Re: Pregnancy and HIV:An urgent note about safe breastfeeding

[Guest guest]

Dear FORUM,

The posting of March 25,2004 [Ref; The posting Mark Cichocki:

http://aids.about.com/cs/womensresources/a/pregnancy.htm] contained this message

- " Avoid breast milk: Because HIV can be transmitted through breast milk, women

who have HIV should not breast feed their babies. Only baby formulas should be

used. "

That should be DISREGARDED. Please read the following a fully informed report.

It's carried on the Breastfeeding page of our website at http://www.aids.net.au

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: " 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, 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.

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.

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).

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?

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.