based on the 2006 guidelines).


This document (2006 guidelines) talks of the need fro acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding which highlights the issues in providing replacement feed.
http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf
HIV and infant feeding : update based on the technical consultation held on behalf of
the Inter-agency Team (IATT) on Prevention of HIV Infections in Pregnant Women,
Mothers and their ...

Here are the 2009 WHO guidelines on HIV and breastfeeding.

WHO. 2009. Rapid advice: revised WHO principles and recommendations on infant feeding in the context of HIV – November 2009. Geneva.
http://www.who.int/child_adolescent_health/documents/9789241598873/en/index.html

I am pasting text from 2 sections. The guidelines advise that HIV positive mothers " breastfeed and receive ARV interventions,1
or
avoid all breastfeeding". The document recognizes that ART reduce the risk of HIV transmission while allowing for the general health benefits of breastfeeding for the infant. A section below discusses that most, but not all, studies have found that breast feeding is not harmful to the mother but there seems to be some debate surrounding this question. There is also a section discussing what to do when ART is not available (based on the 2006 guidelines).


This document (2006 guidelines) talks of the need fro acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding which highlights the issues in providing replacement feed.
http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf
HIV and infant feeding : update based on the technical consultation held on behalf of
the Inter-agency Team (IATT) on Prevention of HIV Infections in Pregnant Women,
Mothers and their Infants, Geneva, 25-27 October 2006.

This is a link to AVERT's summary of the guidelines:
http://www.avert.org/pmtct-guidelines.htm

This is a link to AVERT's discussion on HIV and breastfeeding: http://www.avert.org/hiv-breastfeeding.htm

P. 7
Key Principle 3.
Setting national or sub-national recommendations for infant feeding
in the context of HIV
National or sub-national health authorities should decide whether health services will principally counsel and support mothers known to be HIV-infected to either:
K breastfeed and receive ARV interventions,1
or
K avoid all breastfeeding,
as the strategy that will most likely give infants the greatest chance of HIV-free survival.
This decision should be based on international recommendations and consideration of the:
 socio-economic and cultural contexts of the populations served by Maternal, Newborn and Child Health services,
 availability and quality of health services,
 local epidemiology including HIV prevalence among pregnant women,
 main causes of maternal and child undernutrition,
 main causes of infant and child mortality.
Note. WHO is developing guidance to assist countries in this decision-making process including guidance on steps to reach these standards of care.
.....

P. 15
Recommendation 2.
Which breastfeeding practices and for how long
Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.
Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.
(Strong recommendation. High quality of evidence for first 6 months; low quality of evidence for recommendation re. 12 months)
Remarks
The group identified the following key evidence
K Systematic review reported decreased HIV transmission in first 6 months of infant life associated with exclusive breastfeeding (EBF) compared to mixed feeding in populations not on any ARV/ART intervention (Coovadia 2007, Iliff 2005, Kuhn 2007);
K Exclusive breastfeeding is also associated with reduced mortality over the first year of life in HIV-exposed infants compared to mixed feeding and replacement feeding in both research and programme settings, especially if inappropriately chosen by mothers (Mbori-Ngacha 2001, Thior 2006, Doherty 2007).
Additional indirect evidence:
K High quality evidence from non-HIV settings that mixed feeding and non-breastfeeding are associated with increased morbidity and mortality (WHO 2000, Bahl 2005).
Additional considerations that the group placed high value on:
K Transmission risk would be further diminished in presence of ARV interventions;
K Enabling breastfeeding in the presence of ARV interventions to continue to 12 months avoids many of the complexities associated with stopping breastfeeding and providing a safe and adequate diet without breast milk to the infant 6–12 months of age. This was seen as a major advantage;
K Additional developmental and other health benefits for infants who do not become HIV infected.
The group recognized that the risk of HIV transmission continues for as long as the infant breastfeeds.
The group reviewed modelling data that suggested that 12 months represents a reasonable cut-off for most HIV-infected mothers that capitalizes on the maximum benefit of breastfeeding in terms of survival (excluding any consideration of HIV transmission). In presence of ARV intervention to reduce risk of transmission, this combination may give best balance of protection vs. risk;
Data from non-HIV populations indicates that the survival benefits of breastfeeding decrease with age and especially after 12 months of life. However, for the HIV uninfected mother there are many other health benefits to her infant if she continues breastfeeding until 24 months.
However it was noted that EBF is not commonly practised and that medical and nursing staff do not always believe in the sufficiency of EBF. Recommending any breastfeeding has been perceived by some as a double standard compared to the standard of care expected in well-resourced settings
A systematic review also examined the effect of prolonged breastfeeding on the health of mothers who are known to be HIV-infected. This review indicated that there was no clear evidence of harm to the mother if she continued breastfeeding. One report that did report increased mortality in breastfeeding mothers was in conflict with several others including one large meta-analysis that did not find this outcome.