Human Immunodeficiency Virus Transmission during Breastfeeding

Knowledge, Gaps, and Challenges for the Future
  • Ellen G. Piwoz
  • Jay Ross
  • Jean Humphrey
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 554)


A number of risk factors for HIV transmission during breastfeeding have been identified. The experience counseling HIV-infected women on infant feeding options has expanded to consider these risk factors. Programmatic evidence is limited, but the review presented here strongly argues for an end to the polarized debate about whether HIV-infected women should breast or formula feed. In reality, neither alternative is risk-free for HIV-exposed infants, and the balance of risks varies in different settings and over time.


Human Immunodeficiency Virus Human Immunodeficiency Virus Type Human Milk Exclusive Breastfeed Infant Feeding 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Becquart P, Chomont N, Roques P, Ayouba A, Kazatchkine M, Belec L, Hocini H. Compartmentalization of HIV-1 between breast milk and blood of HIV-infected mothers. Virology 2002;300:109–117.PubMedCrossRefGoogle Scholar
  2. Botswana Ministry of Health, UNICEF, Program Review Team, PMTCT Advisory Group, and Infant Feeding Study Group. Prevention of mother-to-child transmission: evaluation of a pilot programme and a follow-up study of infant feeding practices during the scaled-up progamme in Botswana. Evaluation and Program Planning 2002;25(4):421–431.CrossRefGoogle Scholar
  3. Briend A. Highly nutrient-dense spreads: a new approach to delivering multiple micronutrients to high-risk groups. Br J Nutr 2001;85(Suppl 2):S175–S179.PubMedCrossRefGoogle Scholar
  4. Bulterys M, Nolan ML, Jamieson DJ, Dominguez K, Fowler MG. Advances in the prevention of mother-to- child transmission: current issues, future challenges. AID Science 2002;2(4):February 28.Google Scholar
  5. Chopra M, Schaay N, Sanders D, Sengwana J, Puoane T, Piwoz EG, Dunnett L. Summary of the findings and recommendations from a formative research study with the Khayelitsha MTCT Programme, South Africa. Cape Town: University of the Western Cape Public Health Programme; May 2000.Google Scholar
  6. Chopra M, Piwoz E, Sengwana J, Schaay N, Dunnett L, Sanders D. Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa. S Afr Med J 2002;92:298–302.PubMedGoogle Scholar
  7. Coovadia HM, Coutsoudis A. Problems and advances in reducing transmission of HIV-1 through breastfeeding in developing countries. AID Science 2001; 1(4):July.Google Scholar
  8. Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet 1999;354:471–476.PubMedCrossRefGoogle Scholar
  9. Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai W-Y, Coovadia HM. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001a;15:379–387.PubMedCrossRefGoogle Scholar
  10. Coutsoudis A, Coovadia H, Pillay K, Kuhn L. Are HIV-infected women who breastfeed at increased risk of mortality? AIDS 2001b;15:653–655.PubMedCrossRefGoogle Scholar
  11. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, Alnwick DJ, Rogers M, Shaffer N. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA 2000;283:1175–1182.PubMedCrossRefGoogle Scholar
  12. Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet 1992;340:585–588.PubMedCrossRefGoogle Scholar
  13. Ekpini ER, Wiktor SZ, Satten GA, Adjoriolo-Johnson GT, Sibailly TS, Ou CY, Karon JM, Brattegaard K, Whitaker JP, Gnaore E, De Cock KM, Greenberg, AE. Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Cote d’Ivoire. Lancet 1997;349:1054–1059.PubMedCrossRefGoogle Scholar
  14. Embree JE, Njenga S, Datta P, Nagelkerke NJ, Ndinya-Achola JO, Mohammed Z, Ramdahin S, Bwayo JJ, Plummer FA. Risk factors for postnatal mother-child transmission of HIV-1. AIDS 2000;14:2535–2541.PubMedCrossRefGoogle Scholar
  15. Ezzati M, Lopez AD, Rodgers A, Vander Horn S, Murray CJ, and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347–1360.PubMedCrossRefGoogle Scholar
  16. Farquhar C, VanCott TC, Mbori-Ngacha DA, Horani L, Bosire RK, Kreiss JK, Richardson BA, John-Stewart GC. Salivary secretory leukocyte protease inhibitor is associated with reduced transmission of human immunodeficiency virus type 1 through breast milk. J Infect Dis 2002; 186:1173–1176.PubMedCrossRefGoogle Scholar
  17. Fawzi W, Msamanga G, Spiegelman D, Renjifo B, Bang H, Kapiga S, Coley J, Hertzmark E, Essex M, Hunter D. Transmission of HIV-1 through breastfeeding among women in Dar es Salaam, Tanzania. J Acquir Immune Defic Syndr 2002;31:331–338.PubMedCrossRefGoogle Scholar
  18. Filteau SM, Rice AL, Ball JL, Chakraborty J, Stoltzfus R, Francisco J, Willumsen. Breast milk immune factors in Bangladeshi women in supplemented postpartum with retinol or beta-carotene. Am J Clin Nutr 1999;69:953–958.PubMedGoogle Scholar
  19. Flores M, Filteau S. Effect of lactation counselling on subclinical mastitis among Bangladeshi women. Ann Trop Paediatr 2002;22:85–88.PubMedCrossRefGoogle Scholar
  20. Fowler MG, Newell ML. Breastfeeding and HIV-1 transmission in resource-limited settings. J Acquir Immune Defic Syndr 2002;30:230–239.PubMedGoogle Scholar
  21. French R, Brocklehurst P. The effect of pregnancy on survival in women infected with HIV: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol 1998;105:827–835.PubMedCrossRefGoogle Scholar
  22. Gaillard P, Piwoz EG, Farley T. Collection of standardized information on infant feeding in the context of mother-to-child transmission of HIV. Stat Med 2001;20(23):3525–3537.PubMedCrossRefGoogle Scholar
  23. Gavin L, Tavengwa N, Iliff P, Nathoo K, Humphrey J. The development of an intervention to inform women about infant feeding in the context of HIV. Second Conference on Global Strategies for the Prevention of HIV Transmission from Mothers to Infants. Montreal; September 1999. Abstract Number 269.Google Scholar
  24. Haider R, Ashworth A, Kabir I, Huttly SR. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356:1643–1647.PubMedCrossRefGoogle Scholar
  25. Humphrey J, Iliff P. Is breast not best? Feeding babies born to HIV-positive mothers: Bringing balance to a complex issue. Nutr Rev 2001 ;59(4):119–127.PubMedCrossRefGoogle Scholar
  26. Jeffery BS, Webber L, Mokhondo KR, Erasmus D. Determination of the effectiveness of inactivation of human immunodeficiency virus by Pretoria pasteurization. J Trop Pediatr 2001 ;47:345–349Google Scholar
  27. John GC, Nduati RW, Mbori-Ngacha DA, Richardson BA, Panteleeff D, Mwatha A, Overbaugh J, Bwayo J, Ndinya-Achola JO, Kreiss JK. Correlates of mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission: association with maternal plasma HIV-1 RNA load, genital HIV-I DNA shedding, and breast infections. J Infect Dis 200la; 183:206–212.Google Scholar
  28. John GC, Richardson BA, Nduati RW, Mbori-Ngacha D, Kreiss JK. Timing of breast milk HIV-1 transmission: a meta-analysis. East Afr Med J 2001b;78:75–79.PubMedGoogle Scholar
  29. Kambarambi RA, Kowo H. The prevalence of nipple disease among breastfeeding mothers of HIV seropositive infants. Cent Afr J Med 1997;43(l):20–22.Google Scholar
  30. Kisakye H, Kukandwa KJ, Ndagire L, Nakyanzi T, Mugula RK, Bakaki PM. Experiences with early abrupt cessation of breastfeeding among HIV infected women in Kampala, Uganda. XIV International AIDS Conference. Barcelona; July 2002. Abstract MoPeE3739.Google Scholar
  31. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic Research: Principles and Quantitative Methods. New York: Van Nostrand Reinhold; 1982.Google Scholar
  32. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E; PROBIT Study Group. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001;285:413–420.PubMedCrossRefGoogle Scholar
  33. Kuhn L, Kasonde P, Vwalika C, Shutes E, Sinkala M, Kankasa C, Aldrovandi G, Thea D. Uptake of interventions to reduce mother-to-child HIV transmission: nevirapine and exclusive breastfeeding in the Zambia Exclusive Breastfeeding Study (ZEBS). XIV International AIDS Conference. Barcelona; July 2002. Abstract TuOrBl 176.Google Scholar
  34. Leroy V, Montcho C, Manigart O, Van de Perre P, Dabis F, Msellati P, Meda N, You B, Simonon A, Rouzioux C. Maternal plasma viral load, zidovudine and mother-to-child transmission of HIV-1 in Africa: DITRAME ANRS 049a trial. AIDS 2001;15:517–522.PubMedCrossRefGoogle Scholar
  35. Leroy V, Karon JM, Alioum A, Ekpini ER, Meda N, Greenberg AE, Msellati P, Hudgens M, Dabis F, Wiktor SZ. Twenty-four month efficacy of a maternal short-course zidovudine regimen to prevent mother-to-child transmission of HIV-1 in West Africa. West Africa PMTCT Study Group. AIDS 2002;16:631–641.PubMedCrossRefGoogle Scholar
  36. Lewis P, Nduati R, Kreiss JK, John GC, Richardson BA, Mbori-Ngacha D, Ndinya-Achola J, Overbaugh J. Cell-free human immunodeficiency virus type 1 in breast milk. J Infect Dis 1998;177:34–39.PubMedCrossRefGoogle Scholar
  37. Magoni M, Kituuka P, Okong P, Bassani L, Merminario E, Massella M, Guiliano M. Effectiveness of the prevention of mother to child transmission program and the influence of feeding options in an urban hospital in Kampala, Uganda. XIV Int. AIDS Conference. Barcelona; July 2002. Abstract TuOrBl 178.Google Scholar
  38. Malkin JE, Noba V, Coulibaly M, Ekpeni A, Chambon JF. Follow up of newborn after prevention of mother-to-child transmission (PMTCT) intervention regarding the method of feeding in Abidjan (Cote d’Ivoire). XIV International AIDS Conference. Barcelona; July 2002. Abstract MoPeD3679.Google Scholar
  39. Mbori-Ngacha D, Nduati R, John G, Reilly M, Richardson B, Mwatha A, Ndinya-Achola J, Bwayo J, Kreiss J. Morbidity and mortality in breastfed and formula-fed infants of HIV-1-infected women: A randomized clinical trial. JAMA 2001;286:2413–2420.Google Scholar
  40. McCoy D, Besser M, Visser R, Doherty T. Interim findings on the National PMTCT Pilot Sites: Lessons and Recommendations. Cape Town, South Africa: Health Systems Trust; 2002.Google Scholar
  41. Miller M, Iliff P, Stoltzfus RJ, Humphrey J. Breastmilk erythropoietin and mother-to-child HIV transmission through breastmilk. Lancet 2002;360:1246–1248.PubMedCrossRefGoogle Scholar
  42. Miotti P, Taha TET, Kumwenda NI, Broadhead R, Mtimavalye LAR, Van der Hoeven L, Chiphangwi JD, Liomba G, Biggar RJ. HIV transmission through breastfeeding: A study in Malawi. JAMA 1999;282:744–749.PubMedCrossRefGoogle Scholar
  43. Mompati K, Luo C, Rollins N, Willumsen J, Kleitjes S, Phegelo M. Evaluation of infant feeding practices in PMTCT and non-PMTCT sites in Botswana. XIV International AIDS Conference. Barcelona; July 2002. Abstract TuPeF5408.Google Scholar
  44. Moodley D, Moodley J, Coovadia H, Gray G, Mclntyre J, Hofmyer J, Nikodem C, Hall D, Gigliotti M, Robinson P, Boshoff L, Sullivan JL, South African Intrapartum Nevirapine Trial (SAINT) Investigators. A multicenter randomized controlled clincial trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus typel. J Infect Dis 2003;187(5):725–735.PubMedCrossRefGoogle Scholar
  45. Morrow AL, Guerrero ML, Shults J, Calva JJ, Lutter C, Bravo J, Ruiz-Palacios G, Morrow RC, Butterfoss FD. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999;353:1226–1231.PubMedCrossRefGoogle Scholar
  46. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J. Effect of breast feeding and formula feeding on transmission of HIV-1: A randomised clinical trial. JAMA 2000;283:1167–1174.PubMedCrossRefGoogle Scholar
  47. Nduati R, Richardson BA, John G, Mbori-Ngacha D, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Kreiss J. Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial. Lancet 2001;357:1651–1655.PubMedCrossRefGoogle Scholar
  48. Newell ML. Prevention of mother-to-child transmission of HIV: Challenges for the current decade. Bull WHO 2001;79(12):1138–1144.PubMedGoogle Scholar
  49. Papathakis PC, Rollins N. Adequacy of feeding recommendations for infants of HIV-infected mothers: assessment of nutrient content, cost and preparation time of breast milk replacements in the South African context. XIV International AIDS Conference. Barcelona; July 2002. Abstract MoOrF1030.Google Scholar
  50. Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind, placebo-controlled trial. Lancet 2002;359:1178–1186.CrossRefGoogle Scholar
  51. Phadke MA, Bharucha KE, Shrotri AN, Sastry J, Gupte NA, Brookmeyer R, Joshi PL, Bollinger RC. High postpartum morbidity in replacement fed infants born to HIV-infected women in India, receiving short-course zidovudine. XIV International AIDS Conference. Barcelona; July 2002. Abstract WePeB5926.Google Scholar
  52. Pillay K, Coutsoudis A, York D, Kuhn L, Coovadia HM Cell-free virus in breast milk of HIV-1-seropositive women. J Acquir Immune Defic Syndr 2000;24:330–336.PubMedGoogle Scholar
  53. Piwoz EG, Creed de Kanashiro H, Lopez de Romana G, Black RE, Brown KH. Potential misclassification of infants’ usual feeding practices using 24-hour dietary assessment methods. J Nutr 1995;125(1):57–65.PubMedGoogle Scholar
  54. Piwoz, EG, Chintu M, Ntombela N, Siyandi R, Kaliwile C, Nyirenda T, Banda A, Maambo L, Maambo R, van den Wyngaart A. Infant feeding options for HIV+ women: Findings and recommendations from a formative research study in Ndola, Zambia. Second Conference on Global Strategies for the Prevention of HIV Transmission from Mothers to Babies. Montreal; September 1999. Abstract Number 484.Google Scholar
  55. Piwoz EG, Huffman SL, Lusk D, Zehner ER, O’Gara C. Issues, risks, and challenges of early breastfeeding cessation to reduce postnatal transmission of HIV in Africa. Washington, DC: Academy for Educational Development; 2002.Google Scholar
  56. Preble EA, Piwoz EG. HIV and Infant Feeding: A chronology of research and policy advances and their implications for programs. Washington, DC: Academy for Educational Development; 1998.Google Scholar
  57. Read JS, Newell ML, Dabis F, Leroy V. Breastfeeding and late postnatal transmission of HIV-1: An individual patient data meta-analysis (Breastfeeding and HIV International Transmission Study). XIV International AIDS Conference. Barcelona; July 2002. Abstract TuOrB 1177.Google Scholar
  58. Rousseau CM, Nduati RW, Richardson BA, Steele MS, John-Stewart GC, Mbori-Ngacha DA, Kreiss JK, Overbaugh J. Longitudinal analysis of human immunodeficiency virus type 1 RNA in breast milk and of its relationship to infant infection and maternal disease. J Infect Dis 2003;187(5):741–747.PubMedCrossRefGoogle Scholar
  59. Sabbaj S, Edwards BH, Ghosh MK, Semrau K, Cheelo S, Thea DM, Kuhn L, Ritter GD, Mulligan MJ, Goepfert PA, Aldrovandi GM. Human immunodeficiency virus-specific CD8(+) T cells in human breast milk. J Virol 2002;76:7365–7373.PubMedCrossRefGoogle Scholar
  60. Semba RD, Miotti PG, Chiphangwi JD, Saah AJ, Canner Jk, Dallabetta GA, Hoover JR. Maternal vitamin A deficiency and mother-to-child transmission of HIV-1. Lancet 1994;343:1593–1597.PubMedCrossRefGoogle Scholar
  61. Semba RD, Kumwenda N, Hoover DR, Taha TE, Quinn TC, Mtimavalye L, Biggar J, Broadhead R, Miotti PG, Sokoll LJ, van der Hoeven L, Chiphangwi JD. Human immunodeficiency virus load in breast milk, mastitis, and mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 1999;180:93–98.PubMedCrossRefGoogle Scholar
  62. Shapiro RL, Lockman S, Thior I, Stocking L, Kebaabetswe P, Wester C, Peter T, Marlink R, Essex M, Heymann SJ. Low adherence to recommended infant feeding strategies in the pilot phase of a randomized trial to prevent mother-to-child HIV transmission in rural Botswana. XIV International AIDS Conference. Barcelona; July 2002. Abstract MoPeD3683.Google Scholar
  63. Thea DM, Piwoz EG, Kasonde P, Vwalika C, Shutes E, Sinkala M, Kankasa C, Aldrovandi G, Kuhn L. The feasibility of early rapid breastfeeding cessation to reduce postnatal transmission of HIV in Lusaka, Zambia. XIV International AIDS Conference, Barcelona; July 2002. Abstract TuPeF5393.Google Scholar
  64. UNAIDS. Report on the global HIV/AIDS epidemic. Geneva: UNAIDS/02.26E; 2002.Google Scholar
  65. UNAIDS/UNICEF/WHO. HIV and Infant Feeding: Guidelines for decision-makers. WHO/FRH/NUT/CHD/ 98.1. WHO/UNAIDS; 1998.Google Scholar
  66. UNAIDS/UNICEF/WHO. HIV and Infant Feeding: Guidelines for decision-makers. Update, 2003, in preparation.Google Scholar
  67. Van de Perre P, Simonon A, Hitimana D, Dabis F, Msellati P, Mukamabano B, Butera JB, Van Goethem C, Karita E, Lepage P. Infective and anti-infective properties of breastmilk from HIV-infected women. Lancet 1993;341:914–918.PubMedCrossRefGoogle Scholar
  68. Van de Perre P. Transmission of human immunodeficiency virus type 1 through breastfeeding: How can it be prevented? J Infect Dis 1999;179(Suppl 3):S405–407.PubMedCrossRefGoogle Scholar
  69. [WHO] World Health Organization, Division of Child Health and Development. Evidence for the ten steps to successful breastfeeding. Geneva: World Health Organization; 1998a.Google Scholar
  70. [WHO] World Health Organization. Complementary feeding of young children in developing countries: A review of current scientific knowledge. WHO/NUT/98.1. Geneva: World Health Organization; 1998b.Google Scholar
  71. [WHO] World Health Organization. New data on the prevention of mother-to-child transmission of HIV and their policy implications: Conclusions and recommendations. Geneva: World Health Organization; 11–13 October 2000, approved January 15, 2001 [Cited 2001 Jan 19]. Available at: Scholar
  72. [WHO] World Health Organization, Collaborative Team on the Role of Breastfeeding in the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000;355:451–455Google Scholar
  73. [WHO] World Health Organization, Department of HIV/AIDS, Family and Community Health Cluster. Scaling up antiretroviral therapy in resource limited settings. Guidelines for a public health approach. Geneva: World Health Organization; 2002.Google Scholar
  74. Willumsen JF, Filteau SM, Coutsoudis A, Uebel KE, Newell ML, Tomkins AM. Subclinical mastitis as a risk factor for mother-infant HIV transmission. Adv Exp Med Biol 2000;478;211–223.PubMedCrossRefGoogle Scholar
  75. Willumsen JF, Filteau SM, Coutsoudis A, Newell ML, Rollins NC, Coovadia HM, Tomkins AM. Breastmilk RNA viral load in HIV-infected South African women: Effects of sub-clinical mastitis and infant feeding. AIDS 2003;17 (3):407–414.Google Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Ellen G. Piwoz
    • 1
  • Jay Ross
    • 2
  • Jean Humphrey
    • 3
    • 4
  1. 1.SARA ProjectAcademy for Educational DevelopmentUSA
  2. 2.LINKAGES ProjectAcademy for Educational DevelopmentUSA
  3. 3.The Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.ZVITAMBO ProjectHarareZimbabwe

Personalised recommendations