[Breastfeeding in Africa: will positive trends be challenged by the AIDS epidemic?]

In Africa, more than 95% of infants are currently breastfed, but feeding practices are often inadequate: feeding water, and other liquids, to breastfed infants is a widespread practice. Consequently, the rate of exclusive breast-feeding is low, particularly in West Africa. The rate of bottle-feeding is high in some countries (exceeding 30% in Tunisia, Nigeria, Namibia and Sudan). Nevertheless prolonged breastfeeding is common, and the median duration of breastfeeding ranges between 16 and 28 months. Urbanization and mothers' education are the major factors that tend to shorten breastfeeding. Nevertheless recent trends show an increase in early initiation and in duration of breastfeeding as a result of promotion efforts deployed by WHO and Unicef, local governments, and non-governmental organizations. The importance of breastmilk as a food resource of African countries is generally not recognized. In 31 countries where data on prevalence of breastfeeding are available, consumption of breastmilk by children under three years is estimated at 3.5 million tons per year. The AIDS epidemic could threaten breastfeeding because the virus can be transmitted through breastmilk, as demonstrated by numerous studies. A study suggests that feeding breastmilk and other liquids to infants could be the feeding mode associated with the highest rate of transmission. To prevent mother-to-child transmission of HIV, WHO recommends replacement feeding if it is feasible and safe. Otherwise, mothers are encouraged to practice exclusive breastfeeding for the first months of life followed by early and rapid weaning. The feasibility of replacement feeding with breastmilk substitutes, however, is very uncertain. In a study where free substitutes were given to HIV-positive mothers, the mortality of the formula-fed infants was the same as that of the breastfed infants. HIV-positive mothers may find it difficult to cope with the constraints of replacement feeding, in terms of cost, workload and time, and with the additional health care needs of non-breastfed infants. Exclusive breastfeeding for a few months could carry a lower risk of death than replacement feeding. But success in promoting exclusive breastfeeding has been limited in Africa, and new promotion methods are needed. Infants of all mothers, whether HIV-positive or not, will benefit from improving the rate of exclusive breastfeeding. The major problem is to ensure that early and rapid weaning, between 4 and 6 months, does not have a negative impact on the child's health. Early weaning is known to increase susceptibility to infections and can cause malnutrition. The feasibility and safety of this recommendation will have to be monitored carefully. A strong determination of African governments to promote exclusive breastfeeding among all mothers and to protect prolonged breastfeeding among non-infected mothers will limit the mother-to-child transmission of HIV while preserving the benefits of breastfeeding.