Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. OPINION HIV, infant feeding, and survival: old wine in new bottles, but brimming with promise Hoosen M. Coovadia a and Anna Coutsoudis b AIDS 2007, 21:1837–1840 A string of new studies, most of which have been presented at international meetings and are as yet unpublished, have resulted in a gathering momentum of interest in HIV and infant feeding. In rich and some middle-income countries, transmission of HIV antena- tally, and during labour and delivery, has been substantially reduced by antiretrovirals and other inter- ventions. Postnatal transmission was prevented by advising against breastfeeding; the alternative was replacement feeding with formula milks as these could be safely prepared, were affordable, and were culturally acceptable. The discourse on formula feeding or breastfeeding by HIV-positive mothers in developing countries has been mired in confusion or locked in robust disagreement. WHO/UNICEF/UNAIDS guidelines [1] offered a framework for making choices based on socio- economic conditions and household capability to prepare formula hygienically. The difficulty in the field was to offer an optimum balance of choices between the two types of milk feeding. Exclusive breastfeeding for 6 months is the recommendation for those choosing breastfeeding. Recent data from ongoing and completed studies in Africa have suggested that the effects of avoidance of breastfeeding or cessation even at 6 months by HIV-positive mothers can be disastrous. This finding repeats what has been and remains the bedrock of public health policy for infants and children well before the HIV epidemic, and recognized through centuries of human experience. The new findings have led to the WHO refining its Guidelines on HIV and Infant Feeding in late 2006. New data on HIV and infant feeding Results of recent studies and programmes to prevent mother-to-child transmission of HIV (PMTCT) allow examination of decisions which impact on infants receiving either no breastmilk at all or receiving breastmilk for short periods (4–6 months). The strongest data comes from randomized controlled trials (RCTs) [2,3]. In Botswana [2] infants were randomized to receive either breastfeeding or formula milk for 6 months. Replacement feeding did indeed result in fewer HIV infections but it also led to increased infectious disease mortality; at 18 months, the combination of HIV infection and mortality (the ‘HIV-free’ survival) in the two arms was similar. In Zambia [3], the effects of early cessation of breastfeeding at 4 months, compared to continued breastfeeding, was investigated. By 24 months, the HIV-free survival in the two groups was similar: 17% of 329 infants who stopped breastfeeding early had died, compared with 19% of 331 infants who continued receiving breastmilk. Therefore these two RCTs have shown that neither ‘no breastfeeding’ nor a short period of breastfeeding, holds any overall advantage over continued breastfeeding, as the decrease in HIV transmission is countered by an increase in infectious disease mortality. There are additional data. A study from Cote d’Ivoire [4] allowed women to choose either formula feeding from birth or exclusive breastfeeding from birth. HIV-free survival was similar in replacement fed and breastfed From the a Victor Daitz Professor of HIV Research, and the b Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Congella, South Africa. Correspondence to H.M. Coovadia, Victor Daitz Professor of HIV/AIDS Research, Nelson Mandela School of Medicine, University of Kwazulu/Natal, 719 Umbilo Road, Congella 4013, South Africa. E-mail: coovadiah@ukzn.ac.za Received: 8 March 2007; accepted: 15 March 2007. ISSN 0269-9370 Q 2007 Lippincott Williams & Wilkins 1837