Table 1 Summary of changes to WHO-led infant feeding guidelines for women living with HIV in resource limited settings
Year | 1992 | 1998 | 2001 | 2006 | 2010 | 2013 | 2016 |
|---|---|---|---|---|---|---|---|
Document Title | WHO/UNICEF Consensus Statement on HIV and Breastfeeding [7] | A Review of HIV Transmission through Breastfeeding [8] | New data on the prevention of mother-to-child transmission of HIV and their policy implications: conclusions and recommendations [9] | HIV and Infant Feeding: update based on the technical consultation held on behalf of the Inter-agency Task Team on the Prevention of HIV Infections in Pregnant Women, Mothers and their infants [10] | Guidelines on HIV and infant feeding 2010: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence [11] | Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection [12] | Guideline: updates on HIV and infant feeding: the duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV [13] |
Maternal treatment in postnatal period | Not discussed | Not discussed for breastfed infants | Antiretroviral (ARV) prophylaxis recommended, but drug and duration to be decided locally among regimens shown to be effective in Randomized Controlled Trials (RCTs) | ART if required for mother’s health or maternal ARV prophylaxis through 7 days after birth | Lifelong ART if required for mother’s health or ARV prophylaxis through pregnancy until one week after breastfeeding ends | Lifelong ART regardless of CD4 count or clinical stage | Lifelong ART regardless of CD4 count or clinical stage |
Infant treatment in postnatal period | Not discussed | ARV prophylaxis (prophylactic efficacy unknown for breastfed infants) | ARV prophylaxis recommended, but drug and duration to be decided locally among regimens shown to be effective in RCTs | ARV prophylaxis for 7 days after birth | If mother not on treatment, daily ARV prophylaxis until 1 week after breastfeeding ends (minimum 4 weeks) or if mother on ART for own health, ARV prophylaxis from birth to 4–6 weeks | ARV prophylaxis from birth to 6 weeks | Not discussed |
Infant feeding recommendations for first 6 months | Women should be encouraged to breastfeed regardless of HIV status | 1-Replacement Feeding (RF) if possible 2- Breastfeeding with early cessation 3-Treatment of expressed breastmilk 4-Wet nursing | 1-RF if AFASS criteria met 2-Exclusive breastfeeding (EBF) for the first few months of life (up to six months) | 1- EBF unless AFASS criteria fully satisfied 2-Replacement feeding if AFASS criteria satisfied | EBF | EBF | EBF |
All breastfeeding should end | Not discussed | As early as possible | Before 6 months | At 6 months, only if adequate diet is available | At 12 months, only if adequate diet is available | At 12 months, only if adequate diet is available | 24 months or beyond (unrestricted) in the context of full support of ART |
After EBF ends | Not discussed | Replacement feeding | Replacement feeding | Complementary foods can be introduced at 6 months if replacement feeding is not AFASS | Complementary foods should be introduced at 6 months | Complementary foods should be introduced at 6 months | Complementary foods should be introduced at 6 months |
Breastfeeding cessation | Not discussed | Wean as soon as and as quickly as possible | Wean as soon as and as quickly as possible | Wean over a period of 2–3 days up to 2–3 weeks | Wean over a one month period | Wean over a one month period | Wean over a one month period |
Counseling | Encourage breastfeeding | Informed decision by mother based on all available options | Informed decision by mother based on all available options | Simplified counseling: only RF and EBF are discussed. | Recommend a single infant feeding option as the standard of care (though maternal and infant treatment may differ) | Recommend a single infant feeding and maternal and infant treatment option as the standard of care | Recommend a single infant feeding and maternal and infant treatment option as the standard of care |
Key Evidence | Risk of HIV transmission through breastfeeding was thought to be relatively small [7] | A 1992 Meta-analysis revealed that the risk of HIV transmission through breastmilk was much higher than previously described [14] | Results from a 1999 prospective cohort study showed that EBF in first three months had a much lower risk of HIV transmission than mixed feeding and similar to RF [15] | Evidence reinforced the risk of HIV transmission through mixed feeding and higher rates of child survival through six months of EBF [16, 17] | Evidence of reduced HIV transmission through EBF compared to mixed feeding [18] and results showing reduced transmission risk to < 2% with ART [3, 19] and infant prophylaxis [20] during 6 months of EBF. New evidence showed that abrupt weaning was detrimental to HIV-free child survival [24] | Desire to reduce barriers for pregnant and breastfeeding women to access ART given its demonstrated ability to reduce perinatal HIV transmission [12] | Update to infant feeding guidelines was deemed necessary in light of the introduction of lifelong ART and in response to evidence of the benefits of unrestricted breastfeeding duration among WLWH supported on ART [21,22,23] |