U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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.

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.

Show details

Evidence and recommendations

1. The duration of breastfeeding by mothers living with HIV

In settings where maternal, newborn and child health services promote and support breastfeeding and ART in order to increase HIV-free survival among infants born to mothers living with HIV:

For how long should a mother living with HIV breastfeed if she is receiving ART and there is no evidence of clinical, immune or viral failure?

Background

In 2010, global WHO HIV and infant feeding guidelines were updated to recommend that, in settings in which diarrhoea, pneumonia and undernutrition were still common causes of infant and child mortality, national health authorities should, while providing ARV drugs, promote and support breastfeeding among women and mothers living with HIV (WHO, 2010b). Such mothers were recommended to exclusively breastfeed their infants for the first six months of life, to introduce appropriate complementary foods thereafter and to continue breastfeeding for the first 12 months of life. Mothers living with HIV should then consider stopping breastfeeding at 12 months if they are able to provide a nutritionally adequate and safe diet without breast milk. The guidelines noted that, for women living in food-insecure regions, continuing breastfeeding beyond 12 months may still be important for the child to achieve an adequate diet.

The recommendation to breastfeed until 12 months of age and then consider whether to either stop breastfeeding or continue breastfeeding for longer was based on four considerations.

  • The risk of mortality among young children after 12 months of age is lower than the risk in the first 12 months of life. Even though breastfeeding for longer periods has many other health benefits, it has less impact on mortality in this later period (Victora et al., 2016).
  • From 12 months onward, it is possible to provide a diet based on family foods that excludes breast milk and is still nutritionally adequate for the growing child. Although breast milk is still valuable, whole cow's milk can be given after six months of age without modifying the milk (WHO, 2005).
  • In 2010, it was uncertain whether health services would be able to retain mothers living with HIV in care and consistently provide ART. If a breastfeeding mother living with HIV did not receive ART or did not return to health services, the infant might have some risk of becoming infected with HIV. At that time, few programmatic data were available to inform the Guideline Development Group.
  • It was uncertain whether breastfeeding children would have significant adverse health outcomes from longer-term exposure to ARV drugs through breast milk if the mother was taking ART.

For these reasons, the 2010 Guideline Development Group agreed that, in settings in which diarrhoea, pneumonia and undernutrition were common, breastfeeding until 12 months by a mother living with HIV and taking ART was likely to increase the HIV-free survival of infants and young children compared with replacement feeding or shorter durations of breastfeeding. Concerns regarding the potential for misunderstandings related to these guidelines undermining optimal infant feeding practices in women and mothers not affected by HIV resulted in WHO updating HIV and infant feeding: framework for priority action (WHO, 2012a), which provided guidance to governments on key action to create and sustain a protective environment that encourages appropriate feeding practices for all infants and young children while scaling up interventions to reduce HIV transmission.

In 2013, WHO (2013) recommended lifelong ART for all mothers living with HIV and, since October 2015, to all adults and children as soon as they are known to be living with HIV (WHO, 2016c) and not just for the women fulfilling specific clinical or immunological criteria. Based on these recommendations, the current standard of care and organization within health systems are oriented toward providing lifelong ART, including adherence support and counselling for adults and children living with HIV.

The Guideline Development Group noted that the WHO recommendations for mothers in the general population – that is, HIV negative or of unknown status – remain unchanged: mothers should exclusively breastfeed for the first six months, introduce appropriate complementary feeds and continue breastfeeding until 24 months or beyond because of the many benefits for both mother and child (WHO, 2016b).

Summary of the evidence

Two systematic reviews were commissioned for this guideline and contributed to the GRADE (GRADE Working Group, 2016) tables and evidence for this question (GRADE evidence profile, Annex 1a, Table 4).

  1. Chikhungu L, Bispo S, Newell ML. HIV-free survival at 12–24 months in breastfed infants of HIV-positive women on antiretroviral therapy: a systematic review. (Annex 1a).
  2. Chikhungu L, Bispo S, Newell ML. Postnatal HIV transmission rates at age six and 12 months in infants of HIV-positive women on antiretroviral therapy initiating breastfeeding: a systematic review. (Annex 1b).

Under additional evidence not included in the GRADE tables, findings are presented of a modelling exercise that was also commissioned for the guideline and examined the effect of ART among mothers living with HIV on infant survival according to different background risk assessments of diarrhoeal mortality.

3.

Mallampati D, MacLean R, Ciaranello A. Modelling the impact of maternal antiretroviral drug use and infant mortality. (Annex 1c).

Also included in this section are findings of another systematic review (Zunza et al., 2013) that summarizes evidence how exposure to postnatal ARV drugs affects child growth.

4.

Zunza M, Mercer GD, Thabane L, Esser M, Cotton MF. Effects of postnatal interventions for the reduction of vertical HIV transmission on infant growth and non-HIV infections: a systematic review. J Int AIDS Soc. 2013;16:18865. [PMC free article: PMC3871831] [PubMed: 24369738].

The values and preferences of stakeholders outlined in the decision-making tables were informed by a survey of national health authorities of the 22 priority countries1 for the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (UNAIDS, 2011) (see below and Annex 3).

HIV-free survival by duration of feeding practice and ART use

The systematic review by Chikhungu et al. (Annex 1a) addressed the question of HIV-free survival at 12, 18 or 24 months among infants born to women living with HIV who were receiving ART by infant feeding modality (exclusive breastfeeding, mixed feeding or replacement feeding) and duration of maternal ART. The systematic review did not identify any trial that reported directly comparative data from the population of interest: that is, mothers receiving ART who breastfed for 12 months versus 24 months.

The authors identified 18 cohort studies that provided other data to inform the Guideline Development Group: seven of these studies were nested within randomized controlled trials. Most studies were a follow-up of mothers receiving ART for preventing the mother-to-child transmission of HIV, with mothers advised to exclusively breastfeed for six months with rapid cessation thereafter, in accordance with the prevailing global recommendations. In 11 studies in which women initiated ART specifically for the purpose of preventing the mother-to-child transmission of HIV, ART would have been stopped at the cessation of breastfeeding around six months postpartum, in accordance with previous recommendations (WHO et al., 2006). Six studies offered lifelong ART regardless of CD4 count, and four studies supported breastfeeding for 12 months.

The majority of the cohort studies did not provide details regarding type of feeding: that is, exclusive breastfeeding or mixed feeding in the first six months. The investigators of 10 studies, of whom six responded, were requested to provide additional information. Five confirmed that exclusive breastfeeding was promoted, but feeding practices were inconsistently assessed as part of the study processes, such as self-reporting only. The investigators assumed that some mothers would have exclusively breastfed up to 5 or 6 completed months as recommended, whereas others would have introduced other fluids, milks or solids while breastfeeding: that is, mixed feeding. No study disaggregated transmission rates according to exclusive breastfeeding or mixed feeding where the mother was receiving lifelong ART.

Of the 18 cohort studies, only four had estimates of HIV-free survival by type of feeding; one of these also presented information on HIV transmission by feeding type. One further study compared cumulative transmission rates among children who were either formula-fed from birth or breastfed for less than three months or for three months or longer. Three studies compared transmission or death between breastfed and formula-fed (replacement-fed) infants, and one study provided HIV-free survival separately for children who were mixed-fed and those who stopped breastfeeding early. Eight studies provided HIV-free survival or rates of transmission and mortality from birth; other studies excluded deaths and HIV transmission in the first days or weeks of life and provided only postnatal rates.

Meta-analysis using a random effects model was conducted, but because of the high level of clinical and methodological heterogeneity observed in the data set, the review authors caution about interpreting these results. The pooled estimates of HIV-free survival at 12 and 18 months were marginally higher for infants whose mothers were receiving lifelong ART than for infants whose mothers were receiving ART until six months postnatally only. The pooled estimates for HIV-free survival at 12 months were 89.8% (95% confidence interval [CI]: 86.4–93.1%) for infants whose mothers were receiving ART for six months postnatally (six studies, n = 2366) (Alvarez-Uria et al., 2012; Jamieson et al., 2012; Kilewo et al., 2009; Marazzi et al., 2009; Thistle et al., 2011; Thomas et al., 2011) and 91.8% (95% CI: 87.7–95.9%) for infants whose mothers were receiving lifelong ART (three studies, n = 898) (Cohan et al., 2015; Thakwalakwa et al., 2014; Tonwe-Gold et al., 2007). Estimates of HIV-free survival at 18 months were 89.0% (95% CI: 83.9–94.2%) for infants whose mothers were receiving ART to six months postnatally (five studies, n = 1876) (Cournil et al., 2015; Fowler et al., 2014; Homsy et al., 2010; Kilewo et al., 2009; Thomas et al., 2011) and 96.1% (95% CI: 93.0–99.2%) for infants with mothers receiving lifelong ART (three studies, n = 1271) (Ngoma et al., 2015; Okafor et al., 2014; Sagay et al., 2015) (GRADE evidence profile, Annex 1a, Table 4).

HIV-free survival could not be estimated at 24 months because insufficient data were available for women receiving lifelong ART; the pooled estimate for 24-month HIV-free survival for infants whose mothers were receiving ART until six months postnatally (two studies) (Shapiro et al., 2013; Thomas et al., 2011) was 89.2% (95% CI: 79.9–98.5%). In one additional study, based on a mixed group of infants with respect to the mother's ART status (some were receiving ART up to six months postnatally and others were receiving lifelong ART), estimated HIV-free survival at 24 months was 85.8% (95% CI: 81.4–90.1%) (Giuliano et al., 2013).

Data from the individual studies are difficult to interpret due to heterogeneity and wide confidence intervals (especially in the studies with a shorter duration of ART). In general, HIV-free survival estimates were equivalent or higher for the infants of mothers receiving lifelong ART than for infants of mothers receiving ART for a limited period up to six months postnatal.

  • Among infants whose mothers were receiving ART for up to six months, HIV-free survival:
    –

    at 12 months ranged from 85.0% (95% CI: 74.6–91.7%) to 96.0% (95% CI: 91.0–98.0%);

    –

    at 18 months ranged from 81.6% (95% CI: 73.4–87.7%) to 95.2% (95% CI: 93.2–97.3%).

  • Among infants whose mothers were receiving lifelong ART, HIV-free survival:
    –

    at 12 months ranged from 88.8% (95% CI: 82.6–95.0%) to 95.0% (95% CI: 92.0–97.0%);

    –

    at 18 months ranged from 87.2% (95% CI: 79.2–92.5%) to 97.8% (95% CI: 94.6–99.1%).

However, the range of individual study estimates and confidence intervals cannot be directly compared, since not all the included studies reported outcomes at both 12 and 18 months. Overall, the Guideline Development Group agreed that a longer duration of ART for the mother is associated with greater HIV-free survival for the young child.

Two studies reported 24-month HIV-free survival among infants whose mothers were receiving ART up to six months postnatally at 84.3% (95% CI: 80.6–87.3%) (Thomas et al., 2011) and 93.8% (95% CI: 92.9–96.5%) (Shapiro et al., 2013) respectively. In a third study, 24-month HIV-free survival was estimated to be 85.8% (95% CI: 81.4–90.1%) (Giuliano et al., 2013) in a mixed population of children whose mothers were either receiving lifelong ART because of low CD4 count or receiving ART up to six months.

Four studies provided estimates of HIV-free survival by feeding modality; three reported higher HIV-free survival among breastfed infants than formula-fed infants. HIV-free survival among breastfed infants ranged from 82% (95% CI: 73.4–87.7%) [median weaning: five months] to 96% (95% CI: 91–98%) and among formula-fed infants from 67% (95% CI: 35.5–87.9%) to 97.6% (95% CI: 93.0–98.2%).

All studies were graded as low or very low quality because they were observational in design and downgraded for indirectness. The authors urged caution in quoting the pooled estimates because of heterogeneity (GRADE evidence profile, Annex 1a, Table 4).

HIV transmission by duration of feeding practice and ART use

A second systematic review (Chikhungu et al., Annex 1b) summarized HIV transmission rates at six, nine and 12 months among infants born to women who were receiving ART by infant feeding modality in the first six months of life (GRADE evidence profile, Annex 1b, Table 7).

Eleven studies were identified for analysis; four were cohorts nested in randomized controlled trials. In all studies, mothers started ART before or during pregnancy and continued until at least six months postnatally, in accordance with the WHO recommendations at the time. Eight of the 11 studies followed the recommendation of using ART for preventing the mother-to-child transmission of HIV during pregnancy until cessation of breastfeeding at about six months postnatally; three studies provided lifelong ART for all women, and one study provided lifelong ART for women eligible for treatment in accordance with WHO guidelines only. In most studies, mothers were advised to offer exclusive breastfeeding to the child, with rapid weaning after six months; two studies recommended continuing breastfeeding until 12 months. No study provided estimates of transmission rate according to type of feeding - that is, exclusive versus mixed feeding - although two studies reported the feeding practices of infants found to be infected.

Overall HIV transmission at age six months

Six studies reported overall (including peripartum and postpartum) transmission at six months. In the three studies in which pregnant women received ART early from 15 weeks gestation, overall transmission rates were 0.5% (95% CI: 0.2–1.2%), 1.4% (95% CI: 0.5–3.9%) and 1.9% (95% CI: 0.9–4.1%). When pregnant women initiated ART after 30 weeks of gestation, overall transmission rates were 5.0% (95% CI: 3.4–7.4%), 5.0% (95% CI: 2.9–7.1%) and 7.9% (95% CI: 6.2–9.9%). The pooled estimated rate of overall transmission by age six months was 3.5% (95% CI: 1.15–5.93), with substantial heterogeneity (I2 = 94.0%) (GRADE evidence profile, Annex 1b,Table 7).

Postnatal transmission between 4–6 weeks and six months

Six studies provided estimates of postnatal transmission, excluding peripartum infections diagnosed before 4–6 weeks of age. Among mothers who started ART at the first antenatal visit, estimated postnatal transmission rates ranged from 0.2% (95% CI: 0.0–1.4%) to 3.1% (95% CI: 1.2–7.8%). Among mothers starting ART later in pregnancy, postnatal transmission rates varied from 0.8% (95% CI: 0.3–2.4%) to 2.7% (95% CI: 1.8–4.1%). The pooled postnatal transmission rate by six months of age was 1.08% (95% CI: 0.32–1.85%), with high heterogeneity (I2 = 66.4%) (GRADE evidence profile, Annex 1b, Table 7).

In addition, one study reported postnatal HIV transmission rates between 3 and 28 weeks by maternal ART exposure: that is, maternal ART, no maternal ART but infants received daily nevirapine and a placebo group: 3.0% (95% CI: 1.7–4.1%), 2.0% (95% CI: 0.8–2.6%) and 5% (95% CI: 3.8–7.4%), respectively.

Overall transmission rates at 12 months

Seven studies provided information on transmission at 12 months, of which five reported overall transmission (including peripartum and postpartum). The pooled estimate for the overall rate at 12 months was 4.2% (95% CI: 3.0–5.5%), with I2 = 39.9%, indicating moderate heterogeneity (GRADE evidence profile, Annex 1b, Table 7).

Postnatal transmission rates at 12 months

The rates from two studies reporting postnatal transmission between 4–6 weeks and 12 months of age were 1.7% (95% CI: 0.3–4.1%) and 4.0% (95% CI: 3.0–6.0%) with a pooled estimate of 3.0% (95% CI: 0.7–5.2%), with high heterogeneity (I2 = 71.2%).

Only one study estimated the rate of transmission at 18 months, among infants of mothers on lifelong ART, with a rate of 4.1% (95% CI: 2.2–7.6%).

All studies were rated as having very low quality because of the observational design, indirectness, inconsistency and/or risk of bias.

Although there was substantial statistical heterogeneity between studies in each of the pooled estimates, and the authors (Chikhungu et al.) advised caution when using the absolute pooled estimates, this systematic review provides evidence of reduced postnatal HIV transmission risk under the cover of maternal ART.

Additional evidence not included in the GRADE table

Modelling

A modelling exercise using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) infant model (Mallampati et al., Annex 1c) projected 24-month HIV-free survival among HIV-exposed, uninfected infants when three key parameters were varied: the relative risk of infant and child mortality associated with replacement feeding compared with exclusive breastfeeding (RRRF - a multiplier of mortality when infants are replacement fed); setting-specific neonatal, infant and under-five mortality rates; and the duration of maternal ART use during breastfeeding (as a proxy for retention in care and medication adherence). The primary goals of the analysis were: (1) to determine the “optimal breastfeeding duration” for each scenario, defined as the duration that maximized HIV-free survival; and (2) to quantify the impact of maternal ART adherence on HIV-free survival. Building on a previous analysis (Ciaranello et al., 2014), the authors incorporated updated HIV transmission data for women receiving ART and neonatal, infant and under-five mortality rates from the 22 Global Plan priority countries (UNAIDS, 2011).

The analysis found the following.

  • When the additional mortality risks associated with replacement feeding are high, such as in settings with contaminated water supplies or during diarrhoeal outbreaks, when maternal ART is consistently available, longer durations of breastfeeding, that is, 24 months or more, improve 24-month HIV-free survival. When the risks associated with replacement feeding are lower, then shorter durations of breastfeeding, that is, 12–24 months, result in the highest rates of HIV-free survival as long as maternal ART is consistently available.
  • The difference in HIV-free survival between 12 and 24 months of breastfeeding is minimal, usually <1%, as long as women continue to receive ART throughout breastfeeding.
  • If mothers are lost from care or stop taking ART before stopping breastfeeding, the 24-month HIV-free survival of their children decreases dramatically. This is because the HIV transmission risks are high when women continue to breastfeed after stopping ART. However, in this scenario, HIV-free survival is very much lower if mothers do not breastfeed at all.
  • When the authors simultaneously varied mortality, the relative risk of infant and child mortality associated with replacement feeding compared to exclusive breastfeeding (RRRF) and ART duration, the underlying infant, child and under-five mortality rates were found only to influence optimal breastfeeding duration in scenarios with intermediate RRRF values (RRRF = 4–5). In settings with low to moderate RRRF values (RRRF ≤ 3), the optimal breastfeeding duration is 12 months, and at very high RRRF values (RRRF ≥ 6), the optimal breastfeeding duration is 24 months, regardless of the underlying child mortality rates.

The authors found that the 12-month breastfeeding duration recommended in the 2010 WHO HIV and infant feeding guidelines maximizes infant HIV-free survival at 24 months in many settings, even when RRRF or infant, child and under-five mortality rates are low. If programmes in low-RRRF settings recommended 24 months of breastfeeding instead of 12 months, the anticipated reduction in HIV-free survival would be small (<1%), as long as women continue to receive ART throughout breastfeeding. In settings in which RRFF and mortality rates are both high, breastfeeding for 24 months improves HIV-free survival. In all RRRF scenarios, ART adherence throughout the entire breastfeeding period is critical to improve infant HIV-free survival.

Adverse effects of postnatal ART interventions to prevent transmission of HIV through breastfeeding

A systematic review of the adverse effects of postnatal interventions for preventing the mother-to-child transmission of HIV on infant growth and non-HIV infections (Zunza et al., 2013) was updated with literature published up to August 2015. The earlier 2013 review identified three randomized controlled studies with relevant data. Maternal ARV drugs did not significantly adversely affect the growth of infants and children who were breastfed (RR = 1.12; 95% CI: 0.83–1.50). The evidence suggests that breastfeeding may improve the growth and non-HIV infection outcomes of HIV-exposed infants. Extended ARV drug prophylaxis does not appear to increase the risk for HIV-exposed infants for adverse growth or non-HIV infections compared with short-course ARV drug prophylaxis.

The reviewers rated the evidence as moderate quality.

When this review was updated to 2015, the search identified two further observational studies. Thakwalakwa et al. (2014) found that length-for-age and weight-for-height among HIV-exposed infants who were breastfed by mothers receiving ART and also giving the infants quality complementary foods were comparable or better than the historical growth rates reported among the general child population in Malawi. The second report by Parker et al. (2013) found that earlier cessation of breastfeeding among HIV-exposed infants whose mothers received ART was associated with dietary deficiencies, and female infants experienced reduced growth velocity. However, it was unclear whether these effects were related to earlier cessation of breastfeeding or to other HIV-related factors.

1

Angola, Botswana, Burundi, Cameroon, Chad, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.

Survey of national health authorities of the 22 priority countries of the Global Plan

To learn about the values and preferences of stakeholders regarding infant feeding, WHO conducted a survey among representatives of national health authorities in the 22 priority countries of the Global Plan (UNAIDS, 2011). Most national health authorities in these countries have opted to recommend breastfeeding to mothers living with HIV while providing ART. The findings were presented to the Guideline Development Group and are reported in Annex 3 and also included in the decision-making table (Table 4). The Guideline Development Group considered these findings in their deliberations of the values and preferences of communities and stakeholders that would be affected by the guidelines.

Table 4Considerations when developing infant feeding recommendations in the context of HIV

SUPPORTING EVIDENCE AND ADDITIONAL CONSIDERATIONS
QuestionFor how long should a mother living with HIV breastfeed if she is receiving ART and there is no evidence of clinical, immune or viral failure?
BENEFITS AND HARMDo the desirable effects (of longer breastfeeding by mothers living with HIV receiving ART) outweigh the undesirable effects?

☑ Yes
□ No
□ Uncertain		Extending the period of breastfeeding to 24 months or beyond is likely to improve HIV-free survival among HIV-exposed infants, especially where diarrhoea and pneumonia are significant causes of infant and child mortality: that is, settings with a significantly increased risk of infant and child mortality associated with replacement feeding compared with exclusive breastfeeding. Several other health outcomes among young children and mothers, such as improved child development and reduced maternal breast and ovarian cancer, are also likely to improve as a result of longer duration of breastfeeding.

Harmonizing the recommendations for HIV-exposed infants and children with those for non-exposed infants would lead to programmatic simplification and facilitate the protection, promotion and support of optimal infant feeding practices in the entire population.

Harmonizing the recommendations may also reduce the stigma towards mothers living with HIV associated with stopping breastfeeding early in communities where continued breastfeeding to 24 months or beyond by mothers without HIV is normative.

However, if maternal ART adherence is inconsistent, the potential for HIV transmission increases. In settings where health systems do not reliably provide ART and where maternal adherence is not high, this may result in transmitting HIV to children who are still breastfeeding. The majority of the Guideline Development Group considered that the recommendation should be framed in terms of what health systems should deliver and high levels of maternal ART adherence. Overall, the Guideline Development Group considered that the benefits of recommending breastfeeding to 24 months or beyond outweighed the risks of HIV transmission.

There are potential adverse effects on infant growth and other health outcomes associated with longer ARV drug exposure through breast milk. However, the limited data available have not demonstrated such adverse effects.
VALUES, PREFERENCES AND ACCEPTABILITYIs there important uncertainty or variability about how much people value the options?

☑ Major variability
□ Minor variability
□ Uncertain


Is the option acceptable to key stakeholders?

□ Yes
□ No
☑ Uncertain		Before the guideline meeting, health ministry staff members in the 22 priority countries of the Global Plan (UNAIDS, 2011) were individually invited to participate in a survey. The staff members of one country did not respond. Of the 21 countries responding, 19 reported that health services routinely promote and support breastfeeding among mothers living with HIV while providing ART. In two countries, mothers are individually counselled, and the mother and health worker together decide on the most appropriate feeding practices.

In two of the 19 countries, national authorities already recommend that mothers living with HIV breastfeed for 24 months and provide ART, and this is implemented in at least some facilities. No major difficulties were reported.

National staff members in four countries considered that mothers living with HIV would not agree with a recommendation to prolong breastfeeding, and in six countries national staff members considered that mothers living with HIV would have some difficulty agreeing with this option.

In contrast, in six other countries national staff members considered that a recommendation to prolong breastfeeding among mothers living with HIV would be relatively acceptable, and in two countries it would be very acceptable.

Health ministry officials in 10 countries anticipated difficulties for health workers to accept extending the period of breastfeeding, and eight countries considered this modification acceptable to health workers.
FEASIBILITY AND RESOURCE USEHow large are the resource requirements?

□ Major
☑ Minor
□ Uncertain

Is the option feasible to implement?

☑ Yes
□ No
□ Uncertain		Health systems must already consider using most of the resources for ART and support for ART adherence, since ART is already recommended, and hence these would not be additional costs.

The main additional costs would be for training and developing the capacity of health workers to promote breastfeeding to 24 months or beyond, and these are likely to be modest. In addition, breastfeeding promotion would benefit the entire population and not just a select proportion; thus, the anticipated cost-benefit ratio would be low.

These costs should be differentiated from the substantial funds required to implement systems to adequately protect, promote and support breastfeeding across the entire population, including the Baby-friendly Hospital Initiative and monitoring the Code of Marketing of Breast-milk Substitutes.

Two countries are already implementing the proposed intervention, and no major challenges are reported.
EQUITYWould the option improve equity in health?

☑ Yes
□ No
□ Uncertain		Implementing a recommendation for breastfeeding for 24 months may improve health equity, since the recommendation would then be essentially the same for all populations.

Breastfeeding in the general population tends to improve health equity.

RECOMMENDATION 1

Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or beyond (similar to the general populationa) while being fully supported for ART adherence.

(See the WHO consolidated guidelines on ARV drugs for interventions to optimize adherence).

a

Breastfeeding as recommended by WHO is defined as: (1) initiating breastfeeding within the first hour of life; (2) exclusive breastfeeding for the first six months of life (that is, the infant only receives breast milk without any additional food or drink, not even water); followed by (3) continued breastfeeding for up to two years or beyond (with introduction of appropriate complementary foods at six months); and (4) breastfeeding on demand -that is, as often as the child wants, day and night.

The Guideline Development Group agreed that recommendation 1 should be framed by the following statement.

In settings where health services provide and support lifelong ART, including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted.

Recommendation 1 (2016) updates the component of the 2010 recommendation on which breastfeeding practices and for how long that relates to the duration of breastfeeding. The components of the 2010 recommendation regarding breastfeeding practices and stopping breastfeeding remain unchanged and valid.

Mothers living with HIV should exclusively breastfeed their infants for the first six months of life, introduce appropriate complementary foods thereafter and continue breastfeeding.

Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.

Strength of the recommendationStrong
Quality of the evidence12 months: low

24 months: very low
JustificationThe Guideline Development Group unanimously supported removing any restriction on the duration of breastfeeding for mothers living with HIV in the context of full support for ART. All Guideline Development Group members agreed that the likely benefits outweighed the harm even if breastfeeding in the general population has less protective effect against serious morbidity and mortality in the second year of life than in the first 12 months. The Guideline Development Group recognized that, in settings in which health systems support and promote high rates of retention in care and adherence to ART, the risk of postnatal transmission is likely to be low. The Guideline Development Group also recognized that, as programmes become even more robust and efficient in delivering ART services and communities become more aware of the benefits and reliability of ART in protecting against HIV transmission, the balance of risks in favour of prolonged breastfeeding with the provision of ART will be even stronger. In addition, the Guideline Development Group noted the significant benefit of harmonizing guidelines for women living with HIV and the general population. This action will probably decrease the stigmatization associated with infant feeding practices undertaken by mothers living with HIV and also facilitate improved feeding practices in the entire population.

There are no comparative data from HIV-exposed children on the overall gains in HIV-free survival that would be associated with prolonged breastfeeding versus shorter durations of breastfeeding, and programmatic and historical data demonstrate small but continued postnatal transmission through the second year of life. The ART adherence rates among the mothers of these children were, however, unknown. Some Guideline Development Group members commented that poor adherence to ART by mothers living with HIV will always constitute a risk factor for postnatal transmission, whether in the first or second year of life. (See the 2013 WHO consolidated guidelines on ARV drugs (WHO, 2013) for interventions to optimize adherence to ART.)

The Guideline Development Group noted these concerns and reviewed, on several occasions, the decision to make a strong recommendation. Although some Guideline Development Group members favoured a conditional rather than a strong recommendation in recognition of the diversity of settings in which the recommendation will be implemented, consensus was achieved through discussion and revising how the recommendation should be phrased. The decision to make a strong recommendation was based on agreement on what package of interventions would be best for the individual mother-infant pairs. Where health systems reliably provide and support ART, and mothers retained in care consistently adhere to ART, the Guideline Development Group considered that prolonged breastfeeding to 24 months or beyond by mothers living with HIV is the best option for HIV-exposed infants. The Guideline Development Group also noted that the change in global recommendations on ART for all people living with HIV regardless of CD4 count should result in greater investment and improvement in health services to achieve the quality required to assure high rates of retention and ART adherence.

The Guideline Development Group also noted that, in both the past and current recommendations, women living with HIV are not obligated to adopt a single feeding practice even when recommended by the health services. Similar to all women in everyday life, mothers living with HIV ultimately make decisions about infant feeding practices, including the duration of breastfeeding, according to what is appropriate for their circumstances. The 2010 WHO guidelines on HIV and infant feeding highlighted the need for health services to support mothers living with HIV in their chosen feeding practices even when they are inconsistent with the nationally recommended practices. This principle is still endorsed by WHO and remains relevant to these updated recommendations.
Implementation considerations
  • HIV and maternal and child health programmes need to give priority to integrating ART services, including adherence counselling and support for infant and young child feeding, in all settings.
  • These programmes and partner agencies need to ensure training and developing the capacity of health workers so that they can explain the rationale for the recommendation and to ensure that staff members are able to explain the benefits to mothers living with HIV while emphasizing the value and importance of adherence to ART.
  • These programmes and partner agencies should collect data to monitor the duration of breastfeeding by mothers living with HIV in addition to adherence to ART and the rates of retention in care of mothers and infants. Such data should be used to improve the quality of service delivery at district and local clinics.
  • Investment and action to protect, promote and support breastfeeding in the general population should remain priorities of health ministries, nongovernmental organizations and other partners in all settings.
Research priorities
  • How does long-term postpartum exposure to low-dose ARV drugs in breast milk affect the early and late health outcomes, especially growth, renal and bone metabolism and neurodevelopment, of HIV-exposed breastfeeding infants and children whose mothers are taking ART?

2. Interventions to support infant feeding practices by mothers living with HIV

Can facility- and community-based interventions improve the quality of infant feeding practices among mothers living with HIV?

  • In countries that promote breastfeeding among mothers living with HIV receiving ART, what are the effective interventions to support optimal breastfeeding?
  • In countries that promote replacement feeding among mothers living with HIV, what are the effective interventions to support safe and adequate replacement feeding?

Background

The 2010 WHO guidelines on HIV and infant feeding recommended a public health approach in which national authorities should promote and support one infant feeding practice among mothers living with HIV attending public health facilities, either: (1) exclusive breastfeeding for the first six months followed by introducing appropriate complementary feeding and continued breastfeeding for up to one year, while ARV drugs are provided to either the mother or the infant; or (2) avoiding all breast milk. It was recommended that this decision be taken at the national level following consideration of local HIV and general maternal and child health epidemiology and other health system considerations.

The same guidelines highlighted the principles that skilled counselling and support for infant feeding practices should be available to all pregnant women and mothers. For mothers living with HIV, support for ART adherence should also be provided, and guidance on safe replacement feeding should be carefully delivered to avoid undermining optimal breastfeeding practices among the general population.

Guiding principles included in the 2010 WHO guidelines on HIV and infant feeding (WHO, 2010b)

Providing services to specifically support mothers in appropriately feeding their infants

Skilled counselling and support in appropriate infant feeding practices and ARV drug interventions to promote HIV-free survival of infants should be available to all pregnant women and mothers.

Avoiding harm to 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.

Safe replacement feeding

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:

  1. safe water and sanitation are assured at the household level and in the community; and
  2. the mother or other caregiver can reliably provide sufficient infant formula milk to support the normal growth and development of the infant; and
  3. 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
  4. the mother or caregiver can, in the first six months, exclusively give infant formula milk; and
  5. the family supports this practice; and
  6. 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).

The updated HIV and infant feeding: framework for priority action (WHO, 2012a) provided guidance to governments on key priority actions to create and sustain an environment that encourages appropriate feeding practices for all infants and young children while scaling up interventions to reduce HIV transmission.

Since 2010, evidence has become available from studies and programmatic reports about the effectiveness of health system or other community-based interventions in assisting mothers living with HIV to adhere exclusively to one feeding practice or the other.

At the guideline scoping meeting, Guideline Development Group members considered it important to review these data and guiding principles from 2010 and to consider formal recommendations on support to improve both breastfeeding and replacement feeding practices by mothers living with HIV. Guideline Development Group members noted that infant feeding practices strongly influence the risk of morbidity and mortality among all infants and children. Therefore, as the risk of HIV transmission decreases, the support to mothers living with HIV regarding infant feeding practices is likely to significantly influence HIV-free survival and the long-term health outcomes of HIV-exposed infants and children.

Summary of the evidence

Two systematic reviews were commissioned to inform consideration of these questions.

  1. Academy of Nutrition and Dietetics. Handu D, Acosta A, Moloney L, Wolfram T, Ziegler P, Steiber A. Effectiveness of interventions to promote exclusive breastfeeding in women living with HIV who are on antiretroviral therapy living in areas that promote exclusive breastfeeding due to limited resources for safe replacement feeding. (Annex 2).
  2. Academy of Nutrition and Dietetics. Handu D, Acosta A, Moloney L, Wolfram T, Ziegler P, Steiber A. Effectiveness of interventions to promote safe replacement feeding in women living with HIV that are living in areas that promote replacement feeding. (Annex 2; no published studies were identified).

A published systematic review that summarized evidence on the interventions to improve breastfeeding practices in the general population (Sinha et al., 2015) also contributed to the discussions.

3.

Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S, et al. Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104:114–34. [PubMed: 26183031].

Interventions to improve breastfeeding practices among mothers living with HIV

A systematic review (Academy of Nutrition and Dietetics, 2015, Annex 2) examined the effectiveness of interventions to promote the early initiation of and support for exclusive breastfeeding by women who are living with HIV receiving ART in areas that promote breastfeeding.

A total of 859 citations were identified. Thirteen studies met the inclusion criteria; these were conducted in Cameroon, India, Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe. Of these, one was a randomized controlled trial, seven cohort studies, four cross-sectional studies and one a pre-post study.

Five studies reported exclusive breastfeeding at six months, nine studies reported exclusive breastfeeding at three months, four studies reported early breastfeeding initiation within one hour of birth and six studies reported breastfeeding initiation.

The results from the randomized controlled trial (conducted in South Africa) indicated improved exclusive breastfeeding rates at three months but not of rates of early initiation of breastfeeding. The results from four cohort studies (three of fair1 quality and one poor quality) reported improved exclusive breastfeeding rates at three months following breastfeeding promotion interventions, two of which were statistically significant.

Two observational studies of low quality reported higher exclusive breastfeeding rates at six months among women who received interventions, and there was a positive dose–response effect between intervention visits and exclusive breastfeeding rates.

Evidence for breastfeeding initiation rates and early initiation is mainly supported by studies of low to very low quality. These six observational studies showed an increase in initiation rates post-intervention; however, none of these studies had comparison or control groups.

The review found that breastfeeding promotion and support favourably influenced exclusive breastfeeding and breastfeeding initiation rates. The studies also indicated that frequency of contact was associated with improved exclusive breastfeeding practices – more contacts were associated with higher exclusive breastfeeding rates. Combinations of group education and individual counselling sessions regarding infant feeding, involving fathers and other family members with community health workers and/or trained health-care workers and integrating programmes for preventing mother-to-child transmission of HIV along with access to ART each positively affected exclusive breastfeeding.

No studies reported on the effect of interventions on concurrent improvements in adherence to ART, even though such interventions may have been similar in nature.

Interventions to improve safe replacement feeding by mothers living with HIV

No published studies were identified that provided evidence on promoting and supporting safe and adequate replacement feeding practices by mothers living with HIV.

Interventions in the general population to improve breastfeeding practices

Sinha et al. (2015) evaluated the effect of interventions in the general population on early initiation of, exclusive and continued breastfeeding and any breastfeeding rates when delivered in five settings: (1) health systems and services; (2) home and family environment; (3) community environment; (4) working environment; and (5) policy environment; or a combination of any of the above. A total of 195 articles were included. They found that delivering interventions in a combination of settings led to greater improvement in breastfeeding rates. The greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates were seen when counselling or education were provided concurrently in home and community, health systems and community and health systems and home settings, respectively. Support of baby-friendly hospital interventions at the health system level was the most effective intervention in improving the rates of any breastfeeding. The authors concluded that improving breastfeeding rates requires delivering interventions in a combination of settings by involving health systems, home and family and the community environment concurrently.

In summary, indirect evidence from populations not affected by HIV demonstrates that exclusive breastfeeding rates and also continued breastfeeding can be improved by interventions at the policy level or health facilities and in communities. In general populations, the best outcomes are achieved when interventions are implemented concurrently through multiple channels. Cost-benefit studies were not identified.

As above, the values and preferences of representatives of national health authorities in the 22 priority countriesa for the Global Plan (UNAIDS, 2011) regarding infant feeding were captured in a survey. The findings are included in the decision-making table (Table 5) and reported in Annex 3.

Table 5Considerations when developing infant feeding recommendations in the context of HIV

SUPPORTING EVIDENCE AND ADDITIONAL CONSIDERATIONS
QuestionCan facility- and community-based interventions improve the quality of breastfeeding practices among mothers living with HIV?
BENEFITS AND HARMDo the desirable effects outweigh the undesirable effects?

☑ Yes
□ No
□ Uncertain		Interventions are likely to improve the quality and duration of breastfeeding and therefore the health outcomes of infants, children and mothers. The data from populations affected by HIV are consistent with the experiences in non-HIV settings.

Although the review identified no evidence, the Guideline Development Group considered that similar interventions to mothers living with HIV who are giving replacement feeds would also improve their quality and safety including preventing spill-overa effects into the non-HIV population.

Although not reported in the systematic reviews, interventions to improve feeding practices among mothers living with HIV are also likely to improve breastfeeding practices in the general population not affected by HIV.

The Guideline Development Group considered it likely that properly designed counselling and support interventions could simultaneously improve ART adherence and retention in care among mothers living with HIV.

aInappropriate increased use of replacement feeds among the general population as a result of HIV-related recommendations and practices among mothers living with HIV.
VALUES, PREFERENCES AND ACCEPTABILITYIs there important uncertainty or variability about how much people value the options?

□ Major variability
☑ Minor variability
□ Uncertain

Is the option acceptable to key stakeholders?

☑ Yes
□ No
□ Uncertain		The Guideline Development Group considered that interventions to support improved and safer infant feeding practices are likely to be very acceptable to mothers living with HIV.

The survey conducted among national health ministries before the guideline meeting found that health managers uniformly supported interventions to help mothers living with HIV to feed their infants appropriately and safely. Health services already provide some support for infant feeding practices, both to the general population and to mothers living with HIV. However, investment in these aspects of programme support is only very modest.

The Guideline Development Group also considered that health authorities and individual health workers would be very supportive of individual mothers and also linking with interventions taking place in communities, even if they were not initiated or coordinated by the health authorities.
FEASIBILITY AND RESOURCE USEHow large are the resource requirements?

□ Major
□ Minor
☑ Uncertain

Is the option feasible to implement?

☑ Yes
□ No
□ Uncertain		The investment required to improve health worker skills and competencies to support early initiation of, exclusive and continued breastfeeding may be significant.

Interventions, such as supervision, may also require significant resources to sustain them over time.

However, the initial costs may be offset by long-term health benefits in the entire population (they would be cost-effective). These costs need to be considered when health funds are allocated.

Investment should be commensurate with the value of the intervention and health outcome: that is, major resources may be needed but would be fully justified.
EQUITYWould the option improve equity in health?

☑ Yes
□ No
□ Uncertain		Breastfeeding is one of the few types of health behaviour that tends to be more frequently practised among poorer communities than high-income populations.

Interventions to support and improve feeding practices among mothers living with HIV are likely to improve feeding practices in the entire population and therefore reduce inequity. They are also likely to reduce the negative effects of spill-overa messages in which mothers in the general population mistakenly adopt practices specific to mothers living with HIV.

Improving feeding practices is likely to improve health outcomes most in the more vulnerable populations.

Multiple analyses in non-HIV populations have shown that improved breastfeeding tends to improve health equity.
a

Inappropriate increased use of replacement feeds among the general population as a result of HIV-related recommendations and practices among mothers living with HIV

1

The authors of the systematic review used the terms “good, fair and poor” to assess the quality of the evidence.

a

Angola, Botswana, Burundi, Cameroon, Chad, Côte d'lvoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.

RECOMMENDATION 2

In settings where maternal, newborn and child health services promote and support breastfeeding and ART to increase HIV-free survival among infants born to mothers living with HIV.

National and local health authorities should actively coordinate and implement services in health facilities and activities in workplaces, communities and homes to protect, promote and support breastfeedinga among women living with HIV.

a

Breastfeeding as recommended by WHO is defined as: (1) initiating breastfeeding within the first hour of life; (2) exclusive breastfeeding for the first six months of life (that is, the infant only receives breast milk without any additional food or drink, not even water); followed by (3) continued breastfeeding for up to two years or beyond (with introduction of appropriate complementary foods at six months); and (4) breastfeeding on demand -that is, as often as the child wants, day and night.

Strength of the recommendationStrong
Quality of the evidenceHigh quality of evidence
JustificationGuideline Development Group members emphasized that support for breastfeeding should be consistent across policies and programmes, health facilities and community activities for all women, including mothers living with HIV, to create an enabling environment for this practice. Support is needed not only at initiation and during the exclusive breastfeeding period but also to enable mothers to breastfeed for longer: that is, until 24 months or beyond. Therefore, this recommendation would have benefits across the whole population.

The group noted that the public health approach of national authorities promoting a single infant feeding practice among mothers living with HIV has resolved much of the confusion among health workers and communities regarding choice of feeding practice and that a recommendation to counsel and support breastfeeding should not be misunderstood as reverting to individual counselling about initial choice.

Although there was no published evidence base regarding support for safer replacement feeding, additional support by skilled health workers can probably make replacement feeding practices safer.

Long-term investment and sustained support for health workers at all levels are necessary to ensure continued capacity-building.
Implementation considerations
  • Community and health facility approaches to support improved infant feeding practices include:
    –

    combining group education with individual counselling sessions;

    –

    building the skills and competencies of health workers to deliver infant feeding counselling;

    –

    involving fathers and family;

    –

    involving community health workers and trained health-care workers; and

    –

    integrating programmes for preventing mother-to-child transmission of HIV with access to ART.

  • Outcomes are improved by more interventions being implemented concurrently and more frequent points of contact.
  • National authorities need to create and sustain an enabling environment that encourages appropriate feeding practices for all infants and young children while scaling up interventions to reduce HIV transmission. See the updated HIV and infant feeding: framework for priority action (WHO, 2012a).
  • Simple, consistent messaging is essential to support breastfeeding in the general population, including mothers living with HIV. Such messaging should address views and concerns related to the previous recommendations.
  • Health-care providers should be trained to implement national recommendations on infant feeding, including how to identify women who may not be able to breastfeed for medical reasons.
  • As stated in the 2010 WHO guidelines on HIV and infant feeding, health services need to support mothers living with HIV in their chosen feeding practices even when these are inconsistent with nationally recommended practices. This principle is still endorsed by WHO and remains relevant to these updated recommendations.
  • In settings in which national authorities recommend replacement feeding to mothers living with HIV, it is likely that similar coordinated support can improve the safety of replacement feeding practices.
  • WHO/Food and Agriculture Organization (FAO) guidance on safe preparation of powdered infant formula (2007) provides technical information that may be helpful in the context of HIV.
Research priorities
  • Which communication strategies and capacity development approaches are most effective for improving the skills and competencies of health workers to provide support to mothers living with HIV regarding infant feeding practices and adherence to ART?
  • Which communication strategies and engagement approaches are most effective at informing communities and giving confidence to mothers living with HIV regarding infant feeding practices and adherence to ART?
  • In the context of HIV, what support increases exclusive and continued breastfeeding in the general population?

3. What to advise when mothers living with HIV do not exclusively breastfeed

In settings where maternal, newborn and child health services promote and support breastfeeding and ART to increase HIV-free survival among infants born to mothers living with HIV:

If a mother living with HIV does not exclusively breastfeed, is mixed feeding with ART better than no breastfeeding at all?

  • Are ARV drugs effective in preventing the postnatal transmission of HIV through breast milk according to feeding modality?

Background

In 2003 and 2006, when no other interventions were available to reduce the risk of postnatal HIV transmission, WHO guidelines on HIV and infant feeding highlighted the increased risk of HIV transmission associated with mixed feeding in the first six months of life compared with exclusive breastfeeding (UNICEF et al., 2003; WHO et al., 2006).

Mixed feeding, also referred to as partial breastfeeding, is less protective against serious childhood illnesses such as diarrhoea and pneumonia than exclusive breastfeeding. This is true for both HIV-exposed and unexposed infants and children (Bahl et al., 2005). For this reason, WHO recommends exclusive breastfeeding for all infants in the first six months of life. Despite this, rates of exclusive breastfeeding globally have remained either static or increased only modestly (Victora et al., 2016). However, although exclusive breastfeeding provides the greatest benefits for both mothers and infants, even any breastfeeding is associated with improved survival and other health outcomes compared with no breastfeeding (Victora et al., 2016).

In 2010, the WHO guidelines presented high-quality evidence that ARV drugs are effective in reducing the risk of postnatal transmission. Studies confirming this outcome promoted and supported exclusive breastfeeding among the mothers living with HIV participating in the research. However, in these studies, transmission outcomes were not disaggregated according to infant feeding modality.

At that time, WHO infant feeding guidelines for HIV-exposed infants combined recommendations to prevent postnatal HIV transmission, that is, maternal or infant ARV drugs, with recommendations to protect against non-HIV morbidity and mortality, that is, exclusive and continued breastfeeding with appropriate complementary feeding. However, health workers were reportedly uncertain whether or not to promote and implement the WHO 2010 recommendation in settings in which rates of exclusive breastfeeding were low.

Recommendation included in the WHO 2010 guidelines on HIV and infant feeding (WHO, 2010b)

In settings where national authorities have decided that the maternal and child health services will principally promote and support breastfeeding and antiretroviral interventions as the strategy that will most likely give infants born to mothers known to be HIV-infected the greatest chance of HIV-free survival.

Mothers known to be HIV-infected (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.

At the scoping meeting, the Guideline Development Group advised WHO to clarify whether ARV drugs are effective in preventing the postnatal transmission of HIV among mothers living with HIV according to feeding mode: that is, both mixed-feeding and exclusive breastfeeding.

Summary of the evidence

Two systematic reviews commissioned for question 1 (duration of breastfeeding) provided evidence in consideration of this question.

  1. Chikhungu L, Bispo S, Newell ML. HIV-free survival at 12–24 months in breastfed infants of HIV-positive women on ART: a systematic review. (Annex 1a).
  2. Chikhungu L, Bispo S, Newell ML. Postnatal HIV transmission rates at age six and 12 months in infants of HIV-positive women on ART initiating breastfeeding: a systematic review. (Annex 1b).

The first review (Chikhungu et al., Annex 1a) examined the effectiveness of ARV drug interventions in promoting HIV-free survival among HIV-exposed infants by duration of breastfeeding and also according to early infant feeding practices. The systematic review did not identify any randomized controlled trials that directly compared these populations. The review therefore summarized data from cohort studies that reported HIV transmission rates and HIV-free survival among HIV-exposed infants according to early infant feeding practices. However, none reported differences between exclusively breastfed infants and mixed-fed infants (GRADE evidence profile, Annex 1a. Table 4).

The second review (Chikhungu et al., Annex 1b) summarized HIV transmission rates at six, nine and 12 months among infants born to mothers living with HIV who were receiving ART. The review specifically sought evidence regarding transmission rates among infants according to early infant feeding practices, especially among those who were mixed-fed in the first months of life compared with those who were exclusively breastfed.

No randomized controlled trial was identified that directly compared outcomes among infants who were exclusively breastfed versus mixed-fed - conducting a study of this type would be considered unethical.

Eleven studies were identified that provided potentially relevant data. Six provided estimates of postnatal transmission rates, excluding peripartum infections that were diagnosed before six weeks of age, among mothers living with HIV who were receiving ARV drugs. Seven studies provided similar information on transmission rates at age 12 months, five reported overall HIV transmission rates (including peripartum) and two reported postnatal transmission rates (GRADE evidence profile, Annex 1b, Table 7).

However, none of these studies disaggregated transmission rates by early infant feeding modality (exclusive breastfeeding or mixed feeding) among mothers living with HIV who were receiving ARV drugs; indeed, the majority of reports of these studies did not provide any details of feeding practices: that is, exclusive breastfeeding or mixed-feeding in the first six months. In all studies, mothers were recommended to exclusively breastfeed their infants for six months. Alvarez-Uria et al. (2012) noted that one of the children living with HIV was mixed-fed but did not provide the rate of transmission by feeding modality.

The principal investigators of 10 studies were contacted for additional information regarding how feeding type was assessed and supported during the study. Five confirmed that exclusive breastfeeding was promoted but not assessed as part of the study processes. It was assumed that some mothers would have exclusively breastfed up to five or six months as recommended, but others would have introduced other fluids, milks or solids: mixed-feeding. No study had transmission rates available that were disaggregated according to exclusive breastfeeding or mixed feeding where the mother was receiving lifelong ART.

Transmission rates reported by the respective studies in peer-reviewed literature therefore represented a mix of feeding practices. The Guideline Development Group noted the very low postnatal transmission rates when there were high levels of adherence to ARV drugs and viral loads were low. The Guideline Development Group considered that, although there was no direct evidence, it was very likely that ARV drugs were equally effective at reducing postnatal transmission whether mothers were mixed-feeding or were exclusively breastfeeding.

However, in the general population not affected by HIV, high-quality evidence indicates that predominant and partial breastfeeding are associated with improved health outcomes compared with no breastfeeding (Victora et al., 2016).

Table 6Considerations when developing infant feeding recommendations in the context of HIV

SUPPORTING EVIDENCE AND ADDITIONAL CONSIDERATIONS
QuestionIf a mother living with HIV does not exclusively breastfeed, is mixed feeding with ART better than no breastfeeding at all?
BENEFITS AND HARMDo the desirable effects outweigh the undesirable effects?

☑ Yes
□ No
□ Uncertain		Compared with exclusive breastfeeding, mixed feeding is associated with a greater risk of serious morbidity, such as diarrhoea and pneumonia and the related mortality among HIV-exposed infants and children. In the absence of ART, it is also associated with an increased risk of postnatal transmission of HIV.

However, compared with non-breastfeeding (replacement feeding) in resource-limited settings, mixed feeding in the first six months of life (more correctly referred to as partial breastfeeding) is associated with reduced morbidity among both HIV-exposed and unexposed infants (WHO, 2010b).

ARV drugs significantly reduce the risk of postnatal transmission – and appear to be effective when mothers living with HIV either exclusively or partly breastfeed. They also appear to be equally effective in reducing HIV transmission after six months of age when complementary foods are introduced, based on supportive evidence that ARV drugs reduce the transmission risks in the context of mixed feeding among infants younger than six months of age.

However, promoting breastfeeding and ARV drugs when mixed feeding is common may appear to endorse mixed feeding and undermine the principle of exclusive breastfeeding.

Clear messaging and supportive interventions in health services and activities in communities can promote and support exclusive breastfeeding in the general and HIV-exposed populations to achieve the best health outcomes (non-HIV-related) for mothers living with HIV and their infants.
VALUES, PREFERENCES AND ACCEPTABILITYIs there important uncertainty or variability about how much people value the options?

□ Major variability
☑ Minor variability
□ Uncertain

Is the option acceptable to key stakeholders?

☑ Yes
□ No
□ Uncertain		Breastfeeding is very acceptable to mothers living with HIV when ARV drugs are available. Clear messaging that confirms the effectiveness of ARV drugs in reducing postnatal transmission in the context of all feeding modalities would further increase acceptability and confidence.

Clarifying that exclusive breastfeeding is promoted to reduce non-HIV-related morbidity and mortality would provide insight for the rationale and also help to promote exclusive breastfeeding.

Clarifying the effectiveness of ARV drugs in reducing the risk of postnatal transmission is similarly likely to give added confidence to health workers. However, similar to mothers living with HIV, clear explanations and communication are needed in addition to training.
FEASIBILITY AND RESOURCE USEHow large are the resource requirements?

□ Major
☑ Minor
□ Uncertain

Is the option feasible to implement?

☑ Yes
□ No
□ Uncertain		There are minimal additional resource implications. Training and capacity development costs for health workers would be the most immediate requirement. An investment to improve counselling services to mothers living with HIV could also serve to improve services to the general population.

Clarifying evidence and optimal infant feeding practices among health workers would be very feasible, as would implementation by health workers.
EQUITYWould the option improve equity in health?

☑ Yes
□ No
□ Uncertain		The intervention may improve health equity, since any breastfeeding, especially in the poorest populations, reduces the risk of serious morbidity and mortality not related to HIV.

Improving feeding practices is likely to have the greatest positive impact on the health outcomes of the more vulnerable populations.

GUIDING PRACTICE STATEMENT1 1

Mothers living with HIV and health-care workers can be reassured that ARV treatment reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practising mixed feeding is not a reason to stop breastfeeding in the presence of ARV drugs.

Strength of the recommendationNot applicable
Quality of the evidenceVery low
JustificationThe Guideline Development Group unanimously agreed that this should not be a recommendation but instead should be presented as a guiding practice statement. Although the Guideline Development Group was confident of the efficacy of ARV drugs in reducing postnatal transmission even when mothers living with HIV are mixed feeding, the importance and value of exclusive breastfeeding for non-HIV-related health outcomes is such that no recommendation should be perceived as endorsing non-exclusive breastfeeding of infants in the first six months of life.

However, the group considered that it is equally important to clarify the efficacy of ARV drugs in reducing postnatal HIV transmission even when mothers are mixed feeding and that, although not optimal, mixed feeding while the mother is taking ART is better than not breastfeeding at all.
Implementation considerations
  • Implementing recommendations for mothers living with HIV should be contextualized first by the optimal infant feeding practice recommended for all mothers and infants: to exclusively breastfeed for six months and then introduce appropriate complementary foods and continue breastfeeding for 24 months or beyond.
  • When implementing recommendations for mothers living with HIV, national health authorities need to clearly communicate the hierarchy of what is ideal and how recommendations for mothers living with HIV are specific to their circumstances.
  • Programmes should develop clear messaging to avoid misunderstandings among health workers, mothers living with HIV and the general population. If this is not achieved, infant feeding practices and health outcomes among children could be substantially harmed.
Research priorities
  • How to improve exclusive breastfeeding rates among mothers living with HIV who are receiving ARV drugs

4. What to advise when mothers living with HIV do not plan to breastfeed for 12 months

In settings in which maternal, newborn and child health services promote and support breastfeeding and ART to increase HIV-free survival among infants born to mothers living with HIV:

If a mother living with HIV plans to return to work or school, is a shorter duration of planned breastfeeding with ART better than no breastfeeding at all?

  • What is the HIV-free survival of infants breastfed for durations less than 12 months compared with breastfeeding for 12 months?

Background

In 2010, WHO guidelines on HIV and infant feeding were updated to recommend that, in settings in which diarrhoea, pneumonia and undernutrition were still common causes of infant and child mortality, national health authorities should, while providing ARV drugs, promote and support breastfeeding among women and mothers living with HIV (WHO, 2010b). Such mothers were recommended to exclusively breastfeed their infants for the first six months of life, to introduce appropriate complementary foods thereafter and to continue breastfeeding for the first 12 months of life.

The recommendation was informed by evidence that breastfeeding in the first 12 months was associated with significantly lower mortality risks for infants. Studies had also reported low rates of postnatal HIV transmission associated with ARV drugs being given to lactating mothers living with HIV or HIV-exposed breastfeeding infants. Since then, studies in non-HIV populations have shown health benefits to mothers and infants with longer durations of breastfeeding.

Recommendation included in the 2010 WHO guidelines on HIV and infant feeding (WHO, 2010b)

In settings where national authorities have decided that the maternal and child health services will principally promote and support breastfeeding and antiretroviral interventions as the strategy that will most likely give infants born to mothers known to be HIV-infected the greatest chance of HIV-free survival:

Mothers known to be HIV-infected (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.

However, in both HIV-affected populations and in the general population, some women choose to breastfeed for durations less than 12 months or are unable to breastfeed for 12 months or more, because they go back to work or school and do not benefit from sufficient breastfeeding protection, promotion and support at the workplace.

Although longer durations of breastfeeding are generally considered better for the infant, the Guideline Development Group advised WHO to clarify whether, if a mother living with HIV plans to return to work or school, a shorter duration of planned breastfeeding with ART is better than no breastfeeding at all. The Guideline Development Group considered that the most relevant evidence to inform this decision would be the rates of HIV-free survival among infants breastfed for durations less than 12 months compared with breastfeeding for 12 months.

Summary of the evidence

One systematic review commissioned for question 1 (duration of breastfeeding) provided evidence in consideration of this question.

  1. Chikhungu L, Bispo S, Newell ML. HIV-free survival at 12–24 months in breastfed infants of HIV-positive women on ART: a systematic review. (Annex 1a).

The review (Chikhungu et al., Annex 1a) examined the effectiveness of ARV drug interventions to promote HIV-free survival among HIV-exposed infants according to early infant feeding practices, including the duration of breastfeeding in the first 12 months of life. The review summarized data from cohort studies that reported HIV transmission rates and HIV-free survival among HIV-exposed infants according to the duration of breastfeeding versus non-breastfeeding and by ART exposure. Four studies provided estimates of HIV-free survival by feeding modality; three reported higher HIV-free survival among breastfed infants than formula-fed infants (GRADE evidence profile, Annex 1a, Table 4). HIV-free survival among breastfed infants ranged from 82% (95% CI: 73.4–87.7%) [median weaning: five months] to 96% (95% CI: 91–98%) and in formula-fed infants from 67% (95% CI: 35.5–87.9%) to 97.6% (95% CI: 93.0–98.2%). All studies were graded as low or very low quality. (Additional details on this review are cited in the evidence summaries for questions 1 and 3 above).

The Guideline Development Group also noted the standing recommendations in the WHO 2010 guidelines on HIV and infant feeding that were informed by outcome data from infants according to feeding practices among mothers living with HIV who were not receiving lifelong ART (WHO, 2010b). The evidence that informed those recommendations highlighted:

Additional supporting evidence:

  • High-quality evidence from non-HIV settings that mixed feeding and non-breastfeeding are associated with increased morbidity and mortality.

In the general population not affected by HIV, high-quality evidence indicates that predominant and partial breastfeeding are associated with improved health outcomes compared with no breastfeeding.

Table 7Considerations when developing infant feeding recommendations in the context of HIV

SUPPORTING EVIDENCE AND ADDITIONAL CONSIDERATIONS
QuestionIf a mother living with HIV plans to return to work or school, is a shorter duration of planned breastfeeding with ART better than no breastfeeding at all?
BENEFITS AND HARMDo the desirable effects outweigh the undesirable effects?

☑ Yes
□ No
□ Uncertain		In the context of maternal ART, low-quality evidence shows that the HIV-free survival of infants born to mothers living with HIV who are breastfed is better than for infants who are never breastfed.

Data from low-and middle-income settings before the scaling up of ART for mothers living with HIV (in accordance with the 2010 WHO recommendations) demonstrated increased mortality and morbidity, including growth faltering, among infants of mothers living with HIV who were never breastfed or who stopped breastfeeding early. Among these infants, breastfeeding was never initiated or the duration of breastfeeding was limited to reduce the risk of postnatal transmission of HIV. In 2010, this evidence supported the principle that any breastfeeding is better than no breastfeeding at all. Comparable data from mothers receiving ART during the past five years were not identified.

When mothers living with HIV are receiving ART, the rationale for never initiating or reducing the duration of breastfeeding is even weaker, and programmes may focus their support on longer durations of breastfeeding.

Further, in populations not affected by HIV, morbidity and mortality are significantly increased among infants who are never breastfed compared with infants who are exclusively or predominantly breastfed. A dose-related effect is also reported: longer durations of breastfeeding are associated with better health outcomes among both mothers and infants. Even early initiation of breastfeeding in addition to short durations of breastfeeding result in health benefits for neonates and young infants and for older children.

More closely aligning the recommendations for mothers living with HIV with those for mothers without HIV is likely to improve practices across all populations.
VALUES, PREFERENCES AND ACCEPTABILITYIs there important uncertainty or variability about how much people value the options?

□ Major variability
☑ Minor variability
□ Uncertain

Is the option acceptable to key stakeholders?

☑ Yes
□ No
□ Uncertain		A recommendation would be likely to be acceptable to mothers. Clear messaging that confirms the effectiveness of ARV drugs with all breastfeeding durations would further increase acceptability and confidence.

For mothers returning to work or school, efforts and support could be focused on plans and support to enable them to continue breastfeeding, similar to mothers who do not have HIV.

A recommendation would be likely to be acceptable to health workers as long as it is accompanied by guidance on supporting breastfeeding among working mothers or mothers returning to school.

In the survey of health ministry officials (Annex 3), they considered clarifying the value of even short durations of breastfeeding to be advantageous. The value of harmonizing recommendations between mothers living with HIV and mothers in the general population was highlighted.
FEASIBILITY AND RESOURCE USEHow large are the resource requirements?

□ Major
☑ Minor
□ Uncertain

Is the option feasible to implement?

☑ Yes
□ No
□ Uncertain		There are minimal additional resource implications, but training and capacity development would be required.

However, support would be needed for breastfeeding at work – although this is also necessary for all mothers at work, not just those living with HIV.

Implementing this recommendation would be feasible.
EQUITYWould the option improve equity in health?

☑ Yes
□ No
□ Uncertain		This may improve health equity, since any breastfeeding, especially in the poorest populations, reduces the risk of non-HIV-related serious morbidity and mortality.

GUIDING PRACTICE STATEMENT2 2

Mothers living with HIV and health-care workers can be reassured that durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.

Strength of the recommendationNot applicable
Quality of the evidenceLow
JustificationThe Guideline Development Group considered the evidence from the systematic reviews that indicated that infants of mothers living with HIV benefited more from some breastfeeding than breastfeeding never being initiated at all. However, the Guideline Development Group did not want to make a formal recommendation in case it appeared to endorse shorter durations of breastfeeding being better than longer durations. The group felt that a guiding practice statement would respond to day-to-day realities and give sufficient guidance to deal with current situations.

Members of the Guideline Development Group emphasized that infants living with HIV are vulnerable and need breastfeeding the most, so this is one motivation to keep breastfeeding as long as possible. Where early infant testing is carried out, delivering the results should prompt a discussion on feeding, even in countries where formula feeding is the norm.

Accountability of community and service providers could help achieve the type of support needed for continued breastfeeding; however, national policy ensuring adequate maternity leave and maternity benefits will be required as a long-term solution for both non-HIV-affected and HIV-affected populations.
Implementation considerations
  • In all settings, implementing recommendations for mothers living with HIV should be contextualized first by the optimal infant feeding practice recommended for all mothers and infants: to exclusively breastfeed for six months, then introduce appropriate complementary feeds and continue breastfeeding for 24 months or beyond.
  • When implementing recommendations for mothers living with HIV, national health authorities need to clearly communicate the hierarchy of what is ideal and how the recommendations for mothers living with HIV are specific to their circumstances.
  • Programmes should develop clear messaging to avoid misunderstandings among health workers, mothers living with HIV and the general population. If this is not achieved, infant feeding practices and health outcomes among children could be substantially harmed.
Research priorities
  • How to support mothers living with HIV who are receiving ARV drugs to breastfeed for longer in circumstances such as when they return to work or school

Footnotes

1

A guiding practice statement is made to encourage action or clarify an issue of concern. It addresses an area of suboptimal practice and provides a contingency and guidance to health workers regarding how to respond to a specific challenge.

2

A guiding practice statement is made to encourage action or clarify an issue of concern. It addresses an area of suboptimal practice and provides a contingency and guidance to health workers regarding how to respond to a specific challenge.

Copyright © World Health Organization 2016.

All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: tni.ohw@sredrokoob).

Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO website (http://www.who.int/about/licensing/copyright_form/index.html).

Bookshelf ID: NBK379865
Contents

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (964K)

In this Page

Other titles in this collection

Recent Activity

ClearTurn OffTurn On

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...