Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1046-1047 (doi:10.1542/10.1542/peds.2008-0563)
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COMMENTARY

Breastfeeding and HIV Infection

William T. Shearer, MD, PhD

Department of Pediatrics, Section of Allergy and Immunology, Baylor College of Medicine, Houston, Texas

The breastfeeding of infants born to HIV-infected mothers is a subject of continuing debate among developed and developing populations in the world. HIV-infected mothers in developed countries almost universally do not breastfeed their infants because of an ~15% risk of HIV infection being transmitted in breast milk, particularly the cell-rich colostrum fraction of breast milk.1 Avoidance of breastfeeding under these conditions is strongly endorsed by medical experts,2 and their advice is well received by developed societies, primarily out of concern for the health of the infant but also for secondary concerns over loss of income, fast-paced styles of living, inconvenience, and beauty.

In developing societies, however, in which breastfeeding among birthing mothers is almost always the norm, public health concerns over HIV transmission with breastfeeding by HIV-infected mothers has sharpened a continuing debate.3–5 At issue are the serious concerns of diarrheal disease that causes death in HIV-exposed infants who are fed with milk formulas prepared by mixing milk powder with local water, which is almost always contaminated by sewage in impoverished communities. Thus, the extreme alternatives—breastfeeding and formula-feeding—expose the infants to either HIV infection or unremitting bacterial diarrhea, dehydration, and death.

Public health investigations have attempted to find a middle ground for the nutrition of infants born to HIV-infected women in developing countries that would spare them from HIV infection and chronic diarrhea caused by coliform bacteria. Clinical trials of shortened periods (eg, 4–6 months) of breastfeeding after birth followed by formula-feeding has yielded mixed results, with just as many infants dying from HIV infection as from diarrheal illness.6–14 In addition to physical health concerns for HIV-exposed infants in developing countries, there are powerful societal concerns that often force HIV-infected mothers to opt for breastfeeding no matter the risk to their infants.15 These societal concerns include disclosure of their HIV-infection status, inability to find a husband, and family pressure to follow this centuries-old norm of mother-infant bonding.

A new approach of prolonging the antiretroviral treatment of HIV-exposed infants directly or indirectly by treating the mothers for up to 6 months postpartum and at the same time having them continue to breastfeed their infants16–19 was reported at the 15th Conference on Retroviruses and Opportunistic Infection in February 2008. By extending the antiretroviral therapy of infants receiving breast milk the HIV infection rate was 50% lower than control breastfed infants who received antiretroviral drugs for 1 week. The death rate was similarly reduced in 1 study17 but not the other.16 Genotypic- and phenotypic-resistant virus was significantly increased in infants who received prolonged treatment with antiretroviral agents.18,19

These new findings that indicate a need for prolonged antiretroviral drug prophylaxis of breastfed infants who are born to HIV-infected women in developing countries are considerably appealing because they do not proscribe the natural form of infant nutrition that has protected infants from diarrheal illness when contaminated water is used to prepare infant formula. Also, the mother is not forced to admit her HIV-infection status by early discontinuation of breastfeeding. Just how long antiretroviral drug prophylaxis must be maintained to preserve the advantage of infection-free status in the 6-month prophylaxis trials will be the subject of continuing investigation. The threat of spreading antiretroviral drug resistance in the general population has not yet been realized, but it remains a significant threat in underdeveloped countries. It will be important to maintain vigilant long-term studies of the patients who are participating in these large-scale experimental therapies, not only for their own well-being but also for people of the entire world who could fall victim to multidrug-resistant HIV, given the present rapid transportation of infectious persons around an ever-shrinking planet.


   ACKNOWLEDGMENTS
 
Dr Shearer is supported by National Institutes of Health grants AI27551, AI069441, AI36211, HD41983, HD052102, RR0188, HL079533, HL72705, HL78522, and RAT003084A and contract AI41089; the Pediatric Research and Education Fund, Baylor College of Medicine; and the David Fund, Pediatrics AIDS Fund, and Immunology Research Fund, Texas Children's Hospital.


   FOOTNOTES
 
Accepted Feb 21, 2008.

Address correspondence to William T. Shearer, MD, PhD, Texas Children's Hospital, 6621 Fannin St, MC FC330.01, Houston, TX 77030. E-mail: wtsheare{at}texaschildrenshospital.org

The author has indicated he has no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.


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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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