Background
Year | 1992 | 1998 | 2001 | 2006 | 2010 | 2013 | 2016 |
---|---|---|---|---|---|---|---|
Document Title | WHO/UNICEF Consensus Statement on HIV and Breastfeeding [7] | A Review of HIV Transmission through Breastfeeding [8] | New data on the prevention of mother-to-child transmission of HIV and their policy implications: conclusions and recommendations [9] | HIV and Infant Feeding: update based on the technical consultation held on behalf of the Inter-agency Task Team on the Prevention of HIV Infections in Pregnant Women, Mothers and their infants [10] | Guidelines on HIV and infant feeding 2010: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence [11] | Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection [12] | Guideline: updates on HIV and infant feeding: the duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV [13] |
Maternal treatment in postnatal period | Not discussed | Not discussed for breastfed infants | Antiretroviral (ARV) prophylaxis recommended, but drug and duration to be decided locally among regimens shown to be effective in Randomized Controlled Trials (RCTs) | ART if required for mother’s health or maternal ARV prophylaxis through 7 days after birth | Lifelong ART if required for mother’s health or ARV prophylaxis through pregnancy until one week after breastfeeding ends | Lifelong ART regardless of CD4 count or clinical stage | Lifelong ART regardless of CD4 count or clinical stage |
Infant treatment in postnatal period | Not discussed | ARV prophylaxis (prophylactic efficacy unknown for breastfed infants) | ARV prophylaxis recommended, but drug and duration to be decided locally among regimens shown to be effective in RCTs | ARV prophylaxis for 7 days after birth | If mother not on treatment, daily ARV prophylaxis until 1 week after breastfeeding ends (minimum 4 weeks) or if mother on ART for own health, ARV prophylaxis from birth to 4–6 weeks | ARV prophylaxis from birth to 6 weeks | Not discussed |
Infant feeding recommendations for first 6 months | Women should be encouraged to breastfeed regardless of HIV status | 1-Replacement Feeding (RF) if possible 2- Breastfeeding with early cessation 3-Treatment of expressed breastmilk 4-Wet nursing | 1-RF if AFASS criteria met 2-Exclusive breastfeeding (EBF) for the first few months of life (up to six months) | 1- EBF unless AFASS criteria fully satisfied 2-Replacement feeding if AFASS criteria satisfied | EBF | EBF | EBF |
All breastfeeding should end | Not discussed | As early as possible | Before 6 months | At 6 months, only if adequate diet is available | At 12 months, only if adequate diet is available | At 12 months, only if adequate diet is available | 24 months or beyond (unrestricted) in the context of full support of ART |
After EBF ends | Not discussed | Replacement feeding | Replacement feeding | Complementary foods can be introduced at 6 months if replacement feeding is not AFASS | Complementary foods should be introduced at 6 months | Complementary foods should be introduced at 6 months | Complementary foods should be introduced at 6 months |
Breastfeeding cessation | Not discussed | Wean as soon as and as quickly as possible | Wean as soon as and as quickly as possible | Wean over a period of 2–3 days up to 2–3 weeks | Wean over a one month period | Wean over a one month period | Wean over a one month period |
Counseling | Encourage breastfeeding | Informed decision by mother based on all available options | Informed decision by mother based on all available options | Simplified counseling: only RF and EBF are discussed. | Recommend a single infant feeding option as the standard of care (though maternal and infant treatment may differ) | Recommend a single infant feeding and maternal and infant treatment option as the standard of care | Recommend a single infant feeding and maternal and infant treatment option as the standard of care |
Key Evidence | Risk of HIV transmission through breastfeeding was thought to be relatively small [7] | A 1992 Meta-analysis revealed that the risk of HIV transmission through breastmilk was much higher than previously described [14] | Results from a 1999 prospective cohort study showed that EBF in first three months had a much lower risk of HIV transmission than mixed feeding and similar to RF [15] | Desire to reduce barriers for pregnant and breastfeeding women to access ART given its demonstrated ability to reduce perinatal HIV transmission [12] |
Methods
Study setting
Participants
Data collection
Data analysis
Results
Characteristic | Median [IQR] or n (%) |
---|---|
Age (years) | 33 [28,35] |
Education | |
Primary school or lower | 14 (70%) |
Some secondary school or higher | 6 (30%) |
Time on ART (years) | 2.3 [1.8,5.1] |
Number of live births | 4 [2,6] |
Number of living children | 3 [2,4] |
Months between pregnancy outcome and interview | 15 [7,21] |
Most recent CD4 cell count (cells/mm3) | 677 [440,767] |
Suppressed plasma viral load (HIV-1 RNA ≤ 400 copies/ml) | 19 (95%) |
I told them I will buy for him [the baby] milk and… I won’t breastfeed him. … [T]he man became mad at me… he had a doctor, his friend, he called me and told me “I beg you, children are these days breastfed. Breastfeed the baby, things changed.” (Participant #3, Age 40).
…if you are to breastfeed only, the child does not get satisfied and they cry all the time… The child cannot survive on milk alone….I was worried because the child was 2 months and I started to give her what to drink [non-breastmilk liquids] but when I came here they told me that I was not supposed to give her anything to drink before she makes 6 months. So I got scared because they told me the gut is not yet stable. She might get an infection and yet you are still breastfeeding her she can easily get ill, so it kept worrying me. (Participant #2, Age 26).
I had stopped [breastfeeding] like two weeks, and I came to the clinic and the doctor said, ‘you know what, you have to start today, you have to resume.’ …She even wrote it [as a prescription]. I kept quiet and I felt so bad, then I kept wondering, they normally say that these other foods can actually hurt the child, most especially the intestines…does she want me to risk my son? ah ah, I won’t risk. (Participant #4, Age 31).
In those months, from one month to 6 months, I kept having worries of breastfeeding him because I … weaned him at 6 months and when I reached…the clinic, the doctor abused me. He said no, “…children are supposed to breastfeed for a year.” I told him …I already weaned. He said “you did bad [stopping breastfeeding]…don’t you see he had just started [breastfeeding].” (Participant #3, Age 40)
Participant (P): Ehh my friend I couldn’t wait [to stop breastfeeding].Interviewer (I): You couldn’t wait, was that a doctor’s recommendation?P: No, because for them they told us one year. … I was like, ‘one year?’... I don’t want to take risks because … I already know what it means [to have a child with HIV], so I said no, let me stop [breastfeeding] and find how to look after him. (Participant #4, Age 31).
I: So in those six months you were breastfeeding him, what were your thoughts at that time?P: I used to pray to God to be the one to protect him. …So that he does not get infected with HIV … because of breastfeeding…. (Participant #10, Age 28).
Let’s say if you continue breastfeeding, they continue testing and testing [for HIV]. But for this one [her child who stopped breastfeeding at 6 months], they will test him again when he is one and a half years…that will be the last test. But when you are still breastfeeding, they keep testing and testing. (Participant #4, Age 31).
I: When they told you the first results were fine, how did you feel?P: I became somehow strong but I knew maybe it is not yet visible…since I am breastfeeding and…I can’t sustain myself [manage] to stop breastfeeding her.I: …you went a second time, how did you feel?P: I became a bit strong but not so strong because she was still breastfeeding, I said I will be strong after getting the final results when she has weaned. (Participant #20, Age 35).
…when I produced him [gave birth], immediately I never breastfeed him. The man begged me, “please breastfeed the baby.” (Participant #3, Age 40).
There is this woman in the village that…will always come to the health facility but she does not want anyone in the family to know [that she is living with HIV]. If she wants to wean the child the mother-in-law says no, and she continues to breastfeed. (Participant #17, age 31).
They say if you…can manage you should buy all the feeds to look after him, including baby formula, yet I did not have the money. (Participant #10, Age 28).
What prevented me most from breastfeeding was HIV. When I see a child with HIV I feel so sad and when you do not have money and add on a child that is sick [HIV-positive], you may fail to raise them. Because an HIV-positive child needs a lot of care… When you see a sick child in the village you pray for them to die so that they can rest. (Participant #17, Age 31).