Breastfeeding and the HIV positive mother: the debate continues Anna Coutsoudis * Department of Paediatrics and Child Health, Room 261, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Private Bag 7, Congella 4013, South Africa Abstract Breastfeeding is a route of HIV transmission from an HIV-infected mother to her infant. However, breastfeeding is an important pillar of child survival and the ideal way of feeding an infant as well as providing a unique biological and emotional basis for child development. This article highlights the dilemma created by the risks and benefits of breastfeeding and will discuss factors which increase the risk of HIV transmission during breastfeeding as well as strategies which could be employed to reduce these risks. Many questions still remain unanswered. Until further research results are available, women should be encouraged to follow the UNAIDS guidelines bwhen replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended, otherwise, exclusive breastfeeding (EBF) is recommended during the first months of lifeQ. Anti-retroviral therapy to the mother and/or infant is likely to offer the possibility of maintaining breastfeeding as a safe option for HIV-infected women. D 2004 Elsevier Ireland Ltd. All rights reserved. 1. Background This manuscript will only consider transmission of HIV-1 (subsequently referred to as HIV), as mother to child transmission (MTCT) of HIV-2 is rare. The subject of breastfeeding and HIV has become a highly emotive debate because of the polarisation between those whose mandate is preventing the spread of HIV (and would therefore see the importance of replacing breastfeeding) and those whose mandate is child survival and therefore promote breastfeeding as one of the pillars of child survival. Other reasons for the continued debate are the crude mortality rates; on the one hand, breastfeeding is thought to be responsible for about 300,000 HIV infections per year while UNICEF estimates that not breastfeeding is responsible for 1.5 million child deaths per year. The first report which drew attention to the possibility of HIV virus being transmitted through 0378-3782/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.earlhumdev.2004.10.010 * Tel.: +27 31 2604489; fax: +27 31 2604623. E-mail address: coutsoud@ukzn.ac.za. KEYWORDS HIV; Breastfeeding; Infection; Replacement feeding Early Human Development (2005) 81, 87—93 www.elsevier.com/locate/earlhumdev