Historical perspective of African-based research on HIV-1 transmission through breastfeeding: The Malawi experience

Transmission of HIV-1 from the mother to the infant postnatally through breastfeeding remains an important concern in sub-Saharan Africa where breastfeeding is widely practiced. African women continue to breastfeed despite the risk of transmitting HIV to their infants for several reasons [1]: (a) breastfeeding is encouraged by family members and has been culturally adopted by generations of postpartum women; (b) not breastfeeding raises suspicion in the community about the HIV status of the woman and could potentially lead to discrimination; (c) breastfeeding is the most important nutritional source for the growing child; (d) breastfeeding is readily available and convenient for the mother to provide the infant whenever needed; and (e) in several African settings, substitutes of breast milk are either expensive or not safe to use due to lack of safe water to prepare these substitutes and vehicles for feeding the infant can easily become contaminated. Additionally, strong global evidence exists showing that breastfeeding protects against diarrheal and upper respiratory diseases of the infant [2-4]. Biologically, breast milk is known to contain several well-documented protective factors [5-7]. In a pooled analysis of data from multiple countries, the protective effects of breastfeeding were greatest during early infancy and declined with increasing age: the risk of death associated with infectious diseases among infants not breastfed compared to breastfed was 5.8 times higher during the first month, 4.1 times higher during 2-3 months, 2.6 times higher during 4-5 months, 1.8 times higher during 6-8 months, and 1.4 times higher during 9-11 months of age [8].