It is well established that more than 90% of children with HIV acquired it through mother-to-child transmission (MTCT). It is estimated that 750,000 children worldwide become infected with HIV every year, and most of these are in sub-Saharan Africa. Routes of MTCT include: transplacental during pregnancy, during birth, through breast milk and bleeding nipples. The percent risk of MTCT varies with each of the aforementioned routes. In the absence of specific interventions, the rate of MTCT is approximately 15–20% and, with prolonged breastfeeding (>6 months), the rates double to 35–40%. Although the use of breast milk substitutes (BMS) may appear to be the obvious choice to reduce the risk of MTCT via breast milk and bleeding nipples, this option may prove to be deleterious for infants born to mothers in limited resource settings. In such settings, the high risk of infant mortality is due to severe diarrhea and malnutrition, related to unsafe BMS feeding and suboptimal breastfeeding (that is, failure to exclusively breastfeed for the first 6 months of life). According to a recent WHO report (2006), it is estimated that globally as many as 1.45 million lives (children under 2 years of age) are lost per annum due to suboptimal breastfeeding in developing countries, versus the estimated 242,000 infant deaths related to maternal MTCT. The WHO guidelines for infant feeding in HIV are an important framework of principles that governments, policymakers and health workers need to consider when compiling prevention of MTCT policies and protocols. Both developed and developing countries have communities which do and do not have access to safe water and electricity; hence the policies need to address the needs of different communities. The WHO guidelines advise, ‘when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is acceptable’. Vertically acquired HIV infection has been virtually eliminated in developed countries through the appropriate use of antiretroviral therapy, the use and timing of elective cesarean section, and support for the avoidance of breastfeeding, resulting in a MTCT rate reduction to less than 1–2%.

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