Helping Women with HIV Decide About Breastfeeding:
What Family Planning Programs Can Do

A woman infected with HIV can pass HIV on to her child during pregnancy, birth, or breastfeeding. Transmission through breastfeeding is estimated to account for one-fourth to one-half of all mother-to-infant HIV infections, depending on the duration of breastfeeding. Yet among babies born uninfected and who are breastfed by untreated mothers with HIV, on average more than 80% remain uninfected when breastfeeding continues for two years.

Balancing the Risks An HIV-positive mother faces a difficult decision—whether to breastfeed or not. In developing countries diarrheal and respiratory diseases are common and often fatal to infants—and considerably more common and deadly for infants who are not breastfed than for those who are. Infants who do not breastfeed miss the early immunological protection conveyed by breastmilk, and they risk malnutrition and exposure to contaminated water. Breastfeeding could prevent many of these deaths—especially exclusive breastfeeding, because it promotes healthy weight gains during infancy. What Can Family Planning Programs Do? With support from health care providers, women with HIV can weigh the various risks and consequences in deciding whether to breastfeed and, if so, when to begin replacement feeding. Thus family planning providers need to become informed on the chances of mother-to-child transmission of HIV through breastfeeding, on ways to reduce the risk of transmission, and on how to help a woman to develop an infant feeding plan based on the woman’s situation. These topics should be integral components in providers’ training. Specifically, family planning providers can:

HIV Transmission Through Breastfeeding Can Be Reduced Shorter breastfeeding poses less risk. Breastfeeding for even a few weeks or months provides infants with nutrition and protection against illness. Women with HIV can breastfeed to provide these benefits and then stop breastfeeding early and all at once to reduce the chances of infecting their infants. Exclusive breastfeeding is less risky than mixed. Introducing other food or liquid early while breastfeeding increases the likelihood of HIV transmission. In Zimbabwe, among more than 4,000 HIV-positive mothers studied, infants who were mixed-fed for the first three months of life were four times more likely to have acquired HIV at six months than infants who were exclusively breastfed for the first three months.

Prevent unintended pregnancies: Help women who do not want to become pregnant choose a contraceptive method they can use effectively. This includes all women—those who know they are HIV-positive, those who know they are HIV-negative, and those who do not know whether they have HIV or not.

Help pregnant women avoid HIV infection: Pregnant women may acquire HIV more easily than women who are not pregnant, according to evidence from a study in Rakai, Uganda. If a woman and her sexual partner are at risk for HIV, they should consistently use condoms.

Offer counseling and testing: Routinely offer HIV counseling and testing to all pregnant women, or refer them to an HIV-testing service, so they can learn their HIV status. Many women are reluctant to get tested for fear of being stigmatized and condemned by their community if their infection becomes known. Others feel that testing is pointless because they cannot obtain treatment or access to good health care services. Providers can counsel women that knowing their HIV status is important to making informed decisions about their own health and the health of their infants. Also, providers can encourage every woman to seek testing together with her spouse or partner as a way to help overcome some of these barriers.

Provide referrals: Refer women with HIV who are pregnant, or who want to become pregnant, to services offering care for prevention of mother-to-child transmission. If antiretroviral treatment is available, refer women to it. Advise women that antiretroviral treatment can reduce the risk of HIV transmission from mother to child.

Encourage appropriate infant feeding: Counsel women infected with HIV on safe infant feeding practices to reduce the risk of transmission, particularly if treatment is not available. Help them develop a feeding plan based on their individual situation:

• Avoid any breastfeeding if replacement feeding is affordable, feasible, acceptable, sustainable, and safe. If replacement feeding meets these five criteria, the woman can consider either commercial formulas or home-modified animal milk. She will also need to have the utensils and skills to prepare them properly.
• Where replacement feeding is not possible, mothers with HIV should exclusively breastfeed their infants for the first months of life. Mixed feeding—breastfeeding and supplemental feeding—increases the risk of HIV transmission. To further reduce the risk of transmission, when mothers with HIV switch to replacement foods (at six months or sooner), they should stop breastfeeding all at once, with no period of weaning. Alternatively, mothers can express and heat-treat breastmilk before feeding it to their infants.
• Encourage women with HIV who are breastfeeding to maintain adequate nutrition, since HIV infection progresses more rapidly among women who are undernourished. Higher levels of HIV increase the chance that HIV will pass to infants through breastfeeding. Women with HIV should also be encouraged to keep their breasts healthy. Mastitis, breast abscesses, and nipple lesions increase the risk of HIV transmission. (Breastfeeding does not harm a woman’s own health or place her at higher risk of death while breastfeeding.)

Last Revised: 6/26/06
Produced in association with The Maximizing Access and Quality Initiative

Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Published with support from the United States Agency for International Development (USAID), Global, GH/POP/PEC, under the terms of Grant No. GPH-A-00-02-00003-00.