Issues, risks, and challenges of early breastfeeding cessation to reduce postnatal transmission of HIV in Africa

Indirect evidence collected so far suggests that exclusive breastfeeding followed by a rapid transition to exclusive replacement feeding may be one of the safest feeding options for HIV-positive mothers. One challenge associated with this "modified breastfeeding" -- exclusive breastfeeding followed by a relatively rapid transition to exclusive replacement feeding -- is that it conflicts directly with current infant feeding patterns in Africa. Most African women breastfeed for about 2 years but seldom practice exclusive breastfeeding. Abrupt weaning does occur, but it is most frequently practiced in the second year of life, after the child has had time to become accustomed to solid foods. Furthermore, the literature strongly suggests that an abrupt switch from exclusive breastfeeding to exclusive replacement feeding without a transition can have serious health and psychosocial consequences for both mothers and infants. The present review suggests that a three-stage strategy for modified breastfeeding may help HIV-positive mothers mitigate the risks of postnatal transmission of HIV: (1) exclusive breastfeeding (no other liquids or food) for 6 months or until the decision is made to stop breastfeeding if that occurs before 6 months of age; (2) a transition period in which the infant is accustomed to new feeding patterns; and (3) exclusive replacement feeding with breastmilk substitutes (no breastmilk). The paper also describes a step-by-step process for making the transition from exclusive breastfeeding to exclusive replacement feeding. This transition includes accustoming the infant to cup feeding; providing skin-to-skin contact and use of massage and other means to comfort the baby in place of offering the breast; teaching the infant to sleep through the night; monitoring the infant"s urine output to detect and prevent dehydration; switching from breastmilk to replacement foods; and supporting and caring for the mother. Since many of the behaviors discussed in this review represent a major change in traditional infant care practices in Africa, these recommendations must be subjected to additional research and testing before guidelines can be developed for implementing them within HIV/AIDS and maternal child health programs for HIV-positive mothers. (Author abstract, modified)