Mothers who are HIV-positive and their babies need special care before, during and after labour and delivery. Therefore, if the mother is counselled and HIV-tested before or during pregnancy, and she knows that she is HIV positive, you should try to convince her to deliver her baby in a health facility. That way she and her baby will get special care from health professionals with special training in delivering babies from HIV-positive mothers, and prevent maternal to child transmission (PMTCT of HIV).

In the postnatal period, she may need to take antiretroviral (ARV) drugs prescribed for her by the HIV clinic, and your support is vital in helping her to keep to her drug regimen.

Maintain confidentiality about her status and conduct frequent visits to this woman as she may require a lot of psychosocial support immediately after the delivery. If it is available link her with the community social support group. Always make sure her partner is counselled and HIV-tested and also involved in the whole care process.

Breast Milk or Formula?

In this study session, our focus is on the risk of HIV being transmitted from the mother to her newborn baby in her breast milk, and how you can support and counsel her about feeding options. If 20 HIV-positive mothers breastfeed their HIV-negative babies exclusively for the first six months, on average one to three of the babies will become infected with HIV through its mother's breast milk.

So the mother has a difficult choice to make. She has to balance the risk to her baby from HIV transmission during breastfeeding, against the risk of not breastfeeding and losing all the benefits described above. Formula feeding also exposes the baby to increased risk of infection from unsterilized bottles and malnutrition from incorrectly made feeds.

Replacement Feeding and the AFASS Criteria

Exclusive breastfeeding is NOT recommended for the babies of HIV-positive women since the only way to protect the baby completely from HIV transmission from its mother is to feed it on formula milk. This is known as replacement feeding. However, many families cannot afford to buy milk formula to feed the baby, and bottle feeding may be socially unacceptable in some communities.

With all these issues in mind the World Health Organization (WHO) has set the following criteria (known as the AFASS criteria), which need to be met before counselling an HIV-positive mother to use formula milk:

• Acceptable: Replacement feeding for breast milk is acceptable by the mother, the family and others who are close to the family.
  
• Feasible: The mother has access to clean and safe water for cleaning the feeding bottles, teats, measuring cup and spoon, and diluting the formula milk if it comes as a powder.
  
• Affordable: The family can afford to buy enough formula milk or animal milk to feed the baby adequately.
  
• Sustainable: The mother can prepare feeds for the child as frequently as recommended and as the baby demands.
  
• Safe: The formula milk should be safe and nutritious for the health of the baby.
  

Reducing the HIV Risk From Breastfeeding

If replacement feeding is rejected by the HIV-positive mother, for whatever reasons, there are some things that she can do to reduce the risk of HIV transmission during breastfeeding. Counsel her to:

• Keep the intervals between breastfeeds as short as possible (no longer than three hours) to avoid accumulation of the virus in her breast milk.
  
• If she develops a bacterial infection (mastitis) of the breast, or she has a cracked nipple, stop feeding from the infected breast and seek urgent treatment.
  
• Check the infant's mouth for sores and seek treatment if necessary.
  
• Make a transition to replacement feeding if her circumstances change and she can meet the AFASS criteria.
  

At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, counsel her to continue breastfeeding, but with additional complementary foods. All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided.