The World Alliance for Breastfeeding Action (Waba) has issued this statement about what women need to know about HIV and infant feeding in conjunction with World AIDS Day.
A combination of factors has contributed to the risk of female HIV infection, particularly in young women aged 15 to 24. These factors inlcude:
- Lack of knowledge - In 2004, UNAIDS reported that up to 50 per cent of young women in high prevalence countries did not know the basic facts about AIDS.
- Biological factors - Women may be biologically more susceptible to HIV infection, and young women, whose reproductive tracts are immature, are at greatest risk.
- Social factors - While levels of HIV infection among men rise slowly, peaking when men are in their mid- to late 30s, prevalence among women rises rapidly at a young age, with higher rates than men and peaking when women are in their late 20s. Sexual violence is widespread and heightens women's risk of infection. In South Africa, 10 per cent of sexually active young women say they were forced into having sex. Women are often unable to negotiate the terms of their sexual interactions with male partners, particularly within marriage. While marriage may serve as a way to protect men who have sex with men against possible prosecution and stigma, recent data on HIV infection patterns in India reveal that 90 per cent of women were infected within long-term relationships.
- Economic factors - A lack of independent resources may force women to engage in unsafe sex, or to exchange sex for money or material favours as a means of survival. In Africa, transactional sex, particularly between young women and older men, is widely accepted.
As a result, more than half of people living with HIV globally are women, and 76 per cent of all HIV-positive women live in sub-Saharan Africa, yet less than half the number of countries who report to UNAIDS have a specific budget for HIV activities related to women.
HIV and infant feeding
The rate ( per cent) of mother-to-child transmission of HIV in the absence of any intervention are as follows:
- During pregnancy - 5 to 10 per cent
- During labour and delivery - 10 to 20 per cent
- Through mixed breastfeeding for 18 to 24 months - 10 to 20 per cent
However, there's a marked difference with interventions to reduce transmission:
- Through exclusive breastfeeding three to six months - 1.3 per cent to 4 per cent
- Through continued breastfeeding 15 to 18 months after exclusive breastfeeding for three months - 5.3 per cent to 5.6 per cent
- With maternal HAART from 18-34 weeks gestation through, labour and delivery and six months' exclusive breastfeeding - 0.28 per cent
- With maternal HAART, exclusive breastfeeding for six months and continued breastfeeding with complementary feeding through 12 months - 2 per cent.
Replacement feeding, mixed feeding, premature weaning
Artificial feeding is not safe in resource-poor countries where babies are at greater risk of death and disease due to lack of sanitation and potable water, and inaccessible or unaffordable healthcare. Feeding other foods and liquids as well as breastfeeding (mixed feeding) before six months greatly increases the risk of transmission of HIV.
Recent research confirms that withholding breastfeeding from birth or in later months provides no child survival advantage in developing countries.
The World Health Organization and UNICEF recommendations on breastfeeding (for non-HIV mothers) are as follows: initiation of breastfeeding within the first hour after the birth; exclusive breastfeeding for the first six months; and continued breastfeeding for two years or more, together with safe, nutritionally adequate, age appropriate, responsive complementary feeding.
Current WHO HIV and infant feeding recommendations are for national or sub-national health authorities to decide whether health services will principally counsel and support HIV-positive mothers to either breastfeed and receive antiretroviral interventions (ARVs) or avoid all breastfeeding
- HIV-positive mothers should receive lifelong ARV therapy/prophylaxis to reduce transmission through breastfeeding and provide their infants with the most likely chance of survival.
- Where ARVs are available, HIV-positive mothers are recommended to breastfeed until 12 months of age. When ARVs are not (immediately) available, breastfeeding may still provide infants with a greater chance of survival. While ARV interventions are being scaled up, national authorities should not be deterred from recommending that HIV-infected mothers breastfeed as the most appropriate infant feeding practice in their setting.
- Breastfeeding should be exclusive for the first six months of life, and should be continued until 12 months with appropriate complementary foods.
- Infants and young children who are already HIV-infected should be breastfed in accordance with recommendations for the general population, ie exclusively for the first six months with continued breastfeeding for up to two years or beyond.
- Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided and weaning should be gradual. ARV prophylaxis should be continued for one week after breastfeeding is fully stopped.
- Non-breastfed infants should be provided with safe and adequate replacement feeds, or heat-treated, expressed breastmilk, to enable normal growth and development. Replacement feeding should only be undertaken when explicit conditions regarding safety and sustainability are met.
Women's nutritional needs
One of the most valuable ways of helping HIV-infected women is to protect their nutritional status. Reduced appetite, poor nutrient absorption, and physiological changes can lead to weight loss and malnutrition in HIV-infected people.
Asymptomatic HIV infection increases energy needs by an estimated 10 per cent, and symptomatic infections increase requirements by up to 30 per cent.
Lactation also increases nutritional requirements by 300-500 Kcal per day. To support lactation and maintain maternal reserves, breastfeeding women (whether infected or not) should consume the equivalent of about one extra meal per day.
HIV-positive women with low appetites should be encouraged to eat well by ensuring that food is available, appetising and nutritious.
Nevertheless, researchers in Zambia recently found that although longer duration of breastfeeding by HIV-infected women was associated with less weight gain, it may be metabolically regulated so that women with low body mass are protected from excess weight loss.
What women need
For women to get the best help and support in the face of HIV, it is essential that they know their status. Therefore, the first priority is to promote the availability and uptake of voluntary counseling and testing.
Mothers known to be HIV-infected should be provided with lifelong ARV therapy and prophylactic interventions to reduce HIV transmission through breastfeeding according to WHO recommendations. Every effort should be made to accelerate access to ARVs for both maternal health and prevention of HIV transmission to infants.
Skilled counselling and support in appropriate infant and young child feeding practices and ARV interventions to promote HIV-free survival of infants should be available to all pregnant women and mothers.