Ted Greiner (
Katherine Krasovec, Program for Appropriate Technology in Health, Seattle, Washington, United States of America
Catherine Wilfert, Elizabeth Glaser Pediatric AIDS Foundation, Chapel Hill, North Carolina, United States of America
The authors have declared that no competing interests exist.
We wholeheartedly agree with Paul Farmer and colleagues [
While exclusive replacement feeding reduces the risk of transmission between HIV-positive mothers and their infants, it does not adequately address the specters of infection and undernutrition that accompany avoidance of breast-feeding. We are convinced—by data from regions that are similar to Rwanda and even from African countries with higher standards of living—that replacement feeding from birth is a dangerous and inappropriate approach for HIV-affected families in countries like Rwanda.
In addition, avoiding breast-feeding from birth can be exceedingly risky, particularly in the same regions where the risk of mother-to-child transmission of HIV is highest. While Partners in Health (PIH) offers high-quality health-care support and financial assistance to reduce the risks associated with breast-feeding avoidance in two districts in Rwanda, it is impossible to eliminate those risks. Researchers have found that children in Ghana, Peru, and India who are not breast-fed between the ages of six weeks and six months have a ten-fold higher risk of death [
Given that breast-feeding avoidance increases the risk of death from other causes, even as it decreases the risk of HIV transmission, is there a net gain? The concept of “HIV-free survival” combines the likelihood of surviving with the likelihood of not becoming HIV infected, allowing a more comprehensive assessment of the risks and benefits of infant feeding. In Botswana [
The risk of mother-to-child HIV transmission in the first six months in a country like Rwanda, where 81% of women are still exclusively breast-feeding at four to six months [
Scientific evidence amply demonstrates the significant risks that accompany replacement feeding and the safety and effectiveness of exclusive breast-feeding for the first six months, and continued breast-feeding thereafter as appropriate and safe. Around the world, researchers, programmers, and policy makers are becoming increasingly convinced that the infant feeding counseling component of prevention of mother-to-child transmission of HIV programs must focus on optimizing HIV-free survival rates, not simply on HIV transmission. Accomplishing this means taking full account of all factors, both social and molecular, that are at work in a particular context, and tailoring responses to meet them.