HIV, Sexual Life, Birth,
among pregnant women are high. AIDS has already doubled the mortality of children
under 5 years of age in some areas. Although only part of this increase is the result of
breastfeeding, there is a pressing need for countries to develop and implement sound
public health policies on HIV and infant feeding.
In 1997, the WHO, UNICEF and UNAIDS issued a joint Policy Statement on HIV
and Infant Feeding (annex 1) which takes account of available scientific evidence of
transmission through breast milk and which promotes fully informed choice of infant
feeding methods by HIV-positive women. Based on the 1997 Statement, the
following guidelines are intended to help decision-makers define what action should
be taken in their own countries or local areas.
The overall objective is to prevent HIV transmission through breastfeeding while
continuing to protect, promote and support breastfeeding for HIV-negative women
and those of unknown status. The issues are multi-sectoral and will be of relevance to
decision-makers in a number of fields, including health, nutrition, family planning,
education, and social welfare.
Different countries are at different stages of the HIV/AIDS epidemic and of their
response to it, and have differing resources at their disposal. The aim of these
guidelines is not to recommend specific policies, but rather to discuss issues that need
to be considered, to give background information and to highlight areas of special
concern on which policy decisions need to be made locally. Further planning and
management details and scientific information are contained in the two
HIV and Infant Feeding: A guide for health care managers and
Breast-milk substitute refers to any food being marketed or otherwise represented as a partial or
total replacement for breast milk, whether or not suitable for that purpose.
CD4 cells (also known as T4 or helper T cells) are lymphocytes (a type of white blood cell),
which are key in both humoral and cell-mediated immune responses. These are the main target
cells for HIV. Their numbers decrease during HIV infection, and their level is used as a marker
of progression of the infection. CD8 cells are a subtype of T lymphocytes, which also play an
important role in fighting infections. Their numbers may be increased during HIV infection.
Cell-associated virus refers to HIV which lives inside the cell, measured as HIV-DNA.
Cell-free virus refers to parts of the virus (virions) not associated with a cell, measured as HIVRNA.
Cessation of breastfeeding means completely stopping breastfeeding, which includes no more
suckling at the breast.
Colostrum is the thick yellow milk secreted by the breasts during the first few days after HIV, Sexual Life, Birth, And Breastfeeding Essay
delivery, which gradually evolves into mature milk at 3–14 days postpartum. It contains more
antibodies and white blood cells than mature breast milk.
Commercial infant formula means a breast-milk substitute formulated industrially in
accordance with applicable Codex Alimentarius standards to satisfy the nutritional requirements
of infants during the first months of life.
Complementary food means any food, whether manufactured or locally prepared, used as a
complement to breast milk or to a breast-milk substitute, when either becomes insufficient to
satisfy the nutritional requirements of the infant.
DNA, an abbreviation for deoxyribonucleic acid, is the carrier of genetic information found in
Exclusive breastfeeding means an infant receives no other food or drink, not even water, other
than breast milk (which can include expressed breast milk), with the exception of drops or syrups
consisting of vitamins, mineral supplements or medicines.
Formula feeding involves the use of commercial infant formula that is formulated industrially in
accordance with applicable Codex Alimentarius standards to satisfy the nutritional requirements
of infants during the first months of life up to the introduction of complementary foods.
HAART, an abbreviation for highly-active antiretroviral therapy, is a combination of three or
more different antiretroviral drugs used in the treatment of those infected with HIV to reduce
Human immunodeficiency virus (HIV) refers to HIV-1 in this review. Cases of mother-to-child
transmission of HIV-2 are rare.
Literature review on HIV and Infant feeding vii
Immunoglobulins are any of the five distinct antibodies present in the serum and external
secretions of the body (IgA, IgD, IgE, IgG and IgM).
Incidence density means the incidence rate of an event, i.e. HIV infection or death per persontime (months or years).
Infant refers to a child from birth to 12 months of age.
Intrapartum means the period during labour and delivery.
Lamivudine, or 3TC, is an antiretroviral drug often used in combination with zidovudine, ZDV,
also known as azidothymidine, AZT.
Late postnatal HIV transmission means transmission that takes place after about six weeks of
life, the earliest time at which it is possible to determine that transmission did not take place
Lipid means any one of a widely varying group of fats and fat-like organic substances.
Macrophage is a large ‘wandering’ phagocytic white blood cell that ingests foreign matter, and
plays an important role in resisting infection.
Mature breast milk is milk produced from about 14 days postpartum until the cessation of
breastfeeding.HIV, Sexual Life, Birth, And Breastfeeding Essay
Mixed feeding refers to breastfeeding with the addition of fluids, solid foods and/or non-human
milks such as formula.
Mother-to-child transmission (MTCT) indicates instances of transmission of HIV to a child
from an HIV-infected woman during pregnancy, delivery or breastfeeding. The term is used in
this document because the immediate source of the child’s HIV infection is the mother. Use of
the term mother-to-child transmission implies no blame, whether or not a woman is aware of her
own infection status.
Neonatal describes the period immediately following birth through the first 28 days of life.
Nevirapine, or NVP, is an antiretroviral drug commonly used as a treatment regimen, either
alone or in combination with other drugs, to prevent MTCT.
Partial breastfeeding means giving a baby some breastfeeds and some artificial feeds, either
milk or cereal, or other food.
PCR means polymerase chain reaction, a laboratory method in which the genetic material (DNA
or RNA) of the virus is detected and amplified. It can be both qualitative and quantitative.
Peripartum transmission is mother-to-child transmission of HIV occurring around the time of
delivery (i.e. late in pregnancy, during or immediately after delivery).
Postnatal transmission is mother-to-child transmission of HIV after delivery, during the
Literature review on HIV and Infant feeding viii
Predominant breastfeeding means breastfeeding is the main source of nourishment, but an
infant is also given small amounts of non-nutritious drinks, such as tea, water and water-based
Replacement feeding means the process of feeding a child who is not receiving any breast milk
with a diet that provides all the nutrients the child needs until the child is fully fed on family
RNA, an abbreviation for ribonucleic acid, is a substance found in the nucleus of all living cells
and in many viruses. An intermediate of DNA, it is the medium by which genetic instructions
from the nucleus are transmitted to the rest of the cell. RNA viral load, expressed as copies of
RNA per ml of plasma or other body fluid, reflects the amount of actively replicating virus in the
body. High viral RNA levels occur (temporarily) immediately after acquisition of infection and
later with progression of disease, and are associated with higher rates of transmission.HIV, Sexual Life, Birth, And Breastfeeding Essay
Virion refers to those parts of the virus that are able to replicate HIV.
Wet-nurse refers to the breastfeeding of an infant by someone other than the infant’s mother.
Zidovudine, or ZDV, is an antiretroviral drug which inhibits HIV replication. It was the first
drug licensed to treat HIV infection. Today it is frequently used in combination with other
antiretroviral drugs and, alone or in combination, it is used in the prevention of mother-to-child
transmission of HIV. (It is also known as retrovir or azidothymidine, AZT.)
How is HIV transmitted from mother to child during pregnancy?
If you are a pregnant woman living with HIV there are a number of ways that HIV might be passed on to your baby. HIV in your blood could pass into your baby’s body. This is most likely to happen in the last few weeks of pregnancy, during labour, or delivery. Breastfeeding your baby can also transmit HIV, because HIV is in your breastmilk.
There is a 15 to 45% chance of passing HIV on to your baby if neither of you take HIV treatment.
However, taking the correct treatment during your pregnancy and while you breastfeed can virtually eliminate this risk.
How do I know if I have HIV?
If you are pregnant, it is important to attend your antenatal appointments, as these are the times when you can get an HIV test.
Your healthcare professional will offer you a test at your first appointment. If the result is positive you will be encouraged to start antiretroviral treatment as soon as possible. You will also be offered a test in your third trimester (from 28 weeks).
Remember that, whether you are pregnant or not, if you do have HIV you may not show any symptoms. The only way to know whether you are HIV-positive is to get tested.HIV, Sexual Life, Birth, And Breastfeeding Essay
If at any point during your pregnancy or breastfeeding stage you think you have been exposed to HIV, you may be able to take post-exposure prophylaxis (PEP). You need to take PEP within 72 hours of possible exposure to prevent HIV from establishing in your body and being passed on to your baby. If you’re breastfeeding, you should discuss whether or not to continue breastfeeding with your healthcare professional.
If you are pregnant, it is important to attend your antenatal appointments, as this is where you can get an HIV test.
How can I prevent passing HIV on to my baby?
If your HIV test result is positive, there are a number of things you can do to reduce the risk of passing on HIV to your baby.
Taking antiretroviral treatment to protect your baby
Taking treatment properly can reduce the risk of your baby being born with HIV to less than 1%.
If you knew that you were HIV-positive before you got pregnant, you may be taking treatment already. If you are not, talk to a healthcare professional about starting treatment as soon as possible.
If you found out that you living with HIV during your pregnancy, it is recommended that you start treatment as soon as possible and continue taking it every day for life.
Your baby will also be given treatment for four to six weeks after they are born to help prevent an HIV infection developing.HIV, Sexual Life, Birth, And Breastfeeding Essay
Protecting your baby during childbirth
If you take your treatment correctly, it will lower the amount of HIV in your body. In some people, the amount of HIV in their body can be reduced to such low levels that it is said to be ‘undetectable’ (undetectable viral load).
This means that you can plan to have a vaginal delivery because the risk of passing on HIV to your baby during childbirth will be extremely small.
If you don’t have an undetectable viral load, you may be offered a caesarean section, as this carries a smaller risk of passing HIV to your baby than a vaginal delivery.
If your HIV test result comes back positive, there are a number of things you can do to reduce the risk of passing HIV to your baby.
I was diagnosed with HIV. After a few years I entered a relationship and we decided to have children. My HIV consultant assured me that it was fine since my viral load was undetectable. I had my twins through C-section, which was planned.
HIV and breastfeeding
Breastmilk contains HIV. However, guidelines on whether or not to breastfeed vary depending on what resources are available to you.
If you always have access to formula and clean, boiled water, you should not breastfeed and give formula instead.HIV, Sexual Life, Birth, And Breastfeeding Essay
If you do not have access to formula and clean, boiled water all of the time, you may be advised to breastfeed while both you and your baby are taking antiretroviral treatment.
If you do breastfeed, you must always take your treatment and exclusively breastfeed (give breastmilk only) for at least six months. Mixing breastmilk and other foods before this time increases your baby’s risk of HIV. You can mix-feed your baby after six months.
As every person’s situation is different, it is best to talk to a healthcare professional to get specific advice.
Does my baby have HIV?
Your baby should be tested for HIV at birth, and again four to six weeks later.
If the result comes back negative, your baby should be tested again at 18 months and/or when you have finished breastfeeding to find out your baby’s final HIV status. It is very important to take your baby for this final HIV test to ensure they are HIV-negative or to get them on treatment if they are positive.
If any of these tests come back positive, your baby will need to start treatment straight away. Talk to your healthcare professional, and attend follow-up appointments to ensure your baby receives treatment.
Recommendations from global health authorities endorse exclusive breastfeeding for all babies for the first six months of life and continued partial breastfeeding for up to two years or beyond. (1) Yet it is commonly believed that the one exception to this recommendation is the baby of a mother who has been diagnosed as HIV-infected, due to the fear that the mother may pass the virus to her baby in her milk. (2)
Most HIV-exposed babies are born in places where breastfeeding is the cultural norm and where formula-feeding is particularly unwelcome, unnatural and stigmatising. (3)HIV, Sexual Life, Birth, And Breastfeeding Essay
Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first six months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival. (4) In other words, recent research suggests that formula-feeding is more risky than breastfeeding with HIV. As more is known, an increasing number of HIV-positive mothers in industrialized countries are questioning whether the risk of HIV transmission through breastfeeding is as high as they have been led to believe and, if it is not, they are asking if they, too, can breastfeed.
What information will help these mothers to make an informed decision about whether breastfeeding will be safe for their babies? What research can they discuss with their doctors and HIV clinicians as they express their ambitions and ask for support?
HOW IS THE RISK OF BREASTFEEDING-ASSOCIATED HIV TRANSMISSION MEASURED?
Firstly, it needs to be remembered that since 1985 breastfeeding in the context of HIV has received very bad press. Fears about early high-risk estimates of HIV transmission persist. But there is a great difference in transmission risk between a mother receiving effective antiretroviral therapy (ART) in 2014 (5) and the unfortunate mother of several decades ago for whom no drug therapy was available and the risk of postnatal transmission through any breastfeeding was estimated to be 15–30% higher than that of no breastfeeding. (6)
THE TRANSFORMING EFFECT OF EFFECTIVE ANTIRETROVIRAL THERAPY (ART)
A growing body of research shows that effective ART can not only improve the health of an infected individual so that he or she can enjoy a normal life-span, (7) but that treatment also constitutes an effective form of prevention between infected and uninfected members of a couple, and between an infected mother and her infant during pregnancy, birth or breastfeeding.HIV, Sexual Life, Birth, And Breastfeeding Essay
No cases of transmission of HIV were found during two years of follow-up of sero-discordant couples when the HIV-infected partner received and took antiretroviral medications. (8) Up-to-date World Health Organization guidance recommends that all women diagnosed as HIV-infected should receive immediate ART, which should be continued for life.5 HIV-infected expectant mothers who are diagnosed as HIV-positive during early pregnancy can receive a long enough course of ART to ensure that the number of viral copies in their blood becomes undetectable by their due date, posing a negligible risk of transmission of the virus during labor and delivery, and allowing them to have a normal vaginal birth. (9) The duration of treatment is important: a study published in 2011 (10) showed that ART needs to be taken for approximately 13 weeks to reduce the number of viral copies to levels that are no longer detectable on a standard HIV test; mothers who received ART for less than four weeks had a five-fold increased risk of HIV transmission to their babies.
The importance of exclusive breastfeeding in reducing the risk of postnatal HIV transmission was first established in a South African study published in 1999, (11) and subsequently confirmed amongst Zimbabwean infants in 2005. (12) In the latter study, compared with early mixed feeding (breast milk and other foods and liquids), exclusive breastfeeding (feeding only breast milk) reduced transmission by 75% in babies tested at six months. It was hypothesized that too-early feeding with other foods and liquids besides breast milk may disturb the normal infant gastrointestinal flora. (13) When babies are mixed fed, pathogens and dietary antigens in formula can cause small sites of damage and inflammation to the baby’s intestinal mucosa. Once the integrity of the baby’s gut has been compromised, it is easier for HIV in breast milk to cross the mucous membranes and to make contact with the baby’s bloodstream. On the other hand, protective components in mother’s milk, for example epidermal growth factor, can help the intestinal epithelial barrier to mature, thus helping to protect against infection with HIV.HIV, Sexual Life, Birth, And Breastfeeding Essay
When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding.
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)HIV, Sexual Life, Birth, And Breastfeeding Essay
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.HIV, Sexual Life, Birth, And Breastfeeding Essay
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)HIV, Sexual Life, Birth, And Breastfeeding Essay
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)
Finally, it is not possible to overstate the need for breastfeeding counselors or IBCLCs to liaise with and be guided by the mother’s and baby’s primary healthcare providers so that all parties can work together as a team for the best health outcomes for both mother and baby.HIV, Sexual Life, Birth, And Breastfeeding Essay
HOPE FOR THE FUTURE
When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding. Up-to-date evidence-based research suggests that when HIV-positive women receive adequate ART, they can safely embark upon a pregnancy and deliver their children vaginally. Research also shows that improved health outcomes can be achieved with breastfeeding compared to not breastfeeding. There are only two provisos:
1) mothers must be meticulously adherent to their medication, and
2) breastfeeding should be practiced exclusively during the first six months of life.
When these two preconditions are met, the risk of mother-to-child transmission of HIV through breastfeeding can be reduced to negligible levels. The World Health Organization describes these findings as “transforming,” and it follows that there should thus be no need to discourage breastfeeding, both within and outside the context of HIV. HIV, Sexual Life, Birth, And Breastfeeding Essay
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