We were dismayed by the absence of infant feeding counseling in the recent publication ‘The global strategy to eliminate HIV infection in infants and young children: a seven-country assessment of costs and feasibility’ . The assessment was based only on the promotion of family planning to people with HIV, HIV testing and counseling of pregnant women in antenatal care, provision of antiretroviral and cotrimoxazole prophylaxis to HIV-infected women and cotrimoxazole prophylaxis to HIV-exposed infants.
In their model, the authors assumed that breastfeeding-related transmission would be controlled by HAART. Although pharmaceutical prophylaxis is indeed part of the solution to preventing mother-to-child transmission (PMTCT), problems with coverage, toxicity and resistance mean that it cannot be the sole solution. This fact is tacit in the 2007 recommendation that infant feeding counseling should be a part of essential postnatal care for HIV-infected mothers by the Inter-agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants .
There are four reasons that infant feeding counseling should not be overlooked in our efforts to reduce mother-to-child transmission (MTCT):
- Transmission of HIV through suboptimal infant feeding practices remains an important source of MTCT. Current low rates of exclusive breastfeeding (EBF) are problematic because EBF has been repeatedly demonstrated to be a safer method of infant feeding than mixed feeding (i.e., breast milk and other foods or liquids) for HIV-exposed infants [3,4]. At 6 months, infants who received mixed feeds had a four-fold increased risk of HIV transmission compared with EBF . Moreover, not breastfeeding in areas where replacement foods are not acceptable, feasible, affordable, sustainable and safe (AFASS) has repeatedly failed to improve HIV-free survival . If more women were to follow WHO's recommendation to EBF for 6 months in the absence of AFASS alternatives, regardless of HIV status, the rate of MTCT would decrease.
- In addition to reducing MTCT of HIV and increasing HIV-free survival of infants, EBF for 6 months would delay the return of maternal fertility. This would reduce both PMTCT costs as well as the potential number of infected children.
- Infant feeding counseling improves infant feeding behaviors. It has been proven that both clinic-based and home-based infant feeding counseling can increase the prevalence and duration of EBF in areas of high HIV prevalence [7,8]. This is consistent with other studies that have shown that infant feeding counseling by peer counselors improves infant feeding practices, including EBF, among the general population [9,10].
- Infant feeding counseling by peer counselors may be a very cost-effective component of PMTCT programs. Although the authors of the cost and feasibility assessment concluded that available human resources were the biggest constraint to achieving the goals set by the United Nation General Assembly Special Session on AIDS , infant feeding counseling programs can be carried out effectively by peer counselors who can be relatively quickly and inexpensively trained, hired and supervised.
Surely, infant feeding counseling merits inclusion in cost comparison analyses and larger scale implementation. Given our growing understanding of the health benefits and cost savings that improved infant feeding can achieve and the acknowledged difficulties with pharmaceutical PMTCT interventions, we urge inclusion of infant feeding counseling in the planning, implementation and evaluation of PMTCT programs.
1. Nakakeeto ON, Umaranayake L. The global strategy to eliminate HIV infection in infants and young children: a seven-country assessment of costs and feasibility. AIDS 2009; 23:987–995.
2. UNICEF, WHO, Interagency Task Team on Prevention of HIV Infection in Pregnant Women Mothers and their Children. Guidance on global scale-up of the prevention of mother-to-child transmission of HIV
. Geneva: WHO Press; 2007.
3. Becquet R, Ekouevi D, Menan H, Amani-Bosse C, Bequet L, Viho I, et al
. Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire. Prev Med 2008; 47:27–33.
4. Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 2007; 369:1107–1116.
5. Iliff P, Piwoz E, Tavengwa N, Zunguza C, Marinda E, Nathoo K, et al
. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005; 19:699–708.
6. Kuhn L, Aldrovandi G, Sinkala M, Kankasa C, Semrau K, Mwiya M, et al
. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med 2008; 359:130–141.
7. Bland R, Little K, Coovadia H, Coutsoudis A, Rollins N, Newell M. Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS 2008; 22:883–891.
8. Piwoz E, Humphrey J, Tavengwa N, Iliff P, Marinda E, Zunguza C, et al
. The impact of safer breastfeeding practices on postnatal HIV-1 transmission in Zimbabwe. Am J Public Health 2007; 97:1249–1254.
9. Haider R, Ashworth A, Kabir I, Huttly S. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000; 356:1643–1647.
10. Morrow A, Guerrero M, Shults J, Calva J, Lutter C, Bravo J, et al
. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999; 353:1226–1231.