Infant feeding practice for HIV-positive mothers has long been a controversial and difficult subject. In South Africa, clinicians have been divided between promoting exclusive breastfeeding (mainly in Kwazulu-Natal) versus formula-milk (mainly Western Cape and Gauteng). Recent studies have shown that the risk of transmitting HIV during breastfeeding can be reduced significantly by providing antiretrovirals (ARVs) to mothers or their infants. Government plans to implement a new policy on infant feeding from 1 April 2012, that states:
"HIV-infected women, who are breastfeeding should breastfeed exclusively for the first 6 months of life, introducing appropriate complementary foods thereafter, and continuing to breastfeed with daily nevirapine prophylaxis up to age of 12 months."
We agree that this is the best advice for many HIV-positive women. However, matters are not this simple. Two things need to be considered:
1. Many women are for various reasons unable to exclusively breastfeed. As scientists, clinicians and activists we cannot ignore this large group of women. Therefore the new policy must cater for these women.
2. The risks associated with formula feeding vary from place to place. It is probably riskier for a woman in rural Kwazulu-Natal to formula feed, than for a woman in Johannesburg. Programmes in Cape Town, Johannesburg and elsewhere have successfully implemented formula-feeding programmes with low transmission and mortality rates.
Many sites have already phased out the provision of formula milk. The policy requires that formula milk be phased out AND that antiretrovirals be introduced. Clinicians at successful predominantly formula-feeding sites are concerned that the first part of the policy will be implemented without the second part: the provision of ARVs. Sites should be able to implement the policy in a responsible, methodical way that does not put infants at unnecessary risk. The Department of Health intends to instruct sites to stop providing formula milk in April 2012 and to end formula milk provision in September 2012. We are concerned that this is too swift and sudden.
Our recommendations are therefore:
Patient education is critical: women should be counselled that the best option is exclusive breastfeeding with antiretroviral prophylaxis. However, women should not be made to feel ashamed if this does not work for them. If they choose not to breastfeed, they must be supported and counselled on how best to protect the health of their baby and themselves.
Prioritise provision of ARVs at PMTCT sites.
There should not be a sudden withdrawal of formula milk, especially at sites where formula milk provision has been successfully implemented.
For more information, contact Catherine Tomlinson on 021 422 1700 or email firstname.lastname@example.org
Treatment Action Campaign Press Release
(Health24, February 2012)