New WHO guidelines on HIV and infant feeding

There has been significant programmatic experience and research on HIV and infant feeding since the World Health Organisation's (WHO) recommendations on infant feeding in the context of HIV were last revised in 2006. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This evidence has major implications for how women living with HIV might feed their infants, and how health workers should counsel these mothers. Together, breastfeeding and ARV intervention have the potential to significantly improve infants' chances of surviving while remaining HIV uninfected. This evidence informs the recently released 'Guidelines on infant feeding and HIV, 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence.' The guidance emphasises that HIV-free child survival - rather than HIV transmission - is the primary consideration.

While the 2010 recommendations are generally consistent with the previous guidance, they recognise the important impact of ARVs during the breastfeeding period. They recommend that national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be promoted at national and sub-national levels. This differs from the previous recommendations in which health workers were expected to individually counsel all HIV-infected mothers about the various infant feeding options.

The recommendation that replacement feeding should not be used unless it is acceptable, feasible, affordable, sustainable and safe (AFASS) remains, but the acronym is replaced by more common, everyday language and terms.

Where national authorities promote breastfeeding and ARVs, mothers known to be HIV-infected are now recommended to breastfeed their infants until at least 12 months of age. If social and environmental conditions are not in place for safe replacement feeding at this stage, breastfeeding should continue in line with recommendations for the general population.

Recognising that ARVs will not be rolled out everywhere immediately, guidance is given on what to do in their absence. When ARVs are not available, mothers should be counselled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding. In circumstances where ARVs are unlikely to be available, such as acute emergencies, breastfeeding of HIV-exposed infants is also recommended to increase survival.

Download the 2010 guidance, including supporting annexes, evidence and presentations at: http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html