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Q. Doesn't HIV change the situation?

Answer 24 May 2004: Baby Milk Action is guided by World Health Assembly Resolutions.

In 2001 the World Health Assembly adopted Resolution 54.2, which calls for action:

"to recognize and assess the available scientific evidence on the balance of risk of HIV transmission through breastfeeding compared with the risk of not breastfeeding, and the need for independent research in this connection; to strive to ensure adequate nutrition of infants of HIV-positive mothers; to increase accessibility to voluntary and confidential counselling and testing so as to facilitate the provision of information and informed decision-making; and to recognize that when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-positive women is recommended; otherwise, exclusive breastfeeding is recommended during the first months of life; and that those who choose other options should be encouraged to use them free from commercial influences;"

In summary, where replacement feeding is feasible this is recommended for HIV-infected mothers. Where it is not, exclusive breastfeeding is recommended. There is a need for risk assessment. For example, where water is unsafe an artificially-fed child, including the child of a mother infected with HIV, is up to 25 times more likely to die as a result of diarrhoea than a breastfed child. UNICEF has stated that while over the past 20 years 1.7 million infants may have been infected with HIV through breastfeeding, 30 million have died through not being breastfed.

The Resolution states that mothers should make their decision on infant feeding: "Free from commercial influences." This means the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions of the World Health Assembly are more important in the context of HIV, not less.

At the European Parliament Public Hearing into Nestlé baby food marketing at the European Parliament in November 2000, UNICEF stated (see press release 23 November 2000):

"Many people have questioned the continued relevance of the Code in the context of mother-to-child transmission of HIV through breastfeeding. Let me assure you that there is an even greater need to ensure Code compliance in areas of high HIV prevalence. The Code protects artificially fed children as well as those mothers who decide to breastfeed.

" One of its aims, as specified in Article 1, is to ensure the proper use of breastmilk substitutes when these are necessary. If incorrectly prepared, infant formula can be lethal. Over-dilution, the result of unsuitable availability of formula, leads to malnutrition. Under-dilution can cause serious health problems such as kidney failure. This is without discussing whether sanitation and access to clean water, fuel, and adequate skills permit safe preparation."

It should also be remembered that the majority of infants, even in countries with high prevalence of HIV, are born to mothers who are not infected.

The World Health Organisation held an Expert Consultation in October 2000 from which the 2001 Resolution derived (see: 000/consultation_documents/new_data_on_mtct_conclusions/New_data_prevention_ MTCT_infant_feeding.en.html).

In addition to considering the relative risks for infants in different conditions, the Expert Consultation states: "There is evidence from one study that exclusive breastfeeding in the first 3 months of life may carry a lower risk of HIV transmission than mixed feeding." (Ref: Coutsoudis, A., et al (1999). 'Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study.' The Lancet 354 (471-476). (Available on - register and search for Coutsoudis to find the paper).

The Expert Consultation also notes: "There are concerns about the possible increased risk of HIV transmission with mixed feeding during the transition period between exclusive breastfeeding and complete cessation of breastfeeding." Further research is required in this area and is underway.

The Coutsoudis study found that exclusively breastfed infants have no more risk of HIV infection than exclusively artificially-fed infants. Increased risk apprears to occur with mixed-feeding, when substances are given in addition to breastmilk, be it water, formula or other substances.

The publication Breastfeeding and replacement feeding practices in the context of Mother-to-Child Transmission of HIV - An assessment tool for research Ref. WHO/RHR/01.12 comments on the study

"Potential mechanisms that could explain a reduced risk of MTCT [Mother to Child Transmission] when children are exclusively breastfed include:

  • Reduction in dietary antigens and enteric pathogens that may maintain integrity of the intestinal mucosal barrier and limit inflammatory responses to the gut mucosa;

  • Promotion of beneficial intestinal microflora that may increase resistance to infection and modulate the infant’s immune response;

  • Modulation of anti-microbial, anti-inflammatory and immuno-modulating properties of breast milk;

  • Maintenance of mammary epithelial integrity that may reduce viral load in breast milk."

In simplified terms, introducing substances other than breastmilk may harm the infant's gut and immune system, putting the child at greater risk of HIV infection. Exclusive breastfeeding, without replacing feeds, may also mean the breastmilk has a better balance of anti-infective properties and lower load of HIV.

WHO's 2004 booklet "HIV transmission through breastfeeding: A review of available evidence" can be downloaded from

Despite the 2001 Resolution, which is reflected in the Global Strategy on Infant and Young Child Feeding, adopted by the World Health Assembly under Resolution 55.25 in 2002, baby food companies sometimes suggest HIV requires the promotion of artificial feeding to HIV-infected mothers and the scrapping of regulations for the marketing of breastmilk substitutes. Indeed, Nestlé set up a nutrition institute in South Africa in 2001 with the expressed intention of promoting infant formula (see Campaign for Ethical Marketing action sheet September/October 2001).

Also see the briefing papers:

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