Abstract

PIP: The first recorded case of HIV-1 transmission via breast milk occurred in 1985. 1985 was also the year HIV-1 was first isolated in breast milk. In developed countries, many hospitals' special neonatal units no longer operated breast milk banks. National policies advised HIV-1 infected mothers to feed their babies breast milk substitutes. They advised pregnant women with HIV-1 risk factors to undergo voluntary HIV-1 testing so interventions could be taken to prevent HIV-1 transmission to their infants if the mothers were indeed HIV-1 positive. Routine HIV-1 testing without pretest counseling poses an ethical dilemma. In developing countries, universal breast feeding is still the policy. Limited resources in developing countries precludes them from voluntary or mandatory HIV-1 testing and administering zidovudine (AZT) treatment before and after the birth. Further, there are no inexpensive and readily available options to breast feeding in developing countries. The risk to the baby of not receiving breast milk outweighs the risk of HIV-1 infection. In 1992, the World Health Organization and UNICEF admitted that breast feeding poses a significant risk of HIV-1 transmission. The mother-to-infant HIV-1 transmission rate is higher in developing countries than developed countries (20-39% vs. 12.9-30%). Breast feeding perhaps explains the difference in risk. HIV-1 transmission to the infant is associated with a maternal CD4 lymphocyte count less than 700/mcl, maternal CD4/CD8 ratio less than 0.5, and p24 antigenemia. Both lymphocytes and cell free fractions of breast milk have been found to have HIV-1. Colostrum has a higher concentration of cells and immunoglobulins than breast milk. Anti-HIV-IgA and IgM are found in breast milk, indicating that HIV is in the mammary glands. Cracked nipples, breast abscesses, and sores in the infant's mouth may increase the risk of HIV-1 transmission. In conclusion, no realistic alternative to breast feeding exists in developing countries. If the mother is known to be HIV-1 positive, the HIV-1 transmission risk to the baby is significant.