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HIV Transmission Through Breastfeeding HIV transmission through breastfeeding For further information, please contact: Department of Child and Adolescent Health and Development ([email protected]) or Department of HIV/AIDS ([email protected]) or Department of Nutrition for Health and Development ([email protected]) 20 Avenue Appia, 1211 Geneva 27, Switzerland website: http://www.who.int UNICEF Nutrition Section – Programme Divisions 3 United Nations Plaza New York, New York 10017, United States of America Tel +1 212 326 7000 A REVIEW OF AVAILABLE EVIDENCE ISBN 92 4 156271 4 WHO HIV transmission through breastfeeding A review of available evidence WHO WHO Library Cataloguing-in-Publication Data HIV transmission through breastfeeding : a review of available evidence. 1.HIV infections – transmission 2.Acquired immunodeficiency syndrome – transmission 3.Breast feeding – adverse effects 4.Disease transmission, Vertical – prevention and control 5.Review literature I.Newell, Marie-Louise. ISBN 92 4 156271 4 (NLM classification: WC 503.3) © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization or of the United Nations Children’s Fund concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization or the United Nations Children’s Fund in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. This publication reflects the activities of separate agencies around an issue of common concern. Each agency implements actions in accordance with the principles and policies of its mandate. Neither the World Health Organization nor the United Nations Chil- dren’s Fund shall be liable for any damages incurred as a result of the use of information contained in this publication. The named authors alone are responsible for the views expressed in this publication. Designed by minimum graphics Printed in China REFERENCES Contents Acknowledgements iv Glossary of terms v Executive summary 1 Introduction 3 Background 5 Benefits of breastfeeding in the general population 5 Anti-infective properties of breast milk of HIV-infected women 5 Benefits of breastfeeding for children born to HIV-infected mothers 6 Mortality among HIV-infected breastfeeding mothers 7 Mother-to-child transmission 8 HIV infection in women 8 Rates of mother-to-child transmission and risk factors 8 Prevention of mother-to-child transmission 9 HIV transmission through breastfeeding 11 Rates of breastfeeding transmission 11 Mechanisms of breastfeeding transmission 11 Timing of postnatal transmission 12 Late postnatal transmission 12 Factors associated with risk of transmission through breastfeeding 13 Maternal factors 13 Infant factors 14 Preventing transmission through breastfeeding 16 Primary prevention 16 Infant feeding options designed to prevent mother-to-child transmission 16 Replacement feeding 17 Exclusive breastfeeding with early cessation 17 The other breast-milk options 18 Current or planned research 19 Conclusion 20 References 21 iii HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF THE EVIDENCE Acknowledgements he author of this review was Prof. Marie-Louise Paulo, Brazil), Dr Nigel Rollins (University of TNewell (Institute of Child Health, London, UK). KwaZulu Natal, South Africa). The helpful suggestions and contributions to the Thanks are also due to Mr David Clark, Mr Arjan document by the following people are gratefully ac- de Wagt and Dr Miriam Labbok (UNICEF, New York knowledged: Dr Hoosen Coovadia (University of Headquarters), Dr Lynn Collins (UNFPA, New York) KwaZulu Natal, South Africa), Dr Anna Coutsoudis and Dr Catherine Hankins (UNAIDS, Geneva) for (University of KwaZulu Natal, South Africa), Dr their continuous support and inputs. François Dabis (ANRS/INSERM, France), Dr Mary Valuable assistance in reviewing the paper was pro- Glenn Fowler (Centers for Disease Control and Pre- vided by Dr Elizabeth Mason and Dr Charles Sagoe- vention, United States of America), Dr Ted Greiner Moses (IMCI Unit, AFRO); Dr Isabelle de Zoysa and (Uppsala University, Sweden), Dr Peter Iliff Dr Rene Ekpini (Department of HIV/AIDS Preven- (ZVITAMBO and University of Zimbabwe, Zimba- tion); Ms Randa Saadeh (Department of Nutrition bwe), Ms Lida Lhotska (IBFAN/GIFA, Switzerland), for Health and Development); Dr Timothy Farley and Dr Lynne Mofenson (National Institutes of Health, Dr Isabelle de Vincenzi (Department of Reproduc- United States of America), Ms Pamela Morrison tive Health and Research); Dr Jose Martines, Dr Peggy (IBCLC, Zimbabwe), Dr Ellen Piwoz (Academy for Henderson and Dr Constanza Vallenas (Department Education and Development, United States of of Child and Adolescent Health and Development). America), Dr Marina Rea (Instituto de Saude, Sao This publication was edited by Dr James Gallagher. iv HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF THE EVIDENCE Glossary of terms AZT (azidothymidine, also known as zidovudine Complementary food: any food, whether manufac- [ZDV]): an antiretroviral drug that inhibits HIV tured or locally prepared, used as a complement to replication. It was the first drug licensed to treat breast milk or to a breast-milk substitute. HIV infection. Today, it is commonly used in com- DNA: deoxyribonucleic acid, the carrier of genetic bination with other antiretroviral drugs to treat HIV information, found in cell nuclei. infection, and, alone or in combination, in the pre- vention of mother-to-child transmission of HIV Enterocytes: the cells that form the lining of the in- infection. testinal wall. Breast-milk substitute: any food being marketed or Exclusive breastfeeding: an infant receives only otherwise represented as a partial or total replace- breast milk, and no other liquids or solids, not even ment for breast milk, whether or not suitable for water, with the exception of drops or syrups con- that purpose. sisting of vitamins, mineral supplements or medi- cines. CD4+ cells (also known as “T4” or “helper T cells”): CD4+ lymphocytes (a type of white blood HAART: Highly Active AntiRetroviral Therapy, a cell) are key to both humoral and cell-mediated im- combination of three or more antiretroviral drugs mune responses. They are the main target cells for used in the treatment of HIV-infected people to the HIV. Their number decreases with progression reduce viral load. of HIV infection, and their level is used as a marker Human immunodeficiency virus (HIV): the virus of severity of the infection. that causes AIDS. In this document, the term HIV CD8+ cells are also a subtype of T lymphocytes, means HIV-1. Mother-to-child transmission of which have an important function in fighting in- HIV-2 is rare. fection. Their number may increase with progres- Immunoglobulins: the five distinct antibodies present sion of HIV infection. in the serum and external secretions off the body Cell-associated virus: HIV which lives inside the cell, (IgA, IgD, IgE, IgG and IgM). measured as HIV-DNA. Infant: a person from birth to 12 months of age. Cell-free virus: parts of the virus (virions) not asso- Intrapartum: the period during labour and delivery. ciated with a cell, measured as HIV-RNA. Lamivudine, or 3TC: an antiretroviral drug often Cessation of breastfeeding: completely stopping used in combination with zidovudine (AZT) breastfeeding, including suckling. Lipid: any one of a widely varied group of fats and Colostrum: the thick, yellow milk secreted by the fat-like organic substances. breasts during the first few days after delivery. It gradually changes into mature milk at 3–14 days Macrophage: a type of white blood cell that ingests postpartum; it contains more antibodies and white foreign material. Macrophages help destroy bacte- blood cells than mature breast milk. ria, protozoa and tumour cells and stimulate other cells of the immune system. Commercial infant formula: a breast-milk substi- tute formulated industrially in accordance with ap- Mature breast milk: milk produced from about 14 plicable Codex Alimentarius standards to satisfy days postpartum. the nutritional requirements of infants during the Mixed feeding: feeding both breast milk and other first months of life up to the introduction of com- foods or liquids. plementary foods. iv HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF THE EVIDENCE Mother-to-child transmission: transmission of HIV Replacement feeding: feeding infants who are re- to a child from an HIV-infected woman during ceiving no breast milk with a diet that provides the pregnancy, delivery or breastfeeding. The term is nutrients the infants need until the age at which used here because the immediate source of the they can be fully fed on family foods. During the child’s HIV infection is the mother. Use of the term first six months of life, replacement feeding should mother-to-child transmission implies no blame, be with a suitable breast-milk substitute. After six whether or not a woman is aware of her own infec- months the suitable breast-milk substitute should tion status. A woman can contract HIV from un- be complemented with other foods. protected sex with an infected partner, from RNA: ribonucleic acid, a substance present in the receiving contaminated blood, from non-sterile in- nucleus of all living cells and in many viruses.
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