WHO official explains stand on breastfeeding and HIV at international Lactation Consultants meeting

by Lenore Goldfarb

At the International Lactation Consultants Association Conference in Sydney, Australia this summer (2003), Lenore attended a lecture by James Akre of the World Health Organization (WHO), which included the WHO’s position on breastfeeding by HIV-positive mothers. Mr. Akre pointed out that this issue is not limited to third world countries but is in fact a global crisis with millions of children whose parents die of AIDS, leaving them behind. Some of these children are themselves infected. Many of these children reside in the West.

The case he presented concerned a father who contracted HIV though contaminated products to treat his haemophilia. He passed the virus on to his pregnant wife, who in turn passed the virus on to her unborn child. The entire family was wiped out except for their 12-year-old daughter, who became an AIDS orphan.

There is evidence that HIV can pass into breastmilk and infect the breastfeeding baby. But that is not the sole route of transmission. HIV can pass to the unborn foetus during pregnancy, or to the baby during birth as well. Health authorities in the United States recommend that an HIV-positive mother not breastfeed provided that there is an ample supply of artificial infant milk. If it is in powdered form, there must also be a safe, clean, ample supply of fresh water. This is sadly often not the case in developing countries and so the WHO recommendation is for exclusive breastfeeding for 6 months and then rapid weaning.

The rationale for this recommendation is that infants of HIV-positive mothers are far more likely to die from contaminated artificial infant milk than from transmission of HIV from their mothers. Previously it was thought that there is a 3% probability of transmission of HIV to the infant but James Akre quoted a 15% probability. The probability rises sharply after 6 months of exclusive breastfeeding or for those infants who are fed a combination of their mother’s milk and artificial infant milk and for that reason, the WHO recommends rapid weaning at 6 months. In spite of the 15% probability of transmission, WHO recommends the above because the benefits of breastfeeding far exceed the risk of illness and death by contaminated artificial infant milk.

It stands to reason that adoptive mothers are open to the risk of infection by babies of HIV-positive mothers if the infant is infected and breastfeeding is managed poorly. A poor latch can damage the mother’s nipples, with the broken tissue offering a site for transmission of the virus and subsequent infection. Proper assistance and good breastfeeding management can drastically reduce this risk. If the mother can bring in her milk supply, she can reduce her baby’s need for supplementation and further reduce the risks associated with the use of artificial infant milk.

La Leche League International released the following statement on July 4, 2001:

“La Leche League International acknowledges the worldwide challenge of making informed infant feeding decisions when HIV transmission is a consideration. Parents and health care providers are urged to weigh the well-known, documented health and emotional benefits of human milk and breastfeeding for both mother and child against the known, documented health hazards of breast milk substitutes, the rates of childhood illness and death from infectious diseases in the mother’s area of the world, and the incomplete understanding of the risk of HIV transmission through human milk. La Leche League International challenges the scientific community to undertake the research necessary to fully define the role of breastfeeding and human milk in HIV transmission and infant protection.

“In general, for women who know they are HIV-positive and where infant mortality is high, exclusive breastfeeding may result in fewer infant deaths than feeding breast milk substitutes and remains the preferred feeding approach. While breastfeeding where infant mortality is low may also carry a risk of HIV transmission for infants whose mothers test HIV positive, there is no clear, published evidence that feeding breast milk substitutes results in lower infant morbidity and mortality in any infants.

“The social costs of not breastfeeding also must be considered. When a woman gives breast milk substitutes in a culture where breastfeeding is traditional, her community may suspect that she is HIV-positive, potentially putting her at risk for physical abuse, ostracism, and abandonment. In most parts of the world women do not know their HIV status, therefore ongoing support of exclusive breastfeeding is most appropriate and much needed.

“While current scientific thinking accepts a risk of vertical transmission with breastfeeding in general, research studies that fully define the role of breastfeeding patterns (particularly exclusive breastfeeding and optimal breastfeeding management) and related maternal and child health on HIV transmission have not yet been done.

“LLLI is not making a recommendation about breastfeeding for HIV-positive mothers at this time due to the inconclusive nature of the research and its various interpretations.”