Ways ahead: protecting, promoting and supporting breastfeeding in the context of HIV

As a final note, let us return to breastfeeding for a moment and discuss how to counteract the pressures that have been exerted against breastfeeding in the context of HIV. As history shows, the threats to breastfeeding have changed over time. During the last decade the greatest threat to breastfeeding has been the confusion over infant feeding in the wake of the HIV pandemic. Through national and local PMTCT programmes and HIV information campaigns, the global community has learnt that breastfeeding in HIV-infected mothers may be a risk to child survival and should, if possible, be avoided. The uncertainty that this has generated is illustrated in this thematic series. In the early phase of the national and local PMTCT programme implementation, breastfeeding advocacy groups were accused of having their "heads in the sand" about the transmission of HIV through breastfeeding. The existing evidence of the superiority of breastfeeding in terms of infant survival, and the 2010 infant feeding guidelines promoting breastfeeding as the first choice of infant feeding method, have demonstrated that the advocacy groups were right in their firm and concerted action to protect breastfeeding. One lesson is learnt: replacement feeding has substantial negative unintended consequences for the individual mother, for her infant, for households and for health systems. In the aftermath of a decade of trial and error in developing guidelines and implementing postnatal PMTCT programmes, the trust in breastfeeding thus needs to be restored. The challenge is how to 'turn the tide' or change the mindset of PMTCT counsellors, mothers and significant others towards breastfeeding as the safest way to feed an infant. The research studies reported in this thematic series suggest that this may prove challenging given the legacy of efforts to implement earlier guidelines. In the first concluding remarks we focused on global policy documents and lessons learnt [1]. Now in this final paper we consid