What Works for Women and Girls

postnatal HIV transmission. These interventions included: 1) decreasing the duration ofbreastfeeding through complete avoidance or early cessation; 2) lowering maternal viral loadin breast milk through the use of maternal antiretrovirals or treating breast milk with heator chemicals to deactivate the HIV virus; 3) providing mothers with adequate education andcounseling so that they understand how to breastfeed properly and the importance of exclusivebreastfeeding when exclusive replacement feeding is not feasible, and how to treat breastabnormalities such as mastitis (which increases the risk of transmission); and 4) improvinginfant’s defense against HIV transmission through extended antiretroviral prophylaxis duringbreastfeeding (Horvath et al., 2009). “Identified risk factors for transmission during breastfeedinginclude increased severity of maternal disease, mastitis and breast abscess, mixedinfant feeding, maternal seroconversion during lactation, lower maternal CD4 cell count, andhigher maternal HIV viral load” (Mmiro et al, 2009: 32).Formula Feeding May Increase Infant Mortality Where There is No Access to CleanWaterInfant formula feeding may avert transmission of HIV via breastfeeding. However, there aremore than one billion people globally without adequate access to clean water, leading to over1.8 million child deaths from diarrhea and other diseases caused by unclean water and poorsanitation. In settings prevalent in most of the developing world where there is no accessto safe, clean drinking water, HIV-positive women who use infant formula may see theirbaby, who was born HIV-negative, die from diarrheal diseases if fed formula. “Several studiesconfirm that the benefits of shortening breastfeeding are offset by adverse outcomes in thoseinfants who escape infection” (Kuhn et al., 2009a: 83). Globally, breastfeeding leads to about300,000 HIV-positive infants every year, while at the same time, UNICEF estimates that notbreastfeeding and having infants formula fed with contaminated water leads to approximatelyone and a half million child deaths per year (Fletcher et al., 2008). Additionally, concerns havebeen raised that promoting infant formula as a best practice to prevent vertical transmissionmay have negative consequences by decreasing breastfeeding of infants.For women who do not have access to ARVs for either treatment or MTCT prophylaxis andwho do not have access to clean water to make formula feeding safe, health providers have beenadvising breastfeeding. Many studies have shown that mixed feeding increases the risk of HIVtransmission from the HIV-positive mother to her infant. Experts thus advise that it is betterfor an HIV-positive mother to exclusively breastfeed than to breastfeed and add any additionalnutrition in the way of food or water prior to six months (Kuhn et al., 2009a). After six months,for HIV-positive mothers who do not have access to clean water, infant survival is increased bycontinued breastfeeding and adding additional nutrients for the child. Breastfeeding beyondsix months, however, may increase the risk of HIV infection of the infant to 9.68% by the timethe infant is two years old (Taha et al., 2007). Experts advise that infants who are HIV-positiveshould be breastfed. However, in most cases, the choice of feeding is often decided before themother knows her infant’s serostatus.250 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION