The publication quoted by author [1] showed the higher risk of breastfeeding-related transmission in early stages of breastfeeding than in the late stages, but the higher risk of mother-to-child transmission was predicted based on the mathematical model developed by them for different sources of epidemiological data. Prior to the 2010 guidelines on HIV and infant feeding [2], avoidance or early cessation of breastfeeding seemed logical or appropriate. However, the repercussions for the health and survival of the infants were serious, with studies showing much higher mortality rate due to diarrhea, malnutrition and other diseases in non-breastfed children. The 2010 recommendations are based on evidence of positive outcomes for HIV-free survival through provision of anti-retrovirals to breastfed HIV-exposed infants. Apart from the above mentioned, there are many publications [3-5] documenting that exclusive breastfeeding at early stage reduces HIV-transmission risk for infants.

In our study, the time of testing (6 weeks of postnatal life) was based on National AIDS Control Organization/guidelines [6]. Three infants who were exclusively breast fed were HIV-1 DNA PCR positive at 6 weeks of life. Based on the papers [3-5] we quoted above, we may attribute HIV DNA PCR positivity to intrapartum transmission. However, we do agree that intrapartum transmission alone may not be the cause in our study. Breastfeeding is a possible factor for PCR positivity. However, we did not carry out DNA PCR at birth, to rule out intra-uterine transmission. Transmission during delivery would be missed if DNA PCR is taken at birth as viral replication takes time. Secondly, DNA PCR demonstrated lower sensitivities at birth and 4 weeks of 68.4% and 87.5%, respectively. One infant who was PCR negative at 6 weeks became positive during the second sampling after stopping breast feeds. This we attributed to breast feeding (25 % of total transmission). Moreover, we recommend further studies in Indian setting to assess the effect of formula feeding in HIV transmission, and overall mortality and morbidity.

Confounding variables like HIV staging of mother, CD 4 counts, mode of delivery, antenatal bleeding per vaginum, prolonged rupture of membrane were comparable as given in Table I in the study [7]. None of the four women had other sexually transmitted diseases during pregnancy. Hence, ART can be singularly taken as the protective factor.

1. Dunn DT, Tess BH, Rodrigues LC, Ades AE. Mother-to-child transmission of HIV: Implications of variation in maternal infectivity. AIDS. 1998;12:2211-6.

2. World Health Organization. Guidelines on HIV and Infant Feeding 2010: Principles and Recommendations for Infant Feeding in the Context of HIV and a Summary of Evidence. Geneva: World Health Organization; 2010. p. 49.

3. Natchu UC, Liu E, Duggan C, Msamanga G, Peterson K, Aboud S, et al. Exclusive breastfeeding reduces risk of mortality in infants up to 6 mo of age born to HIV-positive Tanzanian women. Am J Clin Nutr. 2012;96:1071-8.　

4. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS. 2005:19:699-708.　

5. Rollins NC, Filteau SM, Coutsoudis A, Tomkins AM. Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women. J Acq Imm Def Syndrome. 2001;28:132-9.　

6. Shah NK, Mamta M, Shah I, Deepak U, Lodha R, Pensi T, et al. Guidelines for HIV Care and Treatment in Infants and Children, 1st ed. New Delhi: National AIDS Control Organisation and Indian Academy of Pediatrics, 2006. p. 3-90.