Weighing the Risks
While breastfeeding provides an infant with the optimal nutritional start in life, it also carries a 10 to 20 percent risk of exposure to the virus if the mother is HIV-positive. Substituting breast milk with artificial replacement formula protects the infant from virus transmission during breastfeeding, but formula prepared in low-resource settings increases the infant's risk of death from diarrhea, malnutrition and respiratory infections. UNAIDS, UNICEF and the WHO advise that health-care managers conduct a thorough investigation into local infant feeding options and weigh the relative risks specific to each local context.

In accordance with this recommendation, researchers conducting an assessment in Ndola found that infant morbidity and mortality are high in Ndola, due to infectious diseases such as diarrhea and pneumonia; hygiene, sanitation and access to clean water are poor; the cost of breast milk substitutes is prohibitively high; and the availability of adequate health care is limited. Under these circumstances, the guidelines recommend breastfeeding as the safest option in Ndola, even when the mother knows she is HIV-positive. Current evidence suggests that even if conditions are hygienic and supplies of infant formula are available, mixing breastfeeding and formula feeding exposes the infant to the disadvantages of both methods, without providing the complete benefits of either.

In the Ndola study, all mothers were provided with information about feeding choices and offered the opportunity to learn their HIV status through confidential onsite counseling and testing services. A trained counselor guided each mother through the feeding choices and encouraged each to weigh the relative risks and benefits of infant-feeding options. In accordance with the findings of the local assessment, counselors in Ndola advised HIV-negative women and women who did not know their HIV status to breastfeed their infants exclusively for the first six months, and to continue breastfeeding while introducing supplementary foods for at least two years.

HIV-positive mothers were counseled about the option of exclusive replacement feeding, and warned of the negative effects of mixed feeding. The risks of morbidity and mortality from replacement feeding are greatest in the first few months of life and become lower over time, while the risk of HIV transmission continues for as long as the infant is breastfed. The Ndola guidelines recommend that HIV-positive mothers stop breastfeeding as soon as an infant can digest locally available alternative feeds, in order to reduce the duration of potential virus exposure.

Knowledge, Practices Improve
During the baseline interviews, researchers found that the mothers were already well aware of the possibility of HIV transmission from mother to child. However, most believed nothing could be done to prevent transmission. Twelve months into the intervention, though, more mothers were able to name some of the steps that could be taken to reduce mother-to-child transmission, including abstinence or condom use during pregnancy, labor management, and early weaning.

Following the intervention and enhanced counseling, the percentage of mothers in the community reporting they were exclusively breastfeeding rose from 56 percent to 76 percent, with fewer mothers reporting using the riskier practice of mixed feeding. This trend suggests that, with appropriate counseling, women not only maintain, but also increasingly adopt good breastfeeding practices -- even when the key message in the clinics that HIV can be passed from a mother to her child through breast milk has diffused to reach the wider community.

Exclusive replacement feeding and avoidance of breastfeeding remained unpopular, even among women who knew their HIV status, implying that mothers who knew they were HIV-positive were unwilling to refrain from breastfeeding. This may be due to the expense of purchasing infant formula supplies, the enormous effort involved in obtaining fuel and clean water for its preparation, or the stigma of suspected HIV-positive status associated with artificial feeding.

The study also revealed socio-cultural barriers within Ndola District that inhibit sexual communication and willingness to learn one's HIV status. Status disclosure and risk-reduction discussions between partners remain limited. The survey revealed that VCT is widely perceived not as a source of important information about one's health and about service options, but rather as a source of stress, since there are few treatment options for those who learn they're HIV-positive.

At the clinics, researchers observed that logistical obstacles, including the availability of test kits and other supplies, hampered achievement of some of the intervention's programmatic goals. They recommended that facilities further improve routine services at the same time as adding enhanced PMTCT services. Another important finding is the value of establishing strong community links for providing support structures and continuity of care for both new mothers and people living with HIV/AIDS in general.