Breastfeeding
Breast is best, HIV-infected mothers told - March 31,
2007
Sarah Boseley in London
DOCTORS have called for United Nations guidelines to be
changed following landmark research that shows exclusive
breastfeeding protects the babies of HIV-positive women
from becoming infected with the virus that causes AIDS.
A heated debate has raged over the best advice to give
new mothers with HIV. Guidelines from UNICEF, the World
Health Organisation and the UN say the best option is to
bottle-feed babies where this is safe and practical. In
poor countries where water supplies may be tainted, a child
can be exposed to potentially fatal diarrhoea by taking
infant formula.
Where exclusive bottle-feeding is not possible, mothers
should exclusively breastfeed, the guidelines say.
Until now, the risk of post-natal HIV transmission has
been evaluated as very high - at between 10 and 20 per cent.
The UN says more than 300,000 children each year become
infected with HIV after they are born.
But research published in the medical journal The Lancet
yesterday argues the risk estimates do not distinguish between
exclusive breastfeeding and mixed feeding. Under mixed feeding,
a child is partly breastfed and partly fed with infant formula
or solid food. It is the most widespread practice in sub-Saharan
Africa, where the AIDS pandemic is worst.
The research, by the University of KwaZulu-Natal, in
South Africa, shows that mixed feeding is the worst of all.
Babies of mothers with HIV who receive a mixture of milk
and solid foods are 11 times more likely to become infected
than those who are exclusively breastfed. Those who are
given formula milk as well as breast milk are nearly twice
as likely to become HIV-positive.
The issue is not just HIV. Half the babies in the study
were born to uninfected mothers. Yet researchers found that
about twice as many babies who received mixed feeds died
as babies who were exclusively breastfed.
An earlier series in The Lancet on child mortality found
that the immunity conferred by the mother on her child through
breast milk gave the baby considerable protection from disease.
Even in countries with high HIV prevalence, it calculated,
exclusive breastfeeding could prevent 13 per cent of deaths
in children under five years old.
The KwaZulu-Natal study involved about 2700 babies born
between 2001 and 2005.
Big efforts were made to encourage and support women in
breastfeeding by sending counsellors to their homes twice
a week. The success of the strategy surprised the researchers.
The authors, Hoosen Coovadia and Nigel Rollins, say exclusive
breastfeeding "ordinarily protects the integrity of
the intestinal mucosa, which thereby presents a more effective
barrier to HIV".
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Breastfeeding and HIV/AIDS: is there a conflict?
Prof. R. V. Short
Department of Obstetrics and Gynaecology, University of Melbourne
Royal Women’s Hospital, Carlton, 3053
August 1st, 2003 marked the beginning of World Breastfeeding Week,
and in a circular to commemorate the event Gro Harlem Brundtland, the
former Director-General of the World Health Organization said:
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“The HIV pandemic and the risk of mother-to-child transmission
of HIV through breastfeeding continues to pose unique challenges
to the promotion of breastfeeding, even among unaffected families.
Accurate information, disseminated widely, about breastfeeding’s
benefits for the majority of children and mothers is essential
for preventing baseless doubts in this connection. Support for
HIV-positive women should include counseling about appropriate
infant-feeding options”.
That is a perfect summary of our dilemma. Speaking in Paris on
July 14th, 2003, at the United Nations Global Fund to fight AIDS,
Nelson Mandela said that AIDS was “The greatest health crisis
in human history”. He went on to point out that “we
have failed to translate our scientific progress into action where
it is most needed, in the developing world”. How right he
was.
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The frightening facts
In some Southern African countries, e.g. Botswana and Lesotho, over
40% of pregnant women are HIV-positive; in Swaziland, Zambia and Zimbabwe,
over 30% are HIV-positive (UNAIDS, 2002).
When considering mother-to-child transmission of HIV, this ranges from
14-32% in Europe and the United States, to 25-48% in Sub-Saharan Africa,
and the difference is thought to be due to breastfeeding (De Cock et
al, 2000). 1,600 HIV-positive children a day are born in Sub-Saharan
Africa.
Globally, at the end of 2001, there were 14 million AIDS orphans under
the age of 15 who had lost one or both parents to AIDS. (UNAIDS, 2002).
Since about 40% of mother-to-child transmission of HIV is thought to
be due to breastfeeding, the simple solution might appear to be to recommend
that no HIV positive mother should breastfeed. But in a developing country,
such a recommendation would have disastrous consequences. In the first
place, many women will never know whether they are HIV positive, so
you would have to recommend that no woman breastfed her baby. But the
risk of an infant dying from infectious diseases in the first two months
of life is six times greater for infants who are not breastfed. Thus
the promotion of infant formula feeding to reduce HIV infection may
increase overall infant morbidity, mortality and malnutrition.
A recent analysis of mother-to-child transmission in mothers breastfeeding
for 18-24 months suggests that intrauterine infection accounts for 5-10%
of transmissions, 10-20% occur during the birth process, and can be
reduced by caesarean delivery, or antiretroviral treatment (e.g. Nevirapine)
of the mother and the neonate, 5-10% occurs in the first 2 months of
breastfeeding, and a further 5-10% during subsequent breastfeeding,
giving an overall mother-to-child transmission rate of 25-50% (De Cock
et al, 2000).
Why Breast is still Best
The situation has now changed for the better, with the exciting discoveries
made by Prof. Coovadia and his team from Durban, South Africa (Coutsoudis
et al, 2001). In a large prospective study of HIV-positive women who
chose to either breastfeed or bottlefeed their babies, 118 infants that
were exclusively breastfed for the first 6 months of life had NO increased
risk of acquiring HIV infection compared to 157 infants not given any
breastmilk. However, 276 infants who were on mixed breast and bottle
feeding from birth had a significantly higher rate of HIV infection.
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After 6 months, when the exclusively breastfed babies started
to go on to mixed feeding, their rates of HIV infection started
to rise significantly when compared to babies who were never breastfed.
The explanation for this surprising finding appears to be related
to the viral load in the breastmilk, which determines its infectivity.
With the approach of weaning, or if there is any sub-clinical
mastitis, the white cell count in the milk and hence the viral
load is increased, making it much more infectious to the baby
(Willumsen et al, 2003).
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The conclusion is obvious. In a developing country setting, all mothers
should be encouraged to breastfeed exclusively for at least the first
6 months, regardless of their HIV status, and then to wean the baby
rapidly. Research needs to be done to see what would be the cheapest
and most available weaning food to use.
HIV Prevention during breastfeeding
Of course, the central issue remains – how to protect the mother
from becoming infected with HIV in the first place. Here there is a
sad twist to the tale that involves breastfeeding. In West Africa, and
maybe elsewhere, there are cultural taboos on intercourse during the
first 6 months of lactation. Unfortunately this means that this is the
time when male partners are most likely to seek satisfaction from extra-marital
sex, and hence become infected with HIV. Since viral titres are extremely
high during the early stages of the infection, this means that the men
may be highly infectious once they resume intercourse with their lactating
partners, who in turn will be much more likely to infect their babies
in the early stages of their own infection. Thus men need to be made
aware of the fact that extra-marital sex whilst their partners are lactating
puts three lives at risk – their own, their partner’s, and
their baby’s. If ever there was a time for men to practice Safe
Sex, surely this is it.
A Counsel of Perfection for the HIV+ Mother
We can now begin to summarize the situation. Leaving aside the key
question of how to avoid HIV infection, what should a woman do about
it once she is infected?
The first thing is to consider very carefully the issues around parenting.
Since HIV infection is in effect a death sentence for the mother, even
in developed countries, is it right to bring a new child into the world,
only to become an AIDS orphan when the mother dies?
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If the HIV positive mother does not wish to become pregnant,
and wants to minimize the risk of infecting her partner if he
is HIV negative, what contraceptive should she use? This is a
question that is seldom addressed, and there is no easy answer.
If she becomes pregnant against her wishes, then perhaps she should
seriously consider having an abortion.
If she decides to continue with the pregnancy, she can minimize
the chance of infecting her baby at birth, the time of greatest
risk, when the baby may swallow infected maternal blood and secretions,
by having a Caesarean delivery. Alternatively she can have antiretroviral
treatment, e.g. Nevirapine, for herself antenatally and for the
baby immediately after birth. The chances of being able to afford
a Caesarean, or having access to antiretrovirals in the developing
world are minimal.
The mother should breastfeed her baby exclusively for the first
6 months of its life as this will give it the best possible protection
against diarrhea and respiratory infections, and there is little
or no further risk of HIV transmission. But if she develops mastitis,
she should cease breastfeeding immediately. After 6 months, the
baby should be abruptly weaned from the breast, and introduced
to solid food. By adopting this all-or-nothing breastfeeding policy,
mother-to-child HIV infection should be drastically reduced.
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Future prospects
The HIV pandemic is destined to get much worse before things start
to improve. At the end of 2001 there were 40 million people living with
HIV/AIDS, 2 million of whom were women. There were 5 million new infections,
and 3 million deaths from AIDS, including 580,000 children (UNAIDS,
2002).
Although Sub-Saharan Africa is the epicenter of the epidemic, with
28,500,000 infections, South and South East Asia come next with 5,600,000
infections. It seems likely that India will soon become the new epicenter,
and by 2050 some estimates suggest that globally, over 1 billion people
will be infected.
Stopping HIV infection must be the world’s first priority, and
reducing mother-to-child transmission should be high on the list; here
it seems that the promotion of exclusive breastfeeding has an important
role to play.
References
De Cock et al (2000). Prevention of mother to child HIV transmission
in resource-poor countries. J. Amer. Med. Assocn. 283, 1175-1182.
Coutsoudis, H. M. et al (2001). Method of feeding and transmission
of HIV-1 from mothers to children by 15 months of age: prospective cohort
study from Durban, South Africa. AIDS 15, 379-387.
UNAIDS (2002). Report on the global HIV/AIDS epidemic. Geneva.
Willumsen, J. F. et al (2003). Breastmilk RNA viral load in HIV-infected
South African women: effects of subclinical mastitis and infant feeding.
AIDS 17, 407-414.
ABC TV - The World Today - August 4, 2003
HIV positive mothers in Africa encouraged to breastfeed their children
ELEANOR HALL: While Africa battles
to contain the AIDS pandemic, there's new research about the impact of
breastfeeding on the rate of mother-to-baby infections. The research concludes
that it's vital that women who are HIV positive breast feed exclusively,
rather than provide bottle formula to their newborns, as Toni Hassan reports.
TONI HASSAN: It's a staggering
statistic: In Africa today, 40 per cent of all mothers reported to hospitals
and clinics are HIV positive. Mother-to-child transmission rate ranges
between 25 and 50 per cent.
Up to 10 per cent of those infections occur in the womb – something
practitioners can't do anything about. Another 10 to 20 per cent occur
at birth, probably due to blood-to-blood contact.
Caesarean delivery can reduce that, but that's not an option for women
in the developing world. New mums and their babies could also be given
anti-retroviral drugs, but again it's often not an option.
Another 10 to 20 per cent of transmissions occur during breastfeeding.
But that, according to Roger Short, a specialist in reproduction and
AIDS at Melbourne University that does not mean advocating a ban on
breastfeeding.
Dr Short has been liasing with colleagues in Durban, South Africa who've
done some ground breaking research in the area. The conclusion: breast
milk, exclusively offered, is still best.
ROGER SHORT: Mothers who breast
feed exclusively and don't give the baby any food other than breast
milk – none of them become infected through the breast feeding.
But if the mothers start to introduce supplements and infant formula,
then up goes the transmission rate, and this completely unexpected result
is explained by the fact that once you start partially breastfeeding
and topping up with supplements, the load of virus in the breast milk
shoots up.
And so the recommendation we've now got to make is that we should reinforce
the World Health Organisation's recommendation that all mothers should
breast feed for at least six months exclusively, giving nothing else.
And then, when you decide to wean, you must wean very rapidly, because
it's the process of weaning that, paradoxically, is infecting the babies.
TONI HASSAN: WHO's initial recommendation
that women in the developing world are encouraged to breast feed –
is that even being heard?
ROGER SHORT: Well, I think it's
not, unfortunately. The obvious response when people heard there was
infection occurring through breast milk was oh, right, we've got to
go onto 100 per cent infant formula.
But when we actually look at the statistics, I mean it leaves absolutely
no doubt that putting babies onto exclusive infant formula kills them,
because they going to die of diarrhoea.
TONI HASSAN: Because there's a
bigger problem isn't there, that women in the developing world are tempted
to use formula because it's seen as something developing women use,
despite the fact that the water is obviously more unsafe and therefore
the chance of passing on any sort of infection is greater.
ROGER SHORT: The difficulty of
making up infant formula safely in a developing country setting is enormous,
and sadly there's a new twist to that. When I was in South Africa at
the end of last year, they told me that because of the enormous deforestation
that's occurred, chopping down trees to make coffins, there's no firewood
left – the coffins for the babies and adults who had died of AIDS.
TONI HASSAN: So water isn't even
being boiled?
ROGER SHORT: No.
TONI HASSAN: Well, the challenge
is huge, isn't it.
ROGER SHORT: It's enormous.
ELEANOR HALL: Indeed it is. Professor
Roger Short, a specialist in reproduction at Melbourne University speaking
to Toni Hassan.
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