Beyond informed choice: infant feeding dilemmas for women in low-resource communities of high HIV prevalence

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University of Cape Town

Short regimens of anti-retroviral drugs can significantly reduce the transmission of HIV from mother to child which occurs around the time of delivery, but these drugs do not significantly reduce HIV transmission through breast-feeding. In order to prevent transmission, some have called for the provision of milk formula for HIV-positive women. However, linking milk formula, which is of questionable safety, with anti-retroviral drugs, which are of known benefit, may be dangerous. It may also delay implementation of programmes which provide wider access to anti-retroviral drugs, as well as making access to these drugs contingent (implicitly or explicitly) on willingness to use formula. Implementing international guidelines which support giving HIV-positive women an informed choice between infant feeding alternatives is difficult in practice. The focus on a dichotomised choice has the effect of neglecting to make each choice safer. New findings suggest that the magnitude of HIV transmission associated with breast-feeding can be substantially reduced with optimal breast-feeding practices, including those which maintain the exclusivity of breast-feeding and prevent the development of breast problems. These new findings have created greater awareness of the quality of breast-feeding and have drawn attention to serious deficiencies in the counseling services which assist women regarding lactation issues within maternal and child health services in general, and within programmes aimed at the prevention of mother-to-child HIV transmission in particular. Even if access to anti-retroviral drugs can be improved, training and motivation of counsellors will remain a cornerstone of programmes which are effective in preventing transmission of HIV to children.