Table 3, Principles and recommendations from the 2010 guidelines on HIV and infant feeding - Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV

Table 3Principles and recommendations from the 2010 guidelines on HIV and infant feeding

PRINCIPLES		Notes
	Balancing HIV prevention with protection from other causes of child mortality Infant feeding practices recommended to mothers known to be living with HIV should support the greatest likelihood of HIV-free survival of their children and not harm the health of mothers. To achieve this, giving priority to preventing HIV transmission needs to be balanced with meeting the nutritional requirements of infants and protecting them from non-HIV morbidity and mortality.	Remains valid
	Integrating HIV interventions into maternal and child health services National authorities should aim to integrate HIV testing, care and treatment interventions for all women into maternal and child health services. Such interventions should include access to CD4 count testing and appropriate ART or prophylaxis for the woman's health and to prevent the mother-to-child transmission of HIV.	Remains valid
	Setting national or subnational recommendations for infant feeding in the context of HIV National or subnational health authorities should decide whether health services will mainly counsel and support mothers known to be living with HIV to either (1) breastfeed and receive ARV drug interventions or (2) avoid all breastfeeding as the strategy that will most likely give infants the greatest chance of HIV-free survival. This decision should be based on international recommendations and consideration of: the socioeconomic and cultural contexts of the populations served by maternal and child health services; the availability and quality of health services; the local epidemiology, including the HIV prevalence among pregnant women; and the main causes of maternal and child undernutrition and infant and child mortality.	Remains valid
	When ARV drugs are not (immediately) available, breastfeeding may still provide infants born to mothers living with HIV a greater chance of HIV-free survival Every effort should be made to accelerate access to ARV drugs for both maternal health and preventing HIV transmission to infants. While ARV drug interventions are being scaled up, national authorities should not be deterred from recommending that mothers living with HIV breastfeed as the most appropriate infant feeding practice in their setting. Even when ARV drugs are not available, mothers should be counselled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for and supportive of replacement feeding. In circumstances in which ARV drugs are unlikely to be available, such as acute emergencies, breastfeeding of HIV-exposed infants is also recommended to increase survival.	Remains valid
	Informing mothers known to be living with HIV about infant feeding alternatives Pregnant women and mothers known to be living with HIV should be informed of the infant feeding practice recommended by the national or subnational authority to improve the HIV-free survival of HIV-exposed infants and the health of mothers living with HIV and informed that there are alternatives that mothers might want to adopt.	Remains valid
	Providing services to specifically support mothers to appropriately feed their infants Skilled counselling and support in appropriate infant feeding practices and ARV drug interventions to promote the HIV-free survival of infants should be available to all pregnant women and mothers.	Updated to a formal recommendation. See recommendation 2 (2016)
	Avoiding harming infant feeding practices in the general population Counselling and support to mothers known to be living with HIV and health messaging to the general population should be carefully delivered to avoid undermining optimal breastfeeding practices among the general population.	Remains valid
	Advising mothers who are HIV uninfected or whose HIV status is unknown *Mothers who are known to be HIV uninfected or whose HIV status is unknown* should be counselled to exclusively breastfeed their infants for the first six months of life and then to introduce complementary foods while continuing breastfeeding for 24 months or beyond. *Mothers whose status is unknown* should be offered HIV testing. *Mothers who are HIV uninfected* should be counselled about ways to prevent HIV infection and about the services that are available, such as family planning, to help them to remain uninfected.	Remains valid
	Investing in improving infant feeding practices in the context of HIV Governments, other stakeholders and donors should greatly increase their commitment to and resources for implementing the Global Strategy for Infant and Young Child Feeding, the United Nations HIV and infant feeding framework for priority action and the global scale-up of the prevention of the mother-to-child transmission of HIV to effectively prevent infants from becoming infected with HIV postnatally, improve HIV-free survival and achieve relevant goals of the United Nations General Assembly Special Session on HIV/AIDS.	Remains valid

RECOMMENDATIONS
1.	Ensuring mothers receive the care they need Mothers known to be living with HIV should be provided with lifelong ART or ARV drug prophylaxis interventions to reduce HIV transmission through breastfeeding in accordance with WHO recommendations.	Remains valid
In settings in which national authorities have decided that the maternal and child health services will mainly promote and support breastfeeding and ARV drug interventions as the strategy that will most likely give infants born to mothers known to be living with HIV the greatest chance of HIV-free survival
2.	Which breastfeeding practices and for how long Mothers known to be living with HIV (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter and continue breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.	The 2016 guideline revises the recommended duration of breastfeeding and HIV treatment, see recommendation 1 (2016).
3.	When mothers decide to stop breastfeeding Mothers known to be living with HIV who decide to stop breastfeeding at any time should stop gradually within one month. Mothers or infants who have been receiving ARV drug prophylaxis should continue prophylaxis for one week after breastfeeding is fully stopped. Stopping breastfeeding abruptly is not advisable.	Remains valid. Nevertheless, lifelong ART is recommended now instead of ARV drug prophylaxis.
4.	What to feed infants when mothers stop breastfeeding When mothers known to be living with HIV decide to stop breastfeeding at any time, infants should be provided with safe and adequate replacement feeds to enable normal growth and development. For infants younger than six months of age: Alternatives to breastfeeding include: – commercial infant formula milk if the home conditions outlined in recommendation 5 are fulfilled; or – expressed, heat-treated breast milk (see recommendation 6 below). Home-modified animal milk is not recommended as a replacement food in the first six months of life. For children older than six months of age: Alternatives to breastfeeding include: – commercial infant formula milk if the home conditions outlined in recommendation 5 are fulfilled; or – animal milk (boiled for infants under 12 months), as part of a diet providing adequate micronutrient intake; meals, including milk-only feeds, other foods and combination of milk feeds and other foods, should be provided four or five times per day. All children need complementary foods from six months of age.	Remains valid
5.	Conditions needed to safely formula feed Mothers known to be living with HIV should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status when specific conditions are met: safe water and sanitation are assured at the household level and in the community; and the mother or other caregiver can reliably provide sufficient infant formula milk to support the normal growth and development of the infant; and the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and the mother or caregiver can exclusively give infant formula milk in the first six months; and the family is supportive of this practice; and the mother or caregiver can access health care that offers comprehensive child health services. These descriptions are intended to give simpler and more explicit meaning to the concepts represented by AFASS (acceptable, feasible, affordable, sustainable and safe).	Remains valid
6.	Heat-treated, expressed breast milk Mothers known to be living with HIV may consider expressing and heat-treating breast milk as an interim feeding strategy: in special circumstances, such as when the infant has low birth weight or is otherwise ill in the neonatal period and unable to breastfeed; or when the mother is unwell and temporarily unable to breastfeed or has a temporary breast health problem such as mastitis; or to assist mothers in stopping breastfeeding; or if ARV drugs are temporarily not available.	Remains valid
7.	When the infant is living with HIV If infants and young children are known to be living with HIV, mothers are strongly encouraged to exclusively breastfeed for the first six months of life and continue breastfeeding in accordance with the recommendations for the general population: that is, up to two years or beyond.	Remains valid

From: The 2010 WHO principles and recommendations on HIV and infant feeding: valid and updated

Cover of Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV

Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV.

Geneva: World Health Organization; 2016.

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