Sir: We congratulate BMJ for continuing to follow breastfeeding debates closely, particularly in relation to the issue of HIV transmission through breastfeeding. Jacqui Wise’s article (BMJ 2001; 322: 512e) provides an excellent summary of the Coutsoudis et al article in AIDS and of the responses its predecessor in Lancet received.

Since exclusive breastfeeding is so rare and offers so many other benefits, and since so few HIV+ pregnant women know or are likely to find out about their HIV status, UNAIDS and its partners seem to be missing an opportunity by not focusing more on promoting exclusive breastfeeding for all infants. To the contrary, however, there are worrying signs that breastfeeding in Africa is becoming an endangered practice. Here we explain, mainly via examples from Zimbabwe, how the new UNAIDS/UNICEF/WHO HIV and infant feeding guidelines (1, 2) could contribute to a general decline of breastfeeding in Africa.

These UN Guidelines may be appropriate in industrialized countries where artificial feeding long ago became the norm. In countries where new mothers are expected to choose an infant feeding method, such a plan of care seems reasonable. However, several unforeseen difficulties are emerging in relation to counselling about HIV and infant feeding in the African setting that have no parallel in the industrialised world.

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