Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

BACKGROUND

In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.

OBJECTIVES

The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.

METHODS

We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.

RESULTS

From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.

CONCLUSIONS

From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

Breastfeeding, HIV exposure, childhood obesity, and prehypertension: A South African cohort study

BACKGROUND

Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent.

METHODS AND FINDINGS

The Siyakhula cohort (2012-2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother's age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21-0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26-0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38-1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47-10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65-7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall.

CONCLUSIONS

To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women.

Frontline health workers and exclusive breastfeeding guidelines in an HIV endemic South African community: a qualitative exploration of policy translation

Background

Mothers rely heavily on health worker advice to make infant feeding decisions. Confusing or misleading advice can lead to suboptimal feeding practices. From 2001, HIV positive mothers in South Africa were counseled to choose either exclusive breastfeeding or exclusive formula feeding to minimize vertical HIV transmission. On the basis of revised World Health Organization guidelines, the government amended this policy in 2011, by promoting exclusive breastfeeding and discontinuing the provision of free formula. We explored how health workers experienced this new policy in an HIV endemic community in 2015–16, with attention to their knowledge of the policy, counselling practices, and observations of any changes.

Methods

We interviewed eleven health workers, from four community health clinics, who had counseled mothers before and after the policy change. The transcribed interviews were analyzed thematically, using a hybrid coding approach.

Results

The scientific rationale of the policy was not explained to most health workers, who mostly thought that the discontinuation of the formula program was cost-related. The content of their counseling reflected knowledge about promoting breastfeeding for all women, and accordingly they mentioned the nutritional and developmental benefits of breastfeeding. The importance of exclusive breastfeeding for all infants was not emphasized, instead counseling focused on HIV prevention, even for uninfected mothers. The health workers noted an increased incidence of breastfeeding, but some worried that to avoid HIV disclosure, HIV positive mothers were mixed feeding rather than exclusively breastfeeding.

Conclusions

Causal links between the policy, counseling content and feeding practices were unclear. Some participants believed that breastfeeding practices were driven by finance or family pressures rather than the health information they provided. Health workers generally lacked training on the policy’s evidence base, particularly the health benefits of exclusive breastfeeding for non-exposed infants. They wanted clarity on their counseling role, based on individual risk or to promote exclusive breastfeeding as a single option. If the latter, they needed training on how to assist mothers with community-based barriers. Infant feeding messages from health workers are likely to remain confusing until their uncertainties are addressed. Their insights should inform future guideline development as key actors.

Intervening factors in the feeding of infants vertically-exposed to HIV: an integrative review

Objective

To evaluate the available scientific literature on factors that may intervene in the adequate feeding of infants vertically-exposed to HIV.

Methods

This was an integrative review of the literature, performed on the LILACS, PubMed and Scopus databases in February 2017. The search was guided by the question "What are the factors involved in feeding infants vertically-exposed to HIV." Selected studies met the inclusion criteria of being research articles published in English, Portuguese, or Spanish. Articles excluded were those on exclusive breastfeeding. There was no need to perform a temporal cut off of the studies.

Results

In all, the 32 primary studies selected showed that intervening factors were of three types: individual, such as maternal feelings and desires, beliefs, and practical difficulties; social, such as socioeconomic conditions, social support, and stigma; and political, such as health services structure and organization, supplies, health care guidance, and the knowledge and attitudes of health care professionals.

Conclusions

The factors that interfere with feeding infants vertically-exposed to HIV may be independent or associated with each other. To reduce the risk of inadequate nutrition and its associated diseases, actions must be taken to identify and minimize these factors, guaranteeing a better quality of life and reduction of infant morbidity and mortality.

Barriers to infant and child-feeding practices: a qualitative study of primary caregivers in Rural Uganda

The purpose of this study was to explore the barriers to the use of appropriate infant and young child-feeding practices by primary caregivers living in a rural Ugandan district. A community-based qualitative design and focus group discussions were used for collecting data from primary caregivers of children aged 0 to 24 month(s). On an average, each of the four focus group discussions had 11 participants. The focus group discussions were conducted using a structured interview guide and were tape-recorded. The recorded data were later transcribed and analyzed using qualitative thematic analysis techniques. All the participants were females, and the majority had low levels of education and at least one child in the age-group of 0-24 month(s) in their household. The findings show that the main barriers to the use of appropriate infant and young child-feeding practices fall under four themes: caregiver's knowledge about breastfeeding, caregiver's knowledge about complimentary feeding, influence of culture custodians on the caregivers, and patterns and burden of other responsibilities the caregivers have in the household. The four categories of barriers imply that there are various missed opportunities to implement hospital and community-based interventions to improve infant and young child-feeding practices, which is one way of preventing malnutrition. Therefore, in rural areas of Uganda, the major factors responsible for the high prevalence of malnutrition among infants and children are still those related to knowledge, culture, and social status of the primary caregivers.

HIV status, breastfeeding modality at 5 months and postpartum maternal weight changes over 24 months in rural South Africa

OBJECTIVE

To determine the effect of infant feeding practices on postpartum weight change among HIV-infected and -uninfected women in South Africa.

METHODS

In a non-randomised intervention cohort study of antiretroviral therapy-naïve women in South Africa, infants were classified as exclusive (EBF), mixed (MF) or non-breastfed (NBF) at each visit. We analysed infant feeding cumulatively from birth to 5 months using 24-hour feeding history (collected weekly for each of the preceding 7 days). Using generalised estimating equation mixed models, allowing for repeated measures, we compared postpartum weight change (kg) from the first maternal postpartum weight within the first 6 weeks (baseline weight) to each subsequent visit through 24 months among 2340 HIV-infected and -uninfected women with live births and at least two postpartum weight measurements.

RESULTS

HIV-infected (-0.2 kg CI: -1.7 to 1.3 kg; P = 0.81) and -uninfected women (-0.5 kg; 95% CI: -2.1 to 1.2 kg; P = 0.58) had marginal non-significant weight loss from baseline to 24 months postpartum. Adjusting for HIV status, socio-demographic, pregnancy-related and infant factors, 5-month feeding modality was not significantly associated with postpartum weight change: weight change by 24 months postpartum, compared to the change in the reference EBF group, was 0.03 kg in NBF (95% CI: -2.5 to +2.5 kg; P = 0.90) and 0.1 kg in MF (95% CI: -3.0 to +3.2 kg; P = 0.78).

CONCLUSION

HIV-infected and -uninfected women experienced similar weight loss over 24 months. Weight change postpartum was not associated with 5-month breastfeeding modality among HIV-infected and -uninfected women.

Infant feeding counselling of HIV-infected women in two areas in Kenya in 2008

While WHO no longer recommends individual infant feeding counselling to HIV-positive women, it may still be practised in some settings and for specific cases. In any case, lessons can be learned by examining how well front line health workers are able to take on counselling tasks. This qualitative study was designed to assess how counsellors deal with challenges they face in two Kenyan provinces. It consisted of brief post-counselling exit interviews with 80 mothers, observations of 21 counselling sessions and 11 key informant interviews. Much infant feeding counselling was of reasonable quality, better than often reported elsewhere. However, nutrition and infant feeding were given low priority, counsellors' training was inadequate, individual postnatal counselling as well as growth monitoring and promotion were rarely done and complementary feeding was inadequately covered. Acceptable, feasible, affordable, sustainable and safe (AFASS) assessments were not of satisfactory quality. Breast milk expression was mentioned only to a minority and the possibility of heat treatment during the transition to cessation was not mentioned. Counsellors were often biased in discussing risks of breastfeeding and replacement feeding. Implementing the new WHO guidance will reduce the need for AFASS assessments, greatly simplifying both the government's and counsellors' tasks.

Exclusive breastfeeding, diarrhoeal morbidity and all-cause mortality in infants of HIV-infected and HIV uninfected mothers: an intervention cohort study in KwaZulu Natal, South Africa

INTRODUCTION

Antiretroviral drug interventions significantly reduce the risk of HIV transmission to infants through breastfeeding. We report diarrhoea prevalence and all-cause mortality at 12 months of age according to infant feeding practices, among infants born to HIV-infected and uninfected mothers in South Africa.

METHODS

A non-randomised intervention cohort study that followed both HIV-infected and HIV-uninfected mothers and their infants until 18 months of age. Mothers were supported in their infant feeding choice. Detailed morbidity and vital status data were collected over the first year. At the time, only single dose nevirapine was available to prevent mother-to-child transmission of HIV.

RESULTS

Among 2,589 infants, detailed feeding data and vital status were available for 1,082 HIV-exposed infants and 1,155 HIV non-exposed infants. Among exclusively breastfed (EBF) infants there were 9.4 diarrhoeal days per 1,000 child days (95%CI. 9.12-9.82) while among infants who were never breastfed there were 15.6 diarrhoeal days per 1,000 child days (95%CI. 14.62-16.59). Exclusive breastfeeding was associated with fewer acute, persistent and total diarrhoeal events than mixed or no breastfeeding in both HIV-exposed infants and also infants of HIV uninfected mothers. In an adjusted cox regression analysis, the risk of death among all infants by 12 months of age was significantly greater in those who were never breastfed (aHR 3.5, p<0.001) or mixed fed (aHR 2.65, p<0.001) compared with those who were EBF. In separate multivariable analyses, infants who were EBF for shorter durations had an increased risk of death compared to those EBF for 5-6 months [aHR 2.18 (95% CI, 1.56-3.01); p<0.001].

DISCUSSION

In the context of antiretroviral drugs being scaled-up to eliminate new HIV infections among children, there is strong justification for financial and human resource investment to promote and support exclusive breastfeeding to improve HIV-free survival of HIV-exposed and non-exposed infants.

Individual and Community Perspectives, Attitudes, and Practices to Mother-to-Child-Transmission and Infant Feeding among HIV-Positive Mothers in Sub-Saharan Africa: A Systematic Literature Review

OBJECTIVES

International guidelines on infant feeding for HIV- positive mothers promote Exclusive Replacement Feeding (ERF) (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission of HIV and is strongly discouraged. However, little is known about the ability of women to adhere to recommended feeding strategies to prevent mother-to-child transmission (MTCT) of HIV from breast milk. The objective of this study was to assess the individual and community-level factors that affect perspectives, attitudes and practices of HIV-positive mothers on MTCT and infant feeding in sub-Saharan Africa as documented in peer-reviewed and grey literature.

METHODS

This work is based on an extensive review of peer-reviewed articles and grey literature from the period 2000-2012. The literature search was carried out using electronic databases like Medline Ovid, Google Scholar, PubMed and EBSCOhost. Both quantitative and qualitative studies written in English language on HIV and infant feeding with particular emphasis on Sub-Saharan Africa were included.

RESULTS

The review found low adherence to the chosen infant feeding method by HIV-positive mothers. The following factors emerged as influencing infant feeding decisions: cultural and social norms; economic conditions; inadequate counselling; and mother's level of education.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

Unless local beliefs and customs surrounding infant feeding is understood by policy makers and program implementers, Prevention of Mother-to-Child Transmission (PMTCT) programs will only be partially successful in influencing feeding practices of HIV-positive women. Hence programs should provide affordable, acceptable, feasible, safe and sustainable feeding recommendations that do not erode strong cultural practices. Advice to HIV-positive mothers should be based on local conditions that are acceptable to the community.

Vaccines for prevention of mother-to-child transmission of HIV

PURPOSE OF REVIEW

This review outlines data available on HIV immunization for the interruption of mother-to-child transmission of HIV. There is a critical need for low cost, safe, and universally accessible methods to interrupt mother-to-child transmission of HIV in utero, intrapartum and though breastfeeding including when the mother acquires HIV infection while breastfeeding her child. Active immunization is the only strategy with this potential.

RECENT FINDINGS

There are recent findings in three major areas: studies in neonatal macaques, demonstrating encouraging results in terms of providing partial protection from repeat oral SIV and SHIV challenge with active or passive immunization but limited immunologic correlates of protection; safety and immunogenicity of three different canarypox HIV vaccine constructs with and without gp120 envelope subunit boost in infants and studies evaluating the importance of neutralizing antibody in mother-to-child transmission of HIV.

SUMMARY

To protect infants born to HIV-infected women completely an effective prophylactic vaccine is critical. Candidate vaccines tested in this population to date demonstrate safety, tolerability and immunogenicity. Based on the ongoing risk of infection and the tremendous potential for benefit, further studies of candidate vaccines should proceed in this population.

The prevention of mother-to-child transmission of HIV: are we translating scientific success into programmatic failure?

PURPOSE OF REVIEW

The prevention of mother-to-child transmission of HIV stands as one of the first and most successful applications of scientific enquiry in the AIDS epidemic. While paediatric HIV has virtually been eliminated in industrialized countries, nearly 500 000 children were infected worldwide in 2007. This review considers the global successes and failures of prevention of mother-to-child transmission in order to shed light on the key question: why have relevant research advances not yet been successfully implemented in low-resource settings?

RECENT FINDINGS

This review examines the accumulated evidence that has led to the definition of prevention strategies, and corresponding prevention of mother-to-child transmission guidelines. Numerous field implementation reports, in contrast, point to the global lack of success of prevention of mother-to-child transmission programmes and pinpoint key factors which continue to drive their failure, including the low uptake of HIV counselling and testing, continuing postnatal transmission through breastfeeding, and the lack of linkages between prevention of mother-to-child transmission programmes and primary prevention, family planning and, most importantly, the provision of care and treatment.

SUMMARY

Two country examples, Thailand and South Africa, illustrate that political will is the most important factor for the success of prevention of mother-to-child transmission interventions. Much more needs to be done to translate the remarkable prevention of mother-to-child transmission research progress into programme success.

Development of an AFASS assessment and screening tool towards the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa--a Delphi survey

Background

The rate of mother-to-child transmission of HIV, occurring during pregnancy, delivery/labour and breastfeeding, still remains high in Sub-Saharan Africa (SSA). The World Health Organization recommends HIV infected mothers exclusively breastfeed their infants, unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). Health care workers are responsible for providing counselling to mothers on the risks and benefits of infant feeding options allowing mothers to make an ‘informed choice’, but this role is challenging and mostly subjective. The aim of this study was to develop and content validate an AFASS assessment tool that could be used for infant feeding counselling in SSA.

Methods

An AFASS assessment tool was developed based on the evidence and tools available regarding why replacement feeding is not AFASS in SSA (15 questions). Fifty seven experts involved in PMTCT programmes in five SSA countries were approached to participate as members of the Delphi expert panel (purposive sampling and snowballing). A web-based survey, utilising a 4-point Likert scale, was employed to gain consensus (>75% agreement) from the expert panel following the Delphi technique.

Results

A final panel of 15 experts was obtained. Thirteen of the 15 questions in the tool achieved consensus agreement. Experts suggested some additional questions, and that double-barrelled questions were split. Consensus was achieved regarding the applicability and appropriateness of the tool within a SSA context. Experts all agreed that the tool will be useful for the purpose for which it was designed. Suggestions made by the expert panel were incorporated into the revised tool.

Conclusions

The findings of this study confirm that this AFASS counselling tool may be appropriate and useful for SSA. Ideally the revised tool should be tested by providers of infant feeding advice with the aim of adoption into routine PMTCT programmes in SSA. Within the context of the 2010 WHO guidelines which advocate a public health rather than an individualised approach, it may inform the WHO process of improving counselling tools for health care workers involved in PMTCT programmes.

Maternal HIV infection associated with small-for-gestational age infants but not preterm births: evidence from rural South Africa

BACKGROUND

 Human immunodeficiency virus (HIV) is prevalent in many countries where small-for-gestational age (SGA) and premature delivery are also common. However, the associations between maternal HIV, preterm delivery and SGA infants remain unclear. We estimate the prevalence of SGA and preterm (<37 weeks) births, their associations with antenatal maternal HIV infection and their contribution to infant mortality, in a high HIV prevalent, rural area in South Africa.

METHODS

Data were collected, in a non-randomized intervention cohort study, on all women attending antenatal clinics (2001–2004), before the availability of antiretroviral treatment. Newborns were weighed and gestational age was determined (based on last menstrual period plus midwife assessment antenatally). Poisson regression with robust variance assessed risk factors for preterm and SGA birth, while Cox regression assessed infant mortality and associated factors.

RESULTS

Of 2368 live born singletons, 16.6% were SGA and 21.4% were preterm. HIV-infected women (n= 1189) more commonly had SGA infants than uninfected women (18.1 versus 15.1%; P = 0.051), but percentages preterm were similar (21.8 versus 20.9%; P = 0.621). After adjustment for water source, delivery place, parity and maternal height, the SGA risk in HIV-infected women was higher [adjusted relative risk (aRR) 1.28, 95% confidence interval (CI): 1.06–1.53], but the association between maternal HIV infection and preterm delivery remained weak and not significant (aRR: 1.07, 95% CI: 0.91–1.26). In multivariable analyses, mortality under 1 year of age was significantly higher in SGA and severely SGA than in appropriate-for-gestational-age infants [adjusted hazard ratio (aHR): 2.12, 95% CI: 1.18–3.81 and 2.77, 95% CI: 1.56–4.91], but no difference in infant mortality was observed between the preterm and term infants (aHR: 1.18 95% CI: 0.79–1.79 for 34–36 weeks and 1.31, 95% CI: 0.58–2.94 for <34 weeks).

CONCLUSIONS

Maternal HIV infection increases the risk of SGA, but not preterm births, in this cohort.

Effect of using HIV and infant feeding counselling cards on the quality of counselling provided to HIV positive mothers: a cluster randomized controlled trial

Background

Counselling human immunodeficiency virus (HIV) positive mothers on safer infant and young child feeding (IYCF) options is an important component of programmes to prevent mother to child transmission of HIV, but the quality of counselling is often inadequate. The aim of this study was to determine the effect the World Health Organization HIV and infant feeding cards on the quality of counselling provided to HIV positive mothers by health workers about safer infant feeding options.

Method

This was a un-blinded cluster-randomized controlled field trial in which 36 primary health facilities in Kafue and Lusaka districts in Zambia were randomized to intervention (IYCF counselling with counselling cards) or non- intervention arm (IYCF counselling without counselling cards). Counselling sessions with 10 HIV positive women attending each facility were observed and exit interviews were conducted by research assistants.

Results

Totals of 180 women in the intervention group and 180 women in the control group were attended to by health care providers and interviewed upon exiting the health facility. The health care providers in the intervention facilities more often discussed the advantages of disclosing their HIV status to a household member (RR = 1.46, 95% CI [1.11, 1.92]); used visual aids in explaining the risk of HIV transmission through breast milk (RR = 4.65, 95% CI [2.28, 9.46]); and discussed the advantages and disadvantages of infant feeding options for HIV positive mothers (all p values < 0.05). The differences also included exploration of the home situation (p < 0.05); involving the partner in the process of choosing a feeding option (RR = 1.38, 95% CI [1.09, 1.75]); and exploring how the mother will manage to feed the baby when she is at work (RR = 2.82, 95% CI [1.70, 4.67]). The clients in the intervention group felt that the provider was more caring and understanding (RR = 1.81, 95% CI [1.19, 2.75]).

Conclusion

The addition of counselling cards to the IYCF counselling session for HIV positive mothers were a valuable aid to counselling and significantly improved the quality of the counselling session.

Drinking water quality, feeding practices, and diarrhea among children under 2 years of HIV-positive mothers in peri-urban Zambia

In low-income settings, human immunodeficiency virus (HIV)-positive mothers must choose between breastfeeding their infants and risking transmission of HIV or replacement feeding their infants and risking diarrheal disease from contaminated water. We conducted a cross-sectional study of children < 2 years of age of 254 HIV-positive mothers in peri-urban Zambia to assess their exposure to waterborne fecal contamination. Fecal indicators were found in 70% of household drinking water samples. In a multivariable analysis, factors associated with diarrhea prevalence in children < 2 years were mother having diarrhea (adjusted odds ratio [aOR] = 5.18, 95% confidence interval [CI] = 1.65-16.28), child given water in the past 2 days (aOR = 4.08, 95% CI = 1.07-15.52), child never being breastfed (aOR = 2.67, 95% CI = 1.06-6.72), and rainy (versus dry) season (aOR = 4.60, 95% CI = 1.29-16.42). Children born to HIV-positive mothers were exposed to contaminated water through direct intake of drinking water, indicating the need for interventions to ensure microbiological water quality.

Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme

OBJECTIVES

To evaluate the infant-feeding choices, practices and possible determinants among HIV-positive women enrolled in a prevention of mother-to-child transmission programme in Ibadan, Nigeria.

METHODS

A cross-sectional survey involving HIV-positive women who had received infant-feeding counselling prior to delivery. A structured questionnaire was administered at < or = 72 hrs and not > or = 6 weeks of delivery and was complemented with an in-depth interview.

RESULTS

A total of 241 women were studied. The choice of infant feeding was formula for 223 (93.5%) and in actual practice, 9 (3.7%) mothers admitted mixed feeding. There was no statistical significant difference between the feeding pattern and the socio-demographic characteristics. The major factor influencing the choice of infant feeding was "The desire to reduce the risk of transmission" which was recorded among 204 (84.6%) of the women. Greatest support in maintaining infant-feeding option was the spouse (36.1%). From the in-depth interview of 23 non-breastfeeding (infant formula) mothers, the major challenge faced was stigmatisation.

CONCLUSION

Despite the premium placed on breastfeeding in this locality, with infant-feeding counselling, most HIV-positive women chose and practiced formula feeding. It is necessary to address how best HIV-positive mothers could handle or overcome criticisms and stigmatisation by others.

Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than 6 months in Mozambique: a qualitative study

Only 37% of infants younger than 6 months in Mozambique are exclusively breastfed. A qualitative assessment was undertaken to identify the knowledge, beliefs, and practices around exclusive breastfeeding--specifically, those of mothers, fathers, grandmothers, and nurses--and to identify the support networks. Results show many barriers. In addition to receiving breast milk, infants receive water, traditional medicines, and porridges before 6 months of age. Many mothers had heard of the recommendation to exclusively breastfeed for 6 months. However, other family decision makers had heard less about exclusive breastfeeding, and many expressed doubts about its feasibility. Some of them expressed willingness to support exclusive breastfeeding if they were informed by health workers. Nurses know the benefits of exclusive breastfeeding and pass this information on verbally but have insufficient counseling skills. Interventions to improve exclusive breastfeeding should target family and community members and include training of health workers in counseling to resolve breastfeeding problems.

Changing methods of disclosure. Literature review of disclosure to children with terminal illnesses, including HIV

More than 30 years after the first discovery of the deadly HIV virus, and in the wake of increased knowledge of transmission, treatment and behavioral intervention development, parents are still faced with the difficult task of whether, when and how to inform their child about her or his HIV status. Except for some general ethical considerations, there are no national or international guidelines available for handling HIV status disclosure to a child by parents and health professionals. Most studies on disclosure address the problem of stigma and the barriers to disclosure of HIV-positive status by adults to their sexual partners, caretakers, families and communities, but very few studies focus on disclosure to HIV-positive children. The majority of the studies that address disclosure to children limit themselves to stipulating reasons for barriers to such disclosure instead of the skills and knowledge necessary for effective disclosure to a child. Increasing availability of therapy for HIV across the world presses the issue of disclosure to the child. Even so, disclosure for children who are HIV-positive due to vertical transmission continues to be very difficult. There is a lack of interventions that consider guidelines for healthcare professionals, parents or persons involved with taking care of HIV-positive children. These interventions should be designed in an understanding manner towards the culture where they might be implemented and be as appropriate in the view of integrating different family structures and the child's development.

Survival and health benefits of breastfeeding versus artificial feeding in infants of HIV-infected women: developing versus developed world

Infant feeding policies for HIV-infected women in developing countries differ from policies in developed countries. This article summarizes the epidemiologic data on the risks and benefits of various infant feeding practices for HIV-infected women living in different contexts. Artificial feeding can prevent a large proportion of mother-to-child HIV transmission but also is associated with increases in morbidity and mortality among exposed-uninfected and HIV-infected children. Antiretroviral drugs can be used during lactation and reduce risks of transmission. For most of the developing world, the health and survival benefits of breastfeeding exceed the risks of HIV transmission, especially when antiretroviral interventions are provided.

A cluster randomised controlled trial of the community effectiveness of two interventions in rural Malawi to improve health care and to reduce maternal, newborn and infant mortality

BACKGROUND

The UN Millennium Development Goals call for substantial reductions in maternal and child mortality, to be achieved through reductions in morbidity and mortality during pregnancy, delivery, postpartum and early childhood. The MaiMwana Project aims to test community-based interventions that tackle maternal and child health problems through increasing awareness and local action.

METHODS/DESIGN

This study uses a two-by-two factorial cluster-randomised controlled trial design to test the impact of two interventions. The impact of a community mobilisation intervention run through women's groups, on home care, health care-seeking behaviours and maternal and infant mortality, will be tested. The impact of a volunteer-led infant feeding and care support intervention, on rates of exclusive breastfeeding, uptake of HIV-prevention services and infant mortality, will also be tested. The women's group intervention will employ local female facilitators to guide women's groups through a four-phase cycle of problem identification and prioritisation, strategy identification, implementation and evaluation. Meetings will be held monthly at village level. The infant feeding intervention will select local volunteers to provide advice and support for breastfeeding, birth preparedness, newborn care and immunisation. They will visit pregnant and new mothers in their homes five times during and after pregnancy.The unit of intervention allocation will be clusters of rural villages of 2500-4000 population. 48 clusters have been defined and randomly allocated to either women's groups only, infant feeding support only, both interventions, or no intervention. Study villages are surrounded by 'buffer areas' of non-study villages to reduce contamination between intervention and control areas. Outcome indicators will be measured through a demographic surveillance system. Primary outcomes will be maternal, infant, neonatal and perinatal mortality for the women's group intervention, and exclusive breastfeeding rates and infant mortality for the infant feeding intervention.Structured interviews will be conducted with mothers one-month and six-months after birth to collect detailed quantitative data on care practices and health-care-seeking. Further qualitative, quantitative and economic data will be collected for process and economic evaluations.

TRIAL REGISTRATION

ISRCTN06477126.

Breastfeeding, HIV status and weights in South African children: a comparison of HIV-exposed and unexposed children

OBJECTIVES

To examine growth of children by maternal and infant HIV status allowing for infant feeding mode.

DESIGN

Women enrolled into a nonrandomized intervention cohort.

METHODS

Children of HIV-infected and uninfected women weighed and assessed for HIV status, monthly: from birth to 9 months; quarterly: 10-24 months. Daily infant feeding practices recorded at weekly intervals. Weight-for-age z-scores of children born to HIV-infected mothers compared with the reference population of children of HIV-uninfected mothers. Changes in z-scores over age were examined by HIV infection status and infant feeding practice using linear mixed effects models.

RESULTS

The 1261 children of HIV-infected mothers grew as well as the reference group of 1061 children of HIV-uninfected mothers, irrespective of feeding mode. z-scores for HIV-infected children were consistently lower than those of HIV-exposed but uninfected children: a difference of 420 g for male children and 405 g for female children at 52 weeks of age. Breastfed HIV-infected infants had consistently higher z-scores for weight, especially during first 6 weeks (difference of 130 g for male children; 110 g for female children). In an adjusted regression analysis, maternal mid-upper arm circumference, CD4 cell count, infant birth weight and HIV status had the biggest impact on infant growth (z-score coefficient: 0.38 for mid-upper arm circumference > or =28.35 vs. <25.7 cm; P < 0.001; -0.32 for CD4 cell count <200 vs. > or =500; P = 0.001; -2.01 for birth weight <2500 vs. > or =2500 g; P < 0.001; -0.20 for infected vs. uninfected children; P < 0.001).

CONCLUSION

Optimal early feeding practices ameliorate the effect of being born to an HIV-infected mother and strengthen the recommendation of exclusive breastfeeding for HIV-infected women in terms of long-term child health.

Predictors of breastfeeding cessation among HIV-infected women in Dar es Salaam, Tanzania

This paper examines predictors of breastfeeding cessation among a cohort of human immunodeficiency virus (HIV)-infected women. This was a prospective follow-up study of HIV-infected women who participated in a randomized micronutrient supplementation trial conducted in Dar es Salaam, Tanzania. 795 HIV-infected Tanzanian women with singleton newborns were utilized from the cohort for this analysis. The proportion of women breastfeeding declined from 95% at 12 months to 11% at 24 months. The multivariate analysis showed breastfeeding cessation was significantly associated with increasing calendar year of delivery from 1995 to 1997 [risk ratio (RR), 1.36; 95% confidence interval (CI) 1.13-1.63], having a new pregnancy (RR 1.33; 95% CI 1.10-1.61), overweight [body mass index (BMI) ≥25 kg m(-2) ; RR 1.37; 95% CI 1.07-1.75], underweight (BMI <18.5kg m(-2) ; RR 1.29; 95% CI 1.00-1.65), introduction of cow's milk at infant's age of 4 months (RR 1.30; 95% CI 1.04-1.63). Material and social support was associated with decreased likelihood of cessation (RR 0.83; 95% CI 0.68-1.02). Demographic, health and nutritional factors among women and infants are associated with decisions by HIV-infected women to cease breastfeeding. The impact of breastfeeding counselling programs for HIV-infected African women should consider individual maternal, social and health contexts.

Duration, pattern of breastfeeding and postnatal transmission of HIV: pooled analysis of individual data from West and South African cohorts

Background

Both breastfeeding pattern and duration are associated with postnatal HIV acquisition; their relative contribution has not been reliably quantified.

Methodology and Principal Findings

Pooled data from 2 cohorts: in urban West Africa where breastfeeding cessation at 4 months was recommended but exclusive breastfeeding was rare (Ditrame Plus, DP); in rural South Africa where high rates of exclusive breastfeeding were achieved, but with longer duration (Vertical Transmission Study, VTS). 18-months HIV postnatal transmission (PT) was estimated by Kaplan-Meier in infants who were HIV negative, and assumed uninfected, at age >1 month. Censoring with (to assess impact of mode of breastfeeding) and without (to assess effect of breastfeeding duration) breastfeeding cessation considered as a competing event. Of 1195 breastfed infants, not HIV-infected perinatally, 38% DP and 83% VTS children were still breastfed at age 6 months. By age 3 months, 66% of VTS children were exclusively breastfed since birth and 55% of DP infants predominantly breastfed (breastmilk+water-based drinks). 18-month PT risk (95%CI) in VTS was double that in DP: 9% (7–11) and 5% (3–8), respectively (p = 0.03). However, once duration of breastfeeding was allowed for in a competing risk analysis assuming that all children would have been breastfed for 18-month, the estimated PT risk was 16% (8–28) in DP and 14% (10–18) in VTS (p = 0.32). 18-months PT risk was 3.9% (2.3–6.5) among infants breastfed for less than 6 months, and 8.7% (6.8–11.0) among children breastfed for more than 6 months; crude hazard ratio (HR): 2.1 (1.2–3.7), p = 0.02; adjusted HR 1.8 (0.9–3.4), p = 0.06. In individual analyses of PT rates for specific breastfeeding durations, risks among children exclusively breastfed were very similar to those in children predominantly breastfed for the same period. Children exposed to solid foods during the first 2 months of life were 2.9 (1.1–8.0) times more likely to be infected postnatally than children never exposed to solids this early (adjusted competing risk analysis, p = 0.04).

Conclusions

Breastfeeding duration is a major determinant of postnatal HIV transmission. The PT risk did not differ between exclusively and predominantly breastfed children; the negative effect of mixed breastfeeding with solids on PT were confirmed.

Need for timely paediatric HIV treatment within primary health care in rural South Africa

BACKGROUND

In areas where adult HIV prevalence has reached hyperendemic levels, many infants remain at risk of acquiring HIV infection. Timely access to care and treatment for HIV-infected infants and young children remains an important challenge. We explore the extent to which public sector roll-out has met the estimated need for paediatric treatment in a rural South African setting.

METHODS

Local facility and population-based data were used to compare the number of HIV infected children accessing HAART before 2008, with estimates of those in need of treatment from a deterministic modeling approach. The impact of programmatic improvements on estimated numbers of children in need of treatment was assessed in sensitivity analyses.

FINDINGS

In the primary health care programme of HIV treatment 346 children <16 years of age initiated HAART by 2008; 245(70.8%) were aged 10 years or younger, and only 2(<1%) under one year of age. Deterministic modeling predicted 2,561 HIV infected children aged 10 or younger to be alive within the area, of whom at least 521(20.3%) would have required immediate treatment. Were extended PMTCT uptake to reach 100% coverage, the annual number of infected infants could be reduced by 49.2%.

CONCLUSION

Despite progress in delivering decentralized HIV services to a rural sub-district in South Africa, substantial unmet need for treatment remains. In a local setting, very few children were initiated on treatment under 1 year of age and steps have now been taken to successfully improve early diagnosis and referral of infected infants.

An update on HIV and infant feeding issues in developed and developing countries

The field of mother to child transmission of human-immunodeficiency virus is rapidly evolving. In the United States, prevention focuses on implementation of universal human-immunodeficiency virus testing to assure compliance with recommended treatment regimens and infant-feeding strategies. In most cases, this is the avoidance of all breastfeeding. In developing countries, avoidance of breastfeeding places infants at higher risk of morbidity and mortality. Current World Health Organization recommendations require individualized counseling to determine the best feeding method for each woman.

Operational effectiveness of guidelines on complete breast-feeding cessation to reduce mother-to-child transmission of HIV: results from a prospective observational cohort study at routine prevention of mother-to-child transmission sites, South Africa

OBJECTIVE

Until 2006, HIV-positive women who chose to exclusively breast-feed were advised to completely stop breast-feeding by 6 months. We investigated operational feasibility and predictors of complete breast-feeding cessation (CBC).

DESIGN

A prospective observational cohort study at 3 routine prevention of mother-to-child transmission sites, South Africa.

METHODS

Data on "complete breast-feeding cessation at 24 weeks" and "not breast-feeding (NBF) for 4 days before the last follow-up visit at or before 24 weeks" were gathered during home visits (3, 5, 7, 9, 12, 16, 20, and 24 weeks). The main subgroup of interest for this analysis was women practicing exclusive breast-feeding/predominant breast-feeding at 3 weeks. Univariate analysis, logistic regression, Kaplan-Meier Survival analysis, and Cox regression were performed.

RESULTS

Eighty-eight women (43.6%) reported CBC. "Health staff suggesting formula use: [OR(a) 4.39 (1.76-10.97)] and "infant hospitalization" [OR(a) 3.27 (1.37-7.79)] were the only significant predictors of CBC. The probability of NBF at 5, 7, 9, 12, 16, 20, and 24 weeks was 2.8% [95% confidence interval (CI) 1.8% to 3.8%], 4.3% (3.0% to 5.6%), 5.9% (4.4% to 7.4%, 9.8% (7.9% to 11.7%), 16.1 (13.8% to 18.4%), 23.1% (20.5% to 25.7%), and 37.6% (34.6% to 40.6%), respectively. Infant HIV status [hazard ratio 5.5 95% CI 2.4 to 12.5] was the only predictor of infant death. NBF was not protective against 9-month infant HIV or death in univariate and multivariable analysis.

CONCLUSIONS

At programmatic level, CBC by 24 weeks is uncommon, and success seems unrelated to predetermined social, economic, and environmental (acceptable, feasible, affordable, sustainable, and safe AFASS) criteria. Thus at this level, activities that encourage CBC (amongst women meeting AFASS criteria) need to be identified and tested.

Preventing mother-to-child transmission of HIV in resource-limited settings

Mother-to-child transmission (MTCT) before, during and after delivery may result in the acquisition of HIV for 30–35% of infants of HIV-infected mothers. Peripartum HIV transmission can be reduced to under 5% in resource-limited settings using a feasible prophylactic antiretroviral regimen. Reducing postnatal transmission through breastfeeding, whilst maintaining child survival, is an urgent priority, given that breastfeeding causes one-third to one-half of all infant HIV infections. Recent evidence highlights the impact of breastfeeding duration and pattern, and hazards associated with the avoidance of breastfeeding in different settings. New international guidelines on HIV and infant feeding have been published. Despite knowledge of how to reduce MTCT of HIV in resource-poor settings, an unacceptably low proportion of women access prevention of MTCT services (PMTCT); follow-up of women and children is poor. To improve survival of mothers and children, health services need to be strengthened, with the integration of PMTCT into existing maternal and child health services.

Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs

This study aimed to describe the prevalence and predictors for male partner participation in HIV voluntary counselling and testing (VCT) at two primary healthcare clinics in Moshi urban, Tanzania as well as the effect of partner participation on uptake of HIV perinatal interventions. Pregnant women (n = 2654) in their third trimester, participating in a prevention of mother to child tranmission (PMTCT) program between June 2002 and March 2004 were encouraged to inform and invite their partners for HIV-VCT. Trained nurses conducted pre-test counselling, interviews, clinical examinations and blood sampling from the participating women and their partners. Test results were presented and post-test counselling was conducted individually or in couples, depending on the wishes of the participants. Three-hundred-and-thirty-two male partners (12.5%) came for HIV-VCT. A high proportion (131; 40%) came after the woman had delivered. HIV-seropositive women whose partners attended were three times more likely to use Nevirapine prophylaxis, four times more likely to avoid breastfeeding and six times more likely to adhere to the infant feeding method selected than those whose partners didn't attend. Women were more likely to bring their partner for VCT if they collected their own test results, were living with their partner, had a high monthly income and had expressed at enrolment the intention to share HIV results with their partner. Although PMTCT programs are presumably a good entry point for male involvement in prevention of sexual and perinatal HIV transmission, this traditional clinic-based approach reaches few men. Given the positive influence male participation has on the acceptance of perinatal interventions, a different approach for promoting male participation in VCT is urgently required. Within PMTCT programs, counseling should emphasize the advantages of partner participation to encourage women to inform and convince male partners to come for VCT. Also, promotion of couple VCT outside antenatal settings in male friendly and accessible settings should be given priority.

Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes

OBJECTIVES

To determine the late HIV transmission and survival risks associated with early infant feeding practices.

DESIGN

A nonrandomized intervention cohort.

METHODS

HIV-infected pregnant women were supported in their infant feeding choices. Infant feeding data were obtained weekly; blood samples from infants were taken monthly to diagnose HIV infection. Eighteen-month mortality and HIV transmission risk were assessed according to infant feeding practices at 6 months.

RESULTS

One thousand one hundred and ninety-three live-born infants were included. Overall 18-month probabilities of death (95% confidence interval) were 0.04 (0.03-0.06) and 0.53 (0.46-0.60) for HIV-uninfected and HIV-infected children, respectively. The eighteen-month probability of survival was not statistically significantly different for HIV-uninfected infants breastfed or replacement fed from birth. In univariate analysis of infant feeding practices, the probability of HIV-free survival beyond the first 6 months of life in children alive at 6 months was 0.98 (0.89-1.00) amongst infants replacement fed from birth, 0.96 (0.90-0.98; P = 0.25) and 0.91 (0.87-0.94; P = 0.03) in those breastfed for less or more than 6 months, respectively. In multivariable analyses, maternal unemployment and low antenatal CD4 cell count were independently associated with more than three-fold increased risk of infant HIV infection or death.

CONCLUSION

Breastfeeding and replacement feeding of HIV-uninfected infants were associated with similar mortality rates at 18 months. However, these findings were amongst mothers and infants who received excellent support to first make, and then practice, appropriate infant feeding choices. For programmes to achieve similar results, the quality of counselling and identification of mothers with low CD4 cell count need to be the targets of improvement strategies.

Scaling-up exclusive breastfeeding support programmes: the example of KwaZulu-Natal

Background

Exclusive breastfeeding (EBF) for six months is the mainstay of global child health and the preferred feeding option for HIV-infected mothers for whom replacement feeding is inappropriate. Promotion of community-level EBF requires effective personnel and management to ensure quality counselling and support for women. We present a costing and cost effectiveness analysis of a successful intervention to promote EBF in high HIV prevalence area in South Africa, and implications for scale-up in the province of KwaZulu-Natal.

Methods and Findings

The costing of the intervention as implemented was calculated, in addition to the modelling of the costs and outcomes associated with running the intervention at provincial level under three different scenarios: full intervention (per protocol), simplified version (half the number of visits compared to the full intervention; more clinic compared to home visits) and basic version (one third the number of visits compared to the full intervention; all clinic and no home visits). Implementation of the full scenario costs R95 million ($14 million) per annum; the simplified version R47 million ($7 million) and the basic version R4 million ($2 million). Although the cost of the basic scenario is less than one tenth of the cost of the simplified scenario, modelled effectiveness of the full and simplified versions suggest they would be 10 times more effective compared to the basic intervention. A further analysis modelled the costs per increased month of EBF due to each intervention: R337 ($48), R206 ($29), and R616 ($88) for the full, simplified and basic scenarios respectively. In addition to the average cost effectiveness the incremental cost effectiveness ratios associated with moving from the less effective scenarios to the more effective scenarios were calculated and reported: Nothing – Basic R616 ($88), Basic – Simplified R162 ($23) and Simplified – Full R879 ($126).

Conclusions

The simplified scenario, with a combination of clinic and home visits, is the most efficient in terms of cost per increased month of EBF and has the lowest incremental cost effectiveness ratio.

Infant feeding and prevention of mother-to-child transmission of HIV-1

PURPOSE OF REVIEW

To review new studies and directions regarding infant feeding and HIV-1 transmission.

RECENT FINDINGS

With antiretroviral drugs and shortened breastfeeding, breast milk HIV-1 transmission risk can be decreased from 16 to less than 5%. In the context of peripartum antiretroviral drugs/short breastfeeding, replacement feeding provides negligible benefit in decreasing the risk of HIV-1/death in contrast to previous studies of no antiretroviral drugs/unlimited breastfeeding in which it offered benefit. One study noted a high risk of infant HIV-1 or death (>/=17%) after 4 months, with no difference in risk in infants with shortened breastfeeding versus indefinite breastfeeding. This study suggests that shortened breastfeeding needs caution in implementation. Other African studies have noted minimal risk of HIV-1 or death (< 2%) after shortened breastfeeding, underscoring the heterogeneity of infant survival in different settings and the potential to improve infant survival.

SUMMARY

Antiretroviral drugs and shortened breastfeeding markedly decrease breastfeeding HIV-1 transmission, shifting the balance to make replacement feeding less beneficial. In some settings shortened breastfeeding poses similar risks as replacement feeding and provides no infant health benefit compared with extended breastfeeding. Programmes aimed at decreasing infant HIV-1 need to do so in the context of promoting infant survival. Strengthening systems to promote infant health is critical.

Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa

BACKGROUND

Breast problems, including mastitis, can interfere with the duration and exclusivity of breast-feeding. However, there are no large prospective studies documenting the prevalence, duration, and timing of such problems in breast-feeding women, particularly those who are infected with human immunodeficiency virus (HIV).

METHODS

Women enrolled prenatally underwent a breast-feeding counseling intervention until 6 months after delivery. Breast health problems were documented per breast for 180 days after delivery, with 14-day recall histories.

RESULTS

Breast health problems were rare, and there were no significant differences between HIV-infected and HIV-uninfected women for any of the following conditions: engorgement, 39 HIV-infected women (3.5%) versus 33 HIV-uninfected women (2.7%; P=.30); breast thrush, 17 (1.5%) versus 12 (1.0%; P=.25); bleeding nipple, 6 (0.5%) versus 4 (0.3%; P=.45); and mastitis/abscess, 11 (1.0%) versus 6 (0.5%; P=.17). Most problems occurred during the first month after birth, with few additional mothers experiencing problems after this point: at 1 and 6 months, 13% and 17% of all mothers, respectively, had experienced a minor or major breast health problem, including sore nipples. Women who had not exclusively breast-fed their infants were more likely to experience any of the breast health problems than were women who had exclusively breast-fed their infants (time-dependent variable; adjusted odds ratio, 1.46; 95% confidence interval, 1.13-1.87; P=.003). HIV-infected women who experienced any serious breast health problem (i.e., bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess) were 3.55 times (95% confidence interval, 0.86-14.78 times; P=.08) more likely to transmit HIV postnatally to their infant.

CONCLUSIONS

With encouragement to exclusively breast-feed, women experienced few breast health problems. When those problems did occur, HIV-infected women with bleeding nipple, pus oozing from a nipple or breast, or mastitis/abscess were more likely to transmit HIV to their infants.

Preserving breastfeeding practice through the HIV pandemic

Breastfeeding, particularly for the first 6 months of life, is unquestionably the ideal way to feed most infants. However, the human immunodeficiency virus (HIV) pandemic has caused debate and confusion about the best way for HIV-positive mothers to feed their children. This review provides recent key findings and opinions around making breastfeeding safer for HIV-positive women, and argues for preservation of breastfeeding, as opposed to complete avoidance of breastfeeding for all HIV-positive women.