What Works for Women and Girls

Infant Feeding Research Offers Complex and Contradictory AdviceIn the absence of HAART or safe conditions for infant feeding, questions remain on how longHIV-positive women should breastfeed to minimize the risk of HIV transmission but reducethe risk of their infant dying from diarrheal disease.While WHO recommends breastfeeding to avert infant deaths due to diarrheal disease,breastfeeding beyond six months increases the risk of HIV transmission to the infant. Onestudy analyzed the results of a clinical trial from 2001–2003 in Malawi, Tanzania and Zambiathat followed infants born to HIV-positive mothers over 12 months and found that of 1,979infants, 404 (20.4%) acquired HIV. Breastfeeding longer than six months increased risk ofHIV acquisition by infants. Late postnatal transmission was associated with lower CD4 cellcount and higher viral load at baseline. The analysis used data from the HIV Prevention TrialsNetwork Protocol, which was a randomized controlled trial. The trial provided counseling onbreastfeeding only with no information related to replacement feeding or other alternative andall women received nevirapine (Chasela et al., 2008).Infant feeding studies offer complex and sometimes contradictory advice on the best feedingpractices and the optimal time to wean for both averting HIV transmission and reducing infantmortality (Palombi et al., 2007; Kagaayi et al., 2008; Kuhn et al., 2009c; Kuhn et al., 2010;Taha et al., 2007; Becquet et al., 2008; Sarr et al., 2008; Kuhn et al., 2008; Thior et al., 2006;Leroy et al., 2008 cited in Gray and Saloojee, 2008; Becquet et al., 2007; Rollins et al., 2008).However, it is clear that for women who lack access to ARVs, the CD4 count is importantin the likelihood of HIV transmission to the infant (Kuhn et al., 2009c, Kuhn et al., 2010).Ultimately, HAART for the mothers improves the likelihood that infants will not acquire HIVvia breastfeeding (Kuhn et al., 2009c).Studies show that mixed feeding (when a mother both breastfeeds and provides any otherfood, in addition to breast milk), particularly prior to the infant being four to six months of age,can put the infant at a higher risk of acquiring HIV. Studies describe the increased statisticalrisk of the infant acquiring HIV when mixed feeding is used, but do not describe the mechanism.It may be that the immature gut mucosa in an infant can be damaged by the introductionof other foods and nonhuman milk, thus leading to increased permeability enabling HIVviral entry (Charurat et al., 2009) or it may be that when a mother does not breastfeed regularlyshe can develop mastitis, a painful inflammation of the breast. Mastitis may not alwaysbe severe enough to compel a woman to receive medical care, however, studies have shownthat HIV-positive women with even subclinical cases of mastitis have a higher viral load in thebreast milk of the affected breast (Nussenblatt et al., 2006, Kasonka et al., 2006, Kantarci etal., 2007). Further research is needed.“While the international guidelines of exclusive breastfeeding for a six month period seemto offer the least worst strategy for reducing mother-to-child transmission of HIV duringinfancy, while conferring some immunity through breastfeeding post six months….[this]translates into a complicated painful moral dilemma for HIV-positive mothers….” (Fletcher etal., 2008: 307). How to reduce transmission postnatally remains challenging, as HIV transmissioncan occur during breastfeeding by a woman living with HIV to the infant, but infant252 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION