During the IBFAN Africa Regional Workshop on Infant Feeding and HIV held in Pretoria, South Africa, 23-27 August 1999, participants from 14 African countries re-evaluated the situation in view of currently available information on the risk of HIV transmission through breastmilk and the following statement and recommendations were adopted.

The participants reaffirmed that breastfeeding not only saves lives but greatly improves quality of life through its accredited benefits. It provides impressive nutritional, immunological, economic, ecological and psychological benefits. In short it contributes enormously to the health and well-being of the child.

Breastfeeding also contributes to maternal health in various ways including prolonging the interval between births, emotional and psychological gratification and reduces the risk of ovarian and breast cancer.

The participants recognise that the socio-cultural context of reproductive health and infant feeding practices, should be taken into account. All women and men, irrespective of their HIV status have the right to determine the course of their reproductive life and health and have access to information and services that allow them to protect their own and their family’s health. Where the welfare of children is concerned, decisions should be made that are in keeping with children’s best interests.

Data based on various studies conducted to date indicate that up to about 30% of infants born to women infected with HIV in Sub-Saharan Africa become infected with HIV themselves. Transmission of HIV may occur during pregnancy, delivery or postnatally. The additional risk of transmission via breastfeeding is 14%. Recent research indicates that infants whose mothers are infected with HIV and exclusively breastfed, had a similar risk of acquiring the virus as those who were artificially fed, and this risk was significantly lower than those who were mixed fed. Risk factors for the postnatal transmission include HIV infection acquired by the mother during breastfeeding, cracked nipples, mastitis, breast abscess and oral thrush in the infant.

However, for the general population, exclusive breastfeeding for about 6 months, and continued with appropriate complementary foods until 2 years of age should be protected, promoted and supported. In the light of current research exclusive breastfeeding could also be recommended for a period of at least 3 months for mothers infected with HIV; further research in this area is encouraged.

In the African environment in particular, the benefits of exclusive breastfeeding outweigh the risk of not breastfeeding. Infants who are not breastfed are up to 14 times more likely to die from diarrhoea compared to those who are exclusively breastfed. They are also 3 times more likely to die from acute respiratory infection. Most African countries are experiencing economic decline, which contributes to inadequacy with respect to the availability, accessibility and affordability of basic health services.

High priority should therefore be given, in both the short and long term, to policies and programmes aimed at reducing women’s vulnerability to HIV infection.

1. In all countries, breastfeeding, particularly exclusive breastfeeding, should continue to be protected, promoted and supported.

2. In all countries, the first and overriding priority in preventing HIV transmission from mother-to-infant is to prevent women of child-bearing age and their partners from becoming infected in the first place. Priority activities are:
   a) education aimed at postponing the age of first sexual activity and promoting safe and responsible sexual behavior targeted at the adolescent population;
   b) education of both women, and men on how to avoid HIV infection for their own sake and that of their future children;
   c) ensuring ready access to condoms      and other barrier methods;
   d) providing prevention and appropriate treatment for sexually transmitted diseases, which increase the risk of HIV transmission and supporting couples in their efforts to remain uninfected.

3. All women and men should have access to appropriate reproductive and child health care services.

4. All couples, irrespective of their HIV status, should be encouraged to use condoms during pregnancy and lactation to reduce mother-to-child transmission. Likewise, preventive measures should be taken to reduce transmission during labour and delivery.

5. All health workers engaged in reproductive and child health care provision should be trained in both breastfeeding and HIV counselling. Such training should also be extended to appropriate community based workers.

6. Access to voluntary and confidential HIV-testing and counselling for pregnant women and their partners should be facilitated. This should be done, in part, by ensuring a supportive environment that encourages individuals to be counselled about their HIV status, rather than one which discourages them out of fear of discrimination or stigmatisation.

7. Counselling for women who are aware of their HIV status should include the best available information on the benefits of breastfeeding, on the risk of HIV transmission through breastfeeding and on the risks and possible advantages associated with other methods of infant feeding. Where the mother does not exclusively breastfeed, all the principles of the International Code of Marketing of Breast-milk Substitutes and subsequent, relevant WHA Resolutions, should be adhered to for infants not breastfeeding, feeding by cup (rather than bottle) is recommended.

8. Further research, to be conducted independently of the infant feeding industry, should build on current research - such as the optimal duration of exclusive breastfeeding for infants of mothers infected with HIV. Additionally research should aim to fill existing knowledge gaps, such as the exact timing of postnatal transmission and the appropriateness of alternative infant feeding methods in terms of safety and feasibility.

9. Families should be empowered to make decisions and to take responsibility for their chosen replacement feeding option. The central procurement and distribution of breastmilk substitutes is discouraged.