HIV-specific secretory IgA in breast milk is not associated with protection against HIV transmission

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The case-control study of Kuhn et al performed in Zambia attempts to address the question of why some infants fed milk from HIV-infected mothers do or do not acquire HIV infection. Virus density in milk is the most important factor, but elucidating others might provide insight into pathogen-host interaction, as well as direction for study of safer feeding practices when formula feeding is not possible. Contrary to the investigators’ hypothesis that presence of HIV-specific secretory IgA (sIgA) in milk would reduce transmission, the study findings are that HIV-specific sIgA was found more often in transmitting mothers (77%) than in non-transmitting mothers (47%; P = 0.009). The editorial by Kaul probes the meaning of mucosal immune responses that control the trafficking of viruses and immunopathogens, as well as the difficult issues of preventing HIV transmission in sub-Saharan Africa.