Revised WHO Principles And Recommendations On HIV And Infant Feeding (Rapid Advice: November 2009)

Nutrition News for Africa

Background

Additional research and programmatic evidence has accumulated regarding HIV/AIDS treatment and care since the World Health Organization (WHO) last revised its recommendations on infant feeding in the context of HIV in 2006. In particular, new studies have found that antiretroviral (ARV) treatment provided to either the HIV-infected mother or the HIV-exposed infant can substantially reduce the risk of post-natal transmission of HIV through breastfeeding. Because of the importance of these findings for national HIV treatment and infant feeding guidelines, WHO has just released three rapid advice recommendations concerning these issues. The specific topics covered are: 1) antiretroviral therapy (ART) for HIV infection in adolescents and adults; 2) the use of ART for treating pregnant women and preventing HIV Infection in infants; and 3) the principles and recommendations on infant feeding in the context of HIV. Readers are encouraged to obtain all three rapid advice recommendations at: http://www.who.int/hiv/en/. 

The current issue of NNA summarizes the new WHO recommendations regarding infant feeding in the context of HIV.

Summary of Recommendations

A total of 8 key principles and 7 key recommendations were developed for the new set of WHO guidelines. These principles and recommendations are directed towards policy makers, academics, and health workers; and they are intended to assist national technical groups and international partners in formulating infant feeding recommendations in the context of HIV. The principles reflect a set of values regarding the provision of care; and the most important key principle is that infant feeding practices by mothers known to be HIV-infected should support the greatest likelihood of HIV-free survival of their children and not harm the health of mothers. This principle is meant to balance the risk of infants acquiring HIV through breast milk with the higher risk of dying from other causes, such as diarrhea and lower respiratory tract infections, due to the elevated risk of these non-HIV related diseases among infants who are not breastfed. 

The 7 key recommendations are summarized, as follows:

1.    HIV-infected mothers should be provided with lifelong ART's or antiretroviral prophylaxis interventions to reduce HIV transmission through breast milk. (The specific recommendations on the use of anti-retroviral drugs for treating pregnant women and preventing transmission of HIV infection to infants can be found at: http://www.who.int/hiv/topics/mtct/. Briefly, to prevent HIV transmission to infants via breastfeeding, either: 1) the mother should receive AZT during pregnancy, and the infant should receive daily Nevirapine from birth until the cessation of breastfeeding; or 2) the mother should receive a 3-drug regimen during pregnancy, and this maternal regimen should be continued until the cessation of breastfeeding.)  

2.    HIV-infected mothers with uninfected infants (or infants with unknown HIV status) should exclusively breastfeed for the first 6-months, after which appropriate complementary foods should be introduced. Breastfeeding should be continued through 12 months of life, and should be stopped only after nutritionally adequate and safe dietary alternatives can be provided.

3.    Abruptly stopping breastfeeding is not advisable. HIV-infected mothers who decide to stop breastfeeding should gradually stop over the course of approximately one month. If the mother or child has been taking prophylaxis medications, this treatment should continue for at least one week after stopping breastfeeding.   

4.    Infants of HIV-infected mothers who stop breastfeeding should be provided with safe and adequate replacement feeds to enable normal growth.

5.    HIV-infected mothers with uninfected infants (or infants with unknown HIV status) should only provide commercial infant formula milk as a breast milk replacement if the milk replacement is: affordable, feasible, acceptable, sustainable, and safe (AFASS).

6.    HIV-infected mothers should consider expressing and heat-treating breast milk as an interim strategy in special circumstances, to assist with stopping breastfeeding, or if ART is temporarily unavailable.

7.    HIV-infected infants and young children should be exclusively breastfed for the first 6-months of life, and continue breastfeeding up to 2-years or beyond.

Program Implications

New evidence indicating that provision of ART to either HIV-infected mothers or HIV-exposed infants can markedly reduce or eliminate HIV transmission through breast milk has major implications for infant and young child feeding recommendations. The specifically recommended ART regimens are described on the WHO web site indicated above. If these recommendations are effectively implemented, they should yield improvements in the quality of life and survival of women living with HIV and important reductions in HIV transmission and deaths due to HIV/AIDS and other causes in young children. 

Editorial Comments*

Since the late 1980's it has been known that exclusive breastfeeding of non-HIV exposed infants decreases the incidence of diarrhea and pneumonia and reduces infant mortality; and ongoing breast feeding beyond six months continues to reduce these risks, even into the second year of life. However, infant feeding studies in the context of HIV have indicated that mother-to-child-transmission of HIV (MTCT) can occur via breast milk. As a result, earlier recommendations in settings with high HIV prevalence emphasized the use of replacement feeds when AFASS, to avoid the risk of MTCT of HIV. However, newer data have since shown that children who receive replacement feeds are at greater risk of other (non-HIV) infections and death. Therefore, when developing infant feeding recommendations in the context of HIV, both the risk of HIV transmission and the risk of death from other causes must be considered.

 For these reasons, the new WHO infant feeding recommendations aim to maximize HIV-free survival time. Because the latest studies show that the risk MTCT of HIV via breast milk can be reduced or eliminated if the mother and/or child are given ART, it is now possible to recommend usual breast feeding practices in most cases, as with children of HIV-negative mothers.

* These comments have been added by the editorial team and are not part of the cited publication.