2.1 Mother-to-child transmission How is HIV transmitted to children? When is HIV transmitted? Risk factors
	2.2 Preventing and treating HIV infection in women Preventing infection in women Factors which increase HIV risk How Improved STD control can reduce HIV transmission  If a woman already has HIV infection HIV and women's reproductive choices Antiretroviral therapy
	2.3 Breastfeeding Preventing HIV transmission through breastfeeding 1. Consider the possibility that the mother may have HIV Counselling and testing 2. Help the mother to make a decision about infant feeding Breastfeeding and HIV: assessing the risk 3. Advise the mother about how to feed the infant safely Modified breastfeeding Alternatives to breastfeeding Reducing the risks associated with giving alternatives to breastmilk 4. Follow up the infant's growth and general health
	2.4 Other interventions to reduce transmission Improving nutrition during pregnancy What can health workers do? Safe delivery at home Medical procedures during pregnancy and delivery
	2.5 Transmission through blood transfusion Preventing transmission through blood transfusion
	2.6 Acquired infection

This Section describes how HIV infection can be transmitted to infants and young children. It also discusses strategies for preventing infection in children, in particular reducing HIV infection in women and reducing transmission through blood transfusions.

2.1 Mother-to-child transmission

Key Points    HIV can be transmitted from mother to child during pregnancy, delivery or breastfeeding Recent infection or advanced HIV disease in the mother seem to increase the risk of transmission. The most effective way to prevent HIV infection in children is to prevent HIV infection in women.

Mother-to-child transmission is the most common way in which infants and young children are infected with HIV. It is important to remember that not all HIV-infected mothers pass the virus to their babies. Two-thirds of babies born to HIV-infected women do not become infected with the virus. 

Because most HIV-infected children acquire the infection from their mother, the first priority in preventing transmission must be prevention of HIV infection in women. This means strategies which help women to protect themselves against HIV. 
 
How is HIV transmitted to children? 
HIV can be transmitted from an HIV-infected mother to a baby during:
 

	pregnancy
	delivery
	breastfeeding.

During pregnancy the baby may be infected because the virus passes through the placenta and umbilical cord or is present in the fluid in the womb (amniotic fluid).

During delivery the baby may be infected because he or she is exposed to maternal blood and secretions during labour while passing through the birth canal. 

During breastfeeding the baby is exposed to the virus in breastmilk. 
 
When is HIV transmitted? 
The baby can become infected at any point from early pregnancy until the end of breastfeeding. It is thought that about a third of mother-to-child transmission occurs during pregnancy and about two-thirds around the time of delivery and afterwards. Figures for the proportion of babies infected during breastfeeding vary, but on average it is thought that breastfeeding is responsible for 14 per cent of mother-to-child transmission.

Risk factors 
The risk of HIV transmission to women is increased:
 

	if they have an unrecognised and untreated sexually transmitted disease (STD) (see Sill box on page 10)
	by low status and inability to negotiate safer sex
	by inadequate access to information and condoms.

Based on the evidence available, the risk of HIV transmission from mother to child seems to be increased by: 
 

	Recent infection in the mother. A woman who has recently been infected has more of the virus in her blood and body fluids, including breastmilk. (The amount of virus she has is sometimes described as viral load.) So getting infected during pregnancy may increase the risk of transmission to the baby in the womb. Similarly, if the mother becomes infected during delivery (for example, through blood transfusion) or while she is breastfeeding she is more likely to transmit the virus to her baby through her breastmilk. Analysis of a number of studies of breastfeeding and HIV found that the transmission rate was around 14 per cent from mothers who were already HIV positive at delivery. But the rate of transmission from mothers who were infected after delivery during the breastfeeding period was 29 per cent.
	Advanced HIV disease or AIDS in the mother. A woman who has more advanced HIV disease also has a higher viral load and the risk of HIV transmission to the baby during pregnancy, birth or breastfeeding seems to be higher.
	Low birth weight and premature babies. Higher rates of infection may be because their immune systems are not fully developed and they are less able to fight off HIV.

 
The evidence about other factors which may increase the risk of transmission is not clear. Some studies have suggested that the risk of transmission may be greater if the mother has severe vitamin A deficiency, but more research is needed to determine whether other nutritional deficiencies may also be important.

Other factors being considered that may increase risk include length of labour after rupture of the membranes (the waters have broken), delivery method and practices. But again the evidence is not yet clear and more research is needed.

2.2 Preventing and treating HIV infection in women

Key Points    Empowering women, promoting safer sex, condom (male and female) use, and better detection and treatment of STDs can reduce HIV infection in women and, consequently, reduce the transmission of HIV to children. Antiretroviral therapy has been shown to reduce mother-to-child transmission of HIV.

This section discusses interventions for which there is evidence that they can reduce mother-to-child transmission of HIV. It also briefly describes potential interventions where more research is needed before we can be clear about their effectiveness in reducing transmission.
 
Preventing infection in women 
The most effective intervention to reduce mother-to-child transmission is preventing infection in women before and during pregnancy and while they are breastfeeding. This is especially important, not only for the health of the woman but also because the risk of transmission to the baby is higher if the mother has recently been infected with HIV.

All women are at risk of acquiring HIV infection from:
 

	having unprotected sex-penetrative vaginal or anal sex without using a condom
	receiving an infected blood transfusion
	using unsterilised needles and syringes or cutting instruments that are likely to be contaminated with someone else's blood.

 
Factors which increase HIV risk 
Some cultural practices may increase women's infection risk. For example, avoiding or limiting sex during pregnancy or breastfeeding may encourage men to have sex with other partners, increasing the risk that they acquire HIV infection and in turn infect the woman and the unborn child. 

Sexually transmitted diseases (STDs) and reproductive tract infections (RTIs) increase the risk of HIV transmission in men and women. Studies have shown that men with untreated gonorrhoea and HIV infection have higher levels of HIV in their semen than men with HIV infection only. Treatment of the gonorrhoea reduces the levels of HIV. STDs associated with ulcers, such as chancroid, also increase the risk of HIV transmission. Better detection and treatment of STDs can reduce HIV transmission between men and women and hence reduce transmission to children.

 
What can health workers do? 
The most important thing that health workers can do is to help women to protect themselves against infection with HIV. 

Key aspects include:
 

	reproductive health services providing counselling, education and condoms, and better detection and treatment of STDs for men and women
	promoting safer sex, for men and women, and norms that support safer sex
	increasing women's skills in sexual negotiation, and providing women with information about HIV and STDs
	promoting women-controlled methods such as the female condom.

Health workers should advise women and men about the risks of HIV transmission associated with unprotected sex, contaminated blood transfusions and use of unsterilised equipment. They should help women in particular to take steps to avoid or reduce the risk of HIV infection before and during pregnancy and while women are breastfeeding. 

Avoiding unsafe sex during pregnancy and breastfeeding is the most effective way to reduce the risk of having a child with HIV infection. This means providing young women and girls with the information, skills and means to practise safer sex to protect themselves and their unborn children from HIV infection and other Sills. It also means providing men and boys with information and skills to enable them to practise safer sex. Women cannot easily protect themselves and their unborn children unless men are also aware and concerned about HIV.

Safer sex is any sexual activity that does not involve semen (or blood or vaginal fluid) entering the body or coming into contact with broken skin, and includes:
 

	using a female condom for vaginal sexual intercourse
	using a male condom for vaginal or anal sexual intercourse
	non-penetrative sex
	oral sex (which still carries a little risk but is much less risky than vaginal or anal sex).

If these options are not possible, health workers can advise pregnant and breastfeeding women to reduce their risk of HIV infection by having fewer partners. Sill control strategies to prevent infection and improve detection and treatment of Sills include:
 

	introducing syndromic management of STD
	promoting safer sex and condom use
	improving partner notification.

 
If a woman already has HIV infection 
If a woman knows that she has HIV infection before she becomes pregnant she needs advice about pregnancy. In some places it may be appropriate for her to receive counselling to help her decide whether or not to have a child. If she decides not to have a child now then she needs advice about contraception and safer sex, and access to contraception.
 

However, most women in the world do not find out that they have HIV either until they are pregnant, if counselling and testing are available and they decide to have an HIV test, or until after the baby is born and it becomes sick.  If a woman discovers that she is HIV positive during pregnancy, she needs emotional support and counselling to help her to decide whether or not to continue with the pregnancy, and continued support during her pregnancy.

HIV and women's reproductive choices    HIV should never be used as a reason to pressurise women into having or not having children.  Terminating a pregnancy may be an option in some places, if a woman decides not to have a child knowing that there is a risk it may be born with HIV. However, termination of pregnancy may not be a safe option for women in many countries - in many settings abortion is a very risky and dangerous procedure. In some settings termination of pregnancy is illegal, even for women with HIV. In many cultures having a child is very important; a woman who decides not to have a child may be abandoned by her husband and family. Conversely, there is also anecdotal evidence of HIV-infected women being pressurised to terminate their pregnancies because of the risk that the child may be born with HIV.

What can health workers do? 
Health workers should ensure that an HIV-positive woman receives advice or counselling and:
 

	is aware that a third of babies of women with HIV are born with the infection but that two-thirds are not
	understands that, if infected, her baby may be ill, possibly frequently, and may die at a young age, but that she also understands that her baby has a better chance of being well with good treatment, nutrition and care
	decides what she wants to do based on her individual situation and circumstances
	knows where to go for care and support for herself.

Antiretroviral therapy 
Infected mothers with more virus in their blood and body fluids seem to be more likely to transmit HIV to their babies. Antiretroviral treatment has been shown to reduce HIV in the body and to reduce mother-to-child transmission. 

In a study in 1994 in the USA, researchers found that giving the antiretroviral drug AZT (also called zidovudine) to HIV-positive women from between 14 and 34 weeks of pregnancy until labour begins and during delivery, and to their newborn infants, reduced HIV transmission by two-thirds. In the control group of mothers, 25 per cent of infants were HIV positive, whereas in the group treated with AZT, 8 per cent of infants were HIV positive. 

Although AZT was shown to reduce HIV transmission from mother to child, it is no longer recommended alone for treatment in the USA or Europe. Combination therapy - the use of more than one drug to reduce the amount of HIV in the body - has been shown to be more effective than monotherapy (treatment with one drug). Use of only one drug increases the chance that resistance will develop. Babies who have been exposed to AZT but who still acquire HIV have AZT-resistant strains of the virus making subsequent antiretroviral treatment more difficult However, there are still unanswered questions about antiretroviral treatment during pregnancy. It is not clear:
 

	whether to reduce transmission, pregnant women need to take antiretrovirals throughout their pregnancy or for a short period in the later stage of pregnancy
	how effective antiretroviral therapy is in pregnant women with advanced HIV disease and AIDS
	if there are risks or longer term side effects of antiretroviral treatment during pregnancy for the woman or the infant
	whether giving antiretrovirals prevents transmission during breastfeeding, what effect they have on the amount of virus in breastmilk, or whether breastfeeding should be avoided if antiretrovirals have been used.

 
At the moment, in most developing countries, antiretroviral drugs are only available to wealthy women or those taking part in clinical trials. Although we know that antiretroviral therapy can reduce mother-to-child transmission of HIV, there are a number of obstacles to making this therapy available to HIV-positive pregnant women in developing countries.
 

	Antiretrovirals are very expensive. Treatment of a pregnant woman and an infant with AZT costs about US $1,000. Treatment with combination therapy costs more.
	Many pregnant women in developing countries do not know their HIV status. Antiretroviral treatment requires women to take an HIV test early on in pregnancy. Many pregnant women in developing countries currently do not have access to testing and counselling. Some may prefer not to take an HIV test even if facilities are available.
	Women must take the antiretrovirals regularly during pregnancy and intravenously during delivery. Many women in developing countries do not visit clinics regularly during pregnancy or give birth in a health facility. Health facilities may not have the capacity to give intravenous treatment safely.
	One side effect of antiretroviral therapy is anaemia. Women in many developing countries already suffer from anaemia, because of malaria, parasites, poor diet and iron deficiency, and antiretroviral treatment may contribute to severe anaemia. Blood transfusion is the most common treatment given for anaemia. Where blood is not screened for HIV, blood transfusions would increase the risk of HIV transmission to pregnant women and hence to their infants.
	Health workers need education about prescribing and monitoring antiretroviral treatment.
	Even if antiretrovirals prevent HIV transmission during pregnancy or delivery, some infants may subsequently become infected if their mother breastfeeds.
	If antiretrovirals are made available to pregnant women, other women and men with HIV and AIDS would also wish to have access to treatment. In countries with limited resources it may not be possible to provide antiretroviral treatment to everyone who needs it, but justifying only providing it to pregnant women may be difficult.
	And finally, there is the issue of treatment of the woman herself, for the sake of her own health rather than for the purpose of preventing transmission to the baby. Will women have access to antiretroviral therapy after they have given birth?

Key Points    One in seven babies born to HIV-positive women are thought to become infected with HIV by breastfeeding. HIV transmission risk increases if the mother becomes infected while breastfeeding or if symptoms of AIDS develop while she is breastfeeding. Improved access to voluntary testing and counselling is important in helping HIV-positive women make an informed choice about infant feeding. Once the mother has made a decision about what method of infant feeding is best for her and for her infant, she needs advice about the safest way to do this.

However, a woman who has recently been infected has more of the virus in her breastmilk, and the risk of transmission to the infant is higher if the mother is infected while she is breastfeeding. The additional risk of HIV infection to breastfed infants whose mothers are infected during breastfeeding is thought to be about 29 per cent. However the proportion of women who fall into this category is small, and it is difficult to identify them. It is thus particularly important to advise couples to prevent transmission during the breastfeeding period. Women who have AIDS may also have more virus in their milk and may be more likely to infect their babies. 

Larger concentrations of the virus have been found in colostrum than in breastmilk. However, there is no evidence that giving a baby colostrum increases the risk of HIV transmission. It may just be that the virus is easier to measure in colostrum. 

Some studies suggest that the risk of HIV transmission continues as long as a baby is breastfed and therefore the risk increases cumulatively the longer the breastfeeding period. Because the risk of not breastfeeding to the baby's health decreases after the age of six months, the relative risk of HIV increases. We need to know more about HIV and colostrum and duration of breastfeeding before any clear recommendations can be made. 
 
Preventing HIV transmission through breastfeeding 
 

Where adequate alternatives are available and the risks associated with artificial feeding can be minimised, HIV-positive women are being advised not to breastfeed because of the risk that infants can become infected through breastfeeding.  Advising HIV-positive mothers about the best way to feed their infants in communities where it is difficult to minimise the risks of artificial feeding is much less straightforward. The current recommendation is that women should be provided with information and helped to make an informed decision about whether or not to breastfeed according to their individual circumstances.

Putting this recommendation into practice is not easy and, for health workers and mothers, there are many issues to consider.
  

	Breastfeeding protects babies against other infections and is the best and most hygienic form of infant feeding. In countries where malnutrition and infectious diseases are the main cause of infant deaths, not breastfeeding poses a very great risk to infants and young children. Infants who are not breastfed are much more likely to die from diseases such as diarrhoea and acute respiratory infection.
	Breastmilk substitutes - formula or animal milk - are costly to buy. For example, in Zimbabwe, the monthly cost of formula milk for a baby would be around Zimbabwe $250-300, about the same as the monthly minimum wage.
	Safe and hygienic preparation of alternatives to breastmilk require access to adequate supplies of clean water and fuel.
	In places where hygiene is poor and families lack money there may be no adequate alternatives to breastfeeding and it may not be possible to minimise the risk associated with other forms of feeding adequately. The risk to the infant of not breastfeeding in such circumstances is far greater than the risk of HIV transmission.
	In many places there is no access to voluntary testing and counselling and the HIV status of the mother may not be known.
	If the status of the woman is known, it is difficult to tell whether an infant of an HIV-positive mother has already been infected during pregnancy or delivery. It is also not possible to find out with an HIV antibody test - the most common form of test available - whether an infant of an HIV-positive mother is infected until after the age of 15-18 months. Before that age the baby still has its mother's antibodies, including her HIV antibodies.

In the context of HIV, UNAIDS, WHO and UNICEF agree that it is critical to:    protect, promote and support breastfeeding improve access to voluntary testing and counselling ensure informed choice about infant feeding for HIV-positive women prevent commercial pressures to artificial feeding.

 
1. Consider the possibility that the mother may have HIV 
 

The possibility of HIV infection will depend on how common HIV infection is in your area and on the mother's individual circumstances.  If a mother already knows she has HIV infection, she needs counselling and support to help her consider the implications of being HIV positive and to make a decision about breastfeeding. This includes providing her with information about the benefits of breastfeeding, the risk of HIV transmission through breastfeeding, and the risks and advantages of alternative infant feeding methods.

 
If a woman's status is not known, she is in good general health and there is no reason to think she has been at risk of HIV, and if there are no voluntary counselling and testing - facilities available, it is probably best to assume that she is not infected with HIV and to advise her to breastfeed. It is very important for health workers to explain about the increased risk of passing HIV to the baby if she becomes infected while she is breastfeeding and to advise about preventing infection.

If a woman's status is not known and she is not in good health, it may be helpful for a health worker to assess the possibility that she is sick because of HIV. She may need help to assess whether there is a risk that she may be infected with HIV. This includes the possibility that she may have been infected during pregnancy or delivery. Good counselling is important to help a woman assess whether she has been at risk of HIV infection and to decide whether or not to have an HIV test if voluntary counselling and testing is available. 

An important consideration in deciding about testing is whether knowing her HIV status will make a difference to her decision about breastfeeding. In many situations she may have no choice about whether or not to breastfeed. It may be helpful to find out what people usually do if they cannot breastfeed for other reasons.

Counselling and testing    Counselling aims to enable a person to cope better with stress, find realistic ways to solve problems and make informed decisions. A counsellor's role is to listen and ask questions, and to provide relevant information, practical suggestions and emotional support. Counselling is not about giving advice or telling people what they should do. Counselling is an essential part of voluntary and confidential HIV antibody testing programmes. It also plays a valuable role in HIV prevention and care on its own, without testing. Issues such as reducing the risk of infection, family planning, relationships, sexuality and sexual problems, are all important areas for discussion. Anyone considering an HIV test for whatever reason should always have pre-test counselling, to help assess if he or she has been at risk, learn about the test and its implications, decide whether or not to be tested and think about how to prevent infection. Counselling should mean that a person's consent or refusal to be tested is an informed choice - made freely without pressure, and based on the person's own feelings about the disadvantages and advantages of knowing his or her HIV status. Consent must be expressed, not implicit. Consent must be specific, not general. A person can give informed consent to an HIV test only after he or she has been given a proper explanation of the nature and likely consequences of taking the test. Informed consent means not only agreeing to the test itself but understanding the implications of a positive or negative test for the future. Counselling after an HIV test is equally important, whether or not someone is infected with HIV, or if he or she does not want to know the result. One post-test counselling session is often not enough. A person may need on-going support and more sessions. Confidentiality is an important aspect of a counselling relationship. People are better able to discuss their feelings if they know that the counsellor will not tell anyone else without their permission. Breaking confidentiality can destroy a person's confidence in their counsellor, and expose someone to discrimination at work, or to prejudice from health workers. While it is vital not to discuss a person's situation without his or her permission, too much stress on secrecy can make it more difficult for the person to cope, and for the most appropriate support to be given. Promoting 'shared confidentiality' means encouraging someone to identity others who are trusted, especially his or her doctor, sexual partner, close friends or family members. Health workers who may need to counsel women about HIV and AIDS need to:    know the facts  listen  take time  be concerned  be available  establish trust  be consistent. Things to avoid in counselling include:     telling people what to do  being judgemental  making promises that cannot be kept  giving false reassurances missing appointments  doing all the talking confusing people with conflicting messages  using complicated words. Testing pregnant women  In some countries, pregnant women are routinely offered HIV testing. However, there may be obstacles to overcome to ensure that such testing provides benefits for the woman or the baby.   Some women will prefer not to be tested or to know their status - they may be afraid to tell their partner if they have a positive result. Knowing her status may not affect either the treatment available to the mother or her baby, or her decision about the pregnancy or breastfeeding. Many women have little control over their lives and cannot easily make plans for the future. Health services may not be able to provide follow-up support and care.  If the woman is HIV positive it probably means that her partner is too, and this raises issues such as partner notification and couple counselling. Exercises:  What would you want a woman to know about HIV/AIDS if her partner was infected with HIV? How do you think she might feel? Try a role play with a colleague to practise talking about the issues. Think about how women can protect themselves from becoming infected with HIV in your locality. Practise, with a colleague, describing what safer sex means.

2. Help the mother to make a decision about infant feeding 
This involves talking to the mother who has H1V about breastfeeding, alternative feeding methods and her individual feelings and circumstances. Based on this, the health worker can help her to weigh up the risks to her infant if she does not breastfeed and the benefits and risks to her infant if she does breastfeed. If possible, and the mother wishes it, the father of the baby should also be involved in the decision. 

Deciding whether the chances of HIV transmission are greater or lower than the risks of artificial feeding is the most difficult issue for the health worker and the mother. The following questions are intended to help them reach a decision that is best in the circumstances for the mother and her baby.

 
What alternatives to breastfeeding are available to the mother? 
  

	Are locally available alternatives nutritionally adequate for infants?
	Does the mother have access to a reliable supply of formula or animal milk?
	Is the animal milk sold locally safe or is there a danger than it could be adulterated or diluted? Is it boiled or raw?
	Is wet nursing culturally acceptable? Is there an older member of the family who would be willing and able to nurse the baby?
	Does the mother have access to a breastmilk bank? If so, can it provide milk for long periods of time?

 
What are her circumstances? 
 

	Can the family afford to buy alternatives to breastmilk, not just for a day or a week but for at least six months? Can the family afford to provide adequate complementary foods from six months up to one or two years of age? Are there times of the year when the family has less money?
	Will buying formula or animal milk for the baby mean that there is less money to buy food for other members of the family?
	Does the mother have access to a reliable safe water supply? Does she have time to collect the extra water needed?
	Does she have fuel or the money to buy fuel to boil water and the baby's feeding utensils?
	Does she have the time to prepare milk hygienically and to keep feeding utensils clean?
	Does the mother understand that it is safer to feed a baby with a cup and that bottles are much more difficult to clean?
	Does she have support from family and friends to help her feed the baby safely with alternatives?
	Is she well or does she have symptoms of AIDS?

Breastfeeding and HIV: assessing the risk  The following are examples of different scenarios that health workers may encounter in their work. It may be a useful training and support exercise for health workers to discuss together how they would deal with these different scenarios. You can make up different scenarios that are relevant to local circumstances.    A pregnant woman who knows she is HIV positive approaches you for advice. She has heard that HIV can be passed to babies through breastmilk. An HIV-positive woman who chose to give formula to her baby which subsequently failed to thrive. A pregnant woman from a poor community who does not know her HIV status but has been told by people in her village that she looked thin and might have AIDS, asks what will happen to her and her baby. A woman with a six-month-old son (breastfed and growing well) who recently read that the HIV virus can be spread through breastfeeding. Although she does not know her HIV status, she is worried and wondering whether she should stop breastfeeding.

Weighing up the risks and benefits of breastfeeding 
  

	Would the mother's circumstances allow her to minimise the risks associated with alternatives to breastfeeding?
	How common are childhood infectious diseases such as diarrhoea and respiratory infections?
	Is the chance of her passing HIV to her baby through breastfeeding greater or lower than the risks to the baby of alternative feeding methods?
	How does she feel about the risk?
	Does the mother have access to contraceptives to be able to practise family spacing, if she is no longer receiving this protective effect from breastfeeding?

The most important question is probably whether or not the mother's circumstances would enable her to use alternatives adequately. If she can, then the risk of death and illness from other infections, as well as from HIV, can be minimised. If she is not able to, then the risks to her infant's health of not breastfeeding are probably greater than the risk from the possible transmission of HIV through breastfeeding. 

Having considered all these issues some women may choose not to breastfeed. However, in many communities where families do not have access to clean water and cannot pay for alternatives and where infant mortality from diarrhoea is high, the risk that a baby will die if he or she is not breastfed may be far greater than the risk of HIV transmission. In these circumstances women should continue to be encouraged to breastfeed. 

Mixed feeding, that is combining breastfeeding and artificial feeding, is likely to be the worst option - placing the baby at risk both of HIV and of other infections. So, if a mother decides that breastfeeding is the best option in her circumstances, then probably she should be encouraged and supported to breastfeed exclusively. And if she breastfeeds, she should breastfeed exclusively for at least six months, as the risk of childhood infections is especially high in the first six months of life. 

Where breastfeeding is the norm, it may also be very difficult for a woman not to breastfeed. She may be asked difficult questions by her family and neighbours and by other health workers about why she is not breastfeeding. As one woman in South Africa said, 'Everyone wanted to know why I was not breastfeeding'. Not breastfeeding may signal to others that a mother has HIV and she may wish to keep her status confidential. 
 
3. Advise the mother about how to feed the infant safely 
 

Once the mother has made a decision about what method of infant feeding is best for her and for her infant, a health worker needs to advise her about the safest way to do this.  If a mother decides to breastfeed, she should be counselled about ways to prevent cracked nipples which may increase risk of HIV transmission. Cracked nipples should not occur if the baby is properly attached at the breast.  If the mother has decided not to breastfeed she needs to be advised about preparing and giving alternatives hygienically to minimise the risks associated with artificial feeding, and about care of the child.

 

Modified breastfeeding 
Two possible options that HIV-positive mothers could consider to reduce the risk of HIV transmission are:
  

	stop breastfeeding earlier than normally recommended
	breastfeed the baby but stop if she becomes ill with AIDS-related symptoms.

 
The first approach would mean only breastfeeding for between 6 and 12 months instead of two years, to reduce the length of time that the baby is exposed to the virus in breastmilk. But there are disadvantages of stopping breastfeeding early. The most important is the risk that the