The first proven HIV-1 surrogate transmission case in South Africa was recently published in the world's leading medical journal, The Lancet.

The case highlights the need for safe and appropriate infant feeding practices in Africa, including HIV testing of all breastfeeding surrogates and mothers.

The case describes a ten-week-old girl who was taken to hospital by her HIV-negative mother. Once the daughter was diagnosed, HIV transmission was initially thought to have taken place in hospital; however, the mother confirmed that her sister had been breastfeeding the baby intermittently over the past four weeks. The sister and her own five-month-old child were subsequently found to be HIV positive.

The case is of special importance in view of the decision to halt the provision of formula feeds at public health facilities in South Africa.

The South African ministry of health says the country has one of the highest HIV/AIDS epidemics and one of the lowest exclusive breastfeeding rates in the world, where fewer than 10% of infants are exclusively breastfeed.

In order to increase the rate of exclusive breastfeeding, the health ministry had recently announced that formula feeding should be removed from all public health facilities in the country. This controversial policy is backed by the expanded used of antiretroviral (ARV) drugs and a recent decrease of mother to child HIV transmission in the country. 

The case published in the Lancet highlights the risk of HIV transmission from a surrogate carer (i.e. from a substitute carer). This case was initially suspected of being nosocomial (i.e. hospital) transmission, when the mother presented to a local hospital in Bloemfontein with a 74-day-old infant that was infected with HIV, in spite of her negative status.

The first possible explanation of the case emerged when social workers intervened and the mother confirmed that her sister had breastfed the baby intermittently from 6 weeks of age. The resolution of the case was possible when DNA sequencing of the HIV infecting the infant-case, the aunt and the cousin supported the scenario of surrogate transmission between the aunt and her niece. 

‘This was a devastating case for a family in South Africa. I cannot imagine the pain suffered by them. The aunt breastfed the infant out of great kindness so the mother could go back to work. However, this ended up as a tragedy,’ says Dr Tulio de Oliveira, a senior researcher at the UKZN’s Wellcome Trust-Africa Centre, and the senior author of the manuscript published in the Lancet.

‘I got involved in this case due to my previous work on the DNA analysis of HIV and the HCV nosocomial infection case in Libya, which infected 418 infants in the Al-Fateh hospital. In that case, we used similar DNA analysis techniques to support the scenario of nosocomial (i.e. hospital based) HIV transmission. It was also used to prove the innocence of medical personnel who were accused of deliberately infecting children with HIV in the hospital where they worked. In the current case in South Africa, we could clearly show that the virus infecting the aunt, cousin and infant was linked. This and other evidence ruled out the nosocomial transmission scenario’.

He continues: ‘The resolution of the surrogate transmission case in South Africa was only possible due to the work of a team of medical doctors and social workers. The identities of all the individuals involved were protected and they received the best treatment and care available. Ethics permission was granted by the University of the Free State School of Medicine, where the case was identified, so it could be used to highlight the potential role of surrogate breastfeeding in the transmission of HIV’.

South Africa has one of the highest HIV prevalence rates in the world and the highest number of children infected with HIV. However, even in the light of the AIDS epidemic, supporting evidence has shown that mixed feeding and formula feeding have a higher impact on infant's mortality and morbidity.

The World Health Organization (WHO) supports six months of exclusive breast feeding for all infants, including HIV-exposed infants, who should receive antiretrovirals (ARVs) to prevent mother-to-child transmission. The country will have to work hard to ensure that public health facilities can identify the HIV status of all mothers and surrogate feeders and make sure that the HIV-exposed infant starts ARVs as soon as possible, as otherwise this new decision and policy could backfire.

Reference: Goedhals D, Rossouw I, Hallbauer U, Mamabolo M, de Oliveira T. The tainted milk of human kindness. The Lancet, Vol. 380, p. 702, August 18, 2012.