AIDScience Vol. 1, No. 4, July 2001 Problems and advances in reducing transmission of HIV-1 through breast-feeding in developing countries H. M. Coovadia and A. Coutsoudis 1 * 1 Department of Paediatrics and Child Health, Nelson R. Mandela School of Medicine, University of Natal, Private Bag 7, Congella 4013, South Africa. * To whom correspondence should be addressed. E-mail: coutsoud@nu.ac.za Abstract. The additional risk of an infant acquiring human immunodeficiency virus type 1 (HIV) from its HIV+ mother during breast-feeding is about 15% after 24 months and depends on the duration of breast-feeding. This statistic has been exploited to inflate the disadvantages of breast-feeding. It may be more pertinent for health workers to quote a risk of about 5% if breast-feeding is practiced for 6 months, as will be the case in many programs that recommend shorter periods of breast-feeding for HIV-infected women. This review covers recent studies that highlight methodological complexities, the hazards of formula feeding in Africa, and the finding that the type of breast-feeding may influence transmission risks. Important additional risk factors include breast-milk cell-free viral load and breast health including subclinical mastitis. Interventions that have the potential to reduce breast-feeding transmission include safer obstetric practices, prevention and treatment of infant oral thrush, lactation management, shorter duration of breast-feeding, exclusive breast-feeding, antiretrovirals (to mother and infant) during breast-feeding, and heat treatment of expressed breast milk. HIV-infected mothers should be counseled to avoid any new HIV infection by abstaining from sex or using condoms. Introduction Overall transmission rates of human immunodeficiency virus type 1 (HIV) from mothers to their infants have recently been reported to be between 30% and 45% (1) and 14% to 42% (2). However, mother-to-child transmission rates should be qualified by the presence or absence of breast-feeding. Mother-to-child transmission of HIV occurs during the intrauterine and intrapartum periods and during breast-feeding. In the absence of interventions, the absolute risk of transmission through each of these routes is about 7%, 13%, and 15%, respectively (1). Differentiating between intrapartum and early breast-feeding transmission of HIV will always be difficult because it is not possible to distinguish between the two in breast-feeding women. Data from studies of non-breast-feeding women suggest that intrapartum transmission of HIV is progressively detected up to about 6 weeks. This is probably due to HIV viral loads below the level of detection of currently available tests. We, therefore, have no guarantee, except in a randomized controlled trial (RCT), that the difference in the rate of HIV transmission at 6 weeks for women who breast-feed their children and for those who do not is due to transmission Science's AIDS Prevention and Vaccine Research Site http://aidscience.com/Articles/aidscience004.htm (1 of 12) [7/5/2001 3:57:29 PM]