Breastfeeding provides a miraculously complete food for the infant. The World Health Organization (WHO) recommends that infants should be exclusively breastfed until six months of age, and from six months children should have appropriate and nutritious complementary feeding with continuous breastfeeding until two years of age and beyond.

Breastfeeding is not only good for the child; it has health benefits for the mother, because it reduces the risk of postpartum hemorrhage as well as breast and ovarian cancer. Exclusive breastfeeding for six months also makes it less likely that a woman will conceive again before her infant is six months old.

The WHO recommendation of exclusive breastfeeding for six months is important for all children, as breastmilk is the natural food for all infants. In low-income countries, breastfeeding is almost irreplaceable. It provides all the Recommended Daily Allowance of nutrients (RDA) for a baby of 0-6 months; 50% of RDA for a child of 6-12 months and 35% of RDA for a child 12-24 months. No other food or liquid can achieve this. Artificial feeding is very dangerous in poor communities, because poor mothers are often likely to mix infant formula with unclean water, or dilute it too much, stretching it so that it can reach month end. Many a time mothers will no longer afford it after the baby has become dependent upon it and the mother has ceased to produce breastmilk.

There is a high risk of diarrhea in using artificial feeding in poor communities. A WHO study in 2000 showed, on average, a six-fold increase in deaths from diarrhea when mothers switched from breastfeeding to the use of infant formula and other infant foods.

Despite these serious factors, social pressures of various kinds particularly from employment outside the home without adequate social support cause many African mothers not to practice exclusive breastfeeding for 6 months, or to breastfeed for shorter durations and significantly less often now than in earlier generations. Even more seriously, companies that manufacture infant formula now promote their products insistently to mothers for whom it is not appropriate.

IBFAN Africa was set up over twenty five years ago to respond to these anti-breastfeeding pressures, both through conducting advocacy at the national level and through working with mothers at the community level.

HIV/AIDS has enormously complicated breastfeeding, because when inadequate data was available about postnatal transmission of HIV, it was mistakenly assumed that the solution should be artificial feeding for all HIV positive mothers. Promotion of breastfeeding declined and although mothers continued to breastfeed, they lost the necessary support for it, from health workers and therefore tended to mix breastfeeding with formula milk or solid foods from very early days. This has had ill consequences for child survival.

The WHO/ UNICEF/UNAIDS policy of 2000, considered infant feeding in the context of maternal HIV infection and recommended that HIV positive mothers avoid breastfeeding “where artificial feeding is acceptable, feasible, affordable, sustainable and safe……. …otherwise exclusive breastfeeding was recommended during the first months of life; and those who choose other options should be encouraged to use them free from commercial influences”.. (IATT 2000, WHA Resolution 54.2 May 2001).

Although the policy was sound, its implementation was difficult on the ground for several reasons:

a) There was no allocation of resources towards its implementation both from the government and donors.

b) The training of health workers on counselling skills was inadequate due to inadequate resources.

c) No adequate follow-up schedules were planned in many programmes.

d) Mothers were therefore, not counselled appropriately to make informed decisions about feeding options.

e) It was difficult to find a suitable replacement for breastfeeding in many poor communities.

Optimal skills for counselling are not widely possessed, and need time to develop and apply. But if enough investment can be put into consistent and quality counseling, it would save thousands of lives.

It must be remembered that until the advent of HIV, the choice for most mothers in Africa was obvious. Mothers everywhere instinctively understand breastfeeding. For poor mothers in Africa often illiterate, untrained in using measurements, and not in a position to turn on a light or boil some water in the middle of the night the use of artificial feeding is completely counter-intuitive. However, these mothers are understandably now nervous about breastfeeding when HIV positive, because of the possibility of transmitting the HIV virus to their children. They therefore, often opt for infant formula or other replacement feeding methods. Yet in many situations, the infants of HIV-positive mothers are more likely to die as a result of the mothers shifting away from breastfeeding than they are from transmission of the HIV virus through breastfeeding. Furthermore, many of the mothers who are turning away from breastfeeding because of the fear of HIV transmission are not, in fact, HIV-positive, but don’t have access to the testing that will show this.

Serious weakness of current programmes are that those involved in running them generally don’t have expertise in the complex matter of how an HIV-positive mother should be counselled effectively to make an informed decision about how to feed her infant. New programme data in Africa clearly indicates that inaccurate, insufficient, or non-existent infant feeding counselling in PMTCT programmes has led to inappropriate feeding choices by both HIV-affected and un-affected mothers. This is because of the spill over effect both in terms of inaccurate messages and/or incorrect practices observed from PMTCT programmes by communities. This means that there are higher risks of mortality for all infants as most of them are mixed fed.

The new Consensus Statement of the WHO/UNICEF on HIV and infant feeding (January 2007) has clearly related findings that pose a difficulty in implementing the current policy (WHO, 2000) as it is. The statement has stated that:

· Exclusive breastfeeding for up to six months is associated with up to 3 or 4 times decrease in risk of HIV transmission from the mother to the child compared to mixed feeding.

· New evidence on morbidity suggest that early breastfeeding cessation (at 4 months) was associated with reduced HIV transmission but also with increased child mortality from 4-24 months and that breastfeeding of HIV infected infants beyond six months improved survival of children compared to artificial feeding. · Programme data clearly indicated that adherence to exclusive breastfeeding to six months can be achieved through effective quality (consistent messages, constant support) counselling.

These findings have led the WHO/UNICEF to come up with a CONSENSUS STATEMENT that makes some modifications to their formal guidelines on HIV and infant feeding of 2000. The statement in summary reads:

· Exclusive breastfeeding is recommended for HIV infected women for the first 6 months of the baby life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe.

· After 6 months if replacement feeding still does not meet the AFASS criteria, continued breastfeeding with complementary feeding is recommended while the baby is continually assessed.

· Governments and other stakeholders should revitalise breastfeeding protection, promotion and support in the general population, and of HIV positive mothers who decide to breastfeed.

· Governments should ensure that the full package of interventions for PMTCT as well as the conditions stated in the current guidelines is available before consideration is made for distribution of free infant formula.

These new recommendations place IBFAN in a unique position, the position IBFAN has always held that breastfeeding being a natural food must have unique benefits against HIV and AIDS. Through its decades of experience and its dozens of member organizations in African countries, IBFAN can and has made major contributions in counselling mothers including those who are HIV-positive on how best to improve the chances that their child will survive and be protected from contracting the HIV virus.

In this AIDS epidemic IBFAN expertise and network of community-based organizations are more needed than ever before and resources should be made available in Africa for IBFAN to make a major contribution in this area.

During the 1990s, modest improvements were made in exclusive breastfeeding for the first four months of life. Rates increased from 48 to 52%. Timely complementary feeding has also improved with levels increasing from 43% to 49% between 1990 and 2000. The proportion of infants still breastfeeding at one and two years of age, increased only slightly. Much work still needs to be done to improve feeding practices of all infants but especially exclusive breastfeeding for 6 months. This is critical in reducing HIV transmission from the mother to the infant and ensuring child survival and development for all children.

Recent research by Coovardia H.M (Lancet Vol. 369 March 2007) has made very valuable findings for Africa and the developing world. The researchers from the Africa Centre for Health and Population Studies have found out that there is only a 4% risk of postnatal transmission of HIV to infants who are exclusively breastfed from 6 weeks to 6 months of age. The researchers are now calling for the United Nations Guidelines to be changed to promote exclusive breastfeeding for mothers in developing countries. This study has serious implications for resource poor countries where over 60% of populations live below the poverty line. According to the study, infants who receive supplements such as commercial formula or cow milk were two times as likely to be infected as infants who were solely breastfed, while those given solids in addition to breastmilk were 11 times more likely to be infected than those who exclusively breastfed.

The study that involved around 2700 babies born between 2001 and 2005 further found that the death rate by 3 months of age for babies who were exclusively breastfed was less than half that of infants who received formula milk alone. Over 15% of babies whose HIV positive mothers did not breastfeed them died by 3 months compared to only 6% of the babies whose mothers breastfed them exclusively.

This is a ground breaking study as UNAIDS estimates that, an infant who is breast-fed by an HIV-positive mother has a ten to twenty percent chance that it will become HIV-positive. The natural conclusion in current PMTCT (Prevention of Mother-To-Child Transmission of HIV) programmes was that such infants should, instead, be fed with artificial food infant formula, other milks and infant food. But, unfortunately, the obvious answer is not always the right answer. When infants are switched from breastfeeding to feeding by other methods, there is the chance that the infant will die from diarrhoea and other childhood diseases, because of reduced immunity and early exposure to infection in the environment, especially when the infant is still too young. This problem is particularly serious in poor communities when, as a result of poverty, the mother may have no choice but to mix the milk powder with unclean water. In addition the mother may also dilute the infant milk excessively to stretch it out over longer periods, or simply reach the point that she can no longer afford to purchase adequate amounts.

It is therefore critical that families and mothers are counselled optimally so that they understand the basic principles and criteria for deciding on the feeding option.

Through this programme area, IBFAN conducts the following:

1. IBFAN advocates for all pregnant women to receive counseling and testing.

2. IBFAN trains health workers on appropriate HIV and infant feeding counseling and breastfeeding counseling using the WHO materials

3. IBFAN promotes development of networks that can reach out to grassroots organisations, communities and individuals and be able to deliver ‘tailor-made’ messages and follow up of individual mothers according to their needs. This requires an often one-to-one approach with the target group.

4. IBFAN continuously researches for new data and disseminates it to al government workers, development workers and its network at all levels to facilitate appropriate actions at all levels

5. Governments are also supported in drafting and implementation and monitoring of the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions. National and international companies need to be urged to abide by them. At the Africa regional level IBFAN has done significant work in this area; it is crucial that in-country networks develop sufficient capacity to monitor and follow up as well, especially in the complex context of HIV/AIDS.

6. Governments are also being supported to develop national policies, guidelines and strategies to optimally implement infant and young child feeding in the context of HIV

7. IBFAN is now doubling its efforts to strengthen its links with the grassroots through their in-country networks and mother/father and youth support groups so that there can be improved support for maternal, neonatal and child health.

8. IBFAN is also planning an operational research on effective counseling on HIV and infant feeding in five countries: Swaziland, Mozambique, Zambia, Uganda and Tanzania, if funding should be available.

9. At the international level, IBFAN participates in global consultations to share its views based on its field experiences to help guide global policies and agendas on HIV and infant feeding.

10. IBFAN has and participates at the different levels in the development and pre-testing of global policy and training tools, the process usually spearheaded by the WHO.

Read More:

* Infant Feeding Options in HIV
* HIV and The Code
* WHO HIV and Infant Feeding Technical Consultation
* IBFAN Statement on HIV and Infant Feeding
* WHO HIV and Infant Feeding Technical Consultation
* Declaração de Consenso da OMS sobre HIV e Alimentação Infantil