Saturday, 1 December 2007

Breastfeeding Babies and HIV+ Mothers

Today is World AIDS Day. When I was a volunteer in AIDS and HIV+ issues in the early 1980s, we hoped Acquired Immune Deficiency Syndrome would be gone by now. In some senses, it has, as the treatments now available for people with Human Immunodeficiency Virus active in their bloodstreams, are so effective, AIDS itself can be prevented from being developed for years, allowing infected people to live happy, healthy and fulfilled lives.

When no one knew what was going on in the 80s, when people were mysteriously dying of simple infections that were running rampant through their system, the current situation - where both cause and transmission routes are known, and drugs can slow down replication and deal with symptoms - would have been seen as an almost complete triumph. Although this state of affairs doesn't represent a cure, it does, effectively, mean that the disease should be under control.

What we couldn't see back then, although the evidence was there, is that HIV transmission, and the development of AIDS subsequent to infection, would become an economic issue. It would be about resource poor people, in resource poor countries, not about the biology of the infected person.

At the height of the panic in the UK about HIV, when the UK Gov was pushing leaflets with images of giant carved granite headstones through every letter box, who could have seen that HIV and AIDS was going to develop into a major killer of mothers and their children? That poverty, and the diseases of poverty, would feed into the virus, and devastate family life for generations? Looking at it now, I'd like to think that anyone with a modicum of common sense and the slightest understanding of power, could have seen it plainly (and many did so). But it passed me by.

I just couldn't see a world where treatment was available, but not provided as there wasn't enough money, or political desire to do so. Where transmission routes are clearly known, but culture opens the doors to the virus. Where religion can defend behaviour that puts women's lives at risk to their husband's culturally sanctioned promiscuity, but the same religious viewpoint can condemn the wife for trying to protect her own body. I was a naive soul, in the 1980s. 'Patriarchy' was an outdated term, that could not possible apply to the life I, and others, were living.

Oh, it only that were true! For if it was, I doubt very much I'd be making this post today... for there would be no need to highlight the report I'm about to reproduce here for you! No need to point out that the battle ground over HIV is drawn out on the bodies of poor and dispossessed women. That who controls female bodies, and who has a right of access to them, and how that access is undertaken, are cultural issues, and the self-determination of the woman herself is often the last element considered... and that this impacts greatly with HIV status. That women are both continually put at risk of HIV infection, by the cultural status quo around them, and then their behaviour in response to that status proscribed. Women who had have little to no choice on putting themselves at risk of infection, who then have little to no choice on how their bodies are treated post-infection.

Terrible, isn't it? You're sitting there shocked, and sympathetic, and nodding in agreement, aren't you? Absolutely wrong, that the least enfranchised of us have the least control of their bodies, isn't is?

Is it?

Seriously, is it? Do you think women who are HIV+ have a right to control their bodies? Do you think mothers who are HIV+ have a right to determine what they do with that body? Do you, for instance, that an HIV+ woman, who is becoming a mother, has the right to consider allowing her baby access to her breasts? Does the baby of an HIV+ mother have the same right to breastfeeding as other babies? Does the same right of access to the mother's body if the mother desires, apply to her baby? Do you think this?

I do.

Why I think this, is a complex affair, and one that requires careful analysis of culture, from several perspectives. Not surprisingly really, as we're discussing breastfeeding babies, and one thing that's patently clear is that as soon as you discuss them, you have to engage with cultural values that are hostile to a baby's need to nourish at the mother's breast.

So let's unpick some of the reasons why some of you are sitting there shocked, that such a terrible thing has been said - that mothers with HIV+ status should be allowed to make the same feeding choices as everyone else.

To begin with, let's address the nature of the risk. Do you know what the risk of transmission is, to an exclusively breastfeeding baby? What maternal transmission rates are, if the baby is receiving only the mother's milk for the first six months of life, as is the WHO Gold Standard? Well, the transmission rate on those babies is.... 4%.


So 4 in 100 babies, will absorb HIV from the mother. 96 babies out of a hundred, will not do so. Has that shocked you? Were you expecting much higher figures? How many babies did you think become infected, through mother's milk? Where did you get that idea from.....? Hmm... ?

Is 4% too high for you? All right for the 96, but not to good for the 4? Agreed, it would be better if it was zero, I'll give you that.

Of course, it can be zero, or near as damn it. If you treat the mother with anti-viral drugs during the pregnancy and breastfeeding, which costs the same as formula feeding the baby... the transmission rates are so low they are zero in the groups tested - less than one, to be absolutely clear. so, you can have a range of risk for transmission in breastfeeding from 0% to 4%.

Is 4% still simply too high? Are you sitting there thinking "Even at 4 percent, mother's shouldn't be allowed to take this risk with their infant's life." Do you feel it's legitimate to condemn such mothers, and in some cases, separate them from their babies and enforce formula feeding upon them? Do you think Governments should do everything in their power to get the message through to those mothers that they cannot allow their babies to breastfeed? After all, 4 percent of them will become infected!

Well, you are right, 4 percent of them will be. On the other hand... in the resource poor areas, 15% of them will be dead within three months of birth, as a result of the formula feeding. That's 15 dead babies, versus 4 infected babies.

Do these figures seem right to you.. that more babies will die from the formula use, than would have acquired the infection if they are breastfeeding? Does this tally at all, with the news reports, the debates, the general conversations you've heard over the past few years?

Could it possibly be true, that exclusively breastfeeding by HIV+ mothers improves the health of their babies in resource poor areas?

Well, it is true - and the WHO have finally come out and stated so, unequivocally. Shouting to be heard over the clamour of formula marketeers who have made great profit from scaring every one over 'the need to formula feed if you are HIV+' and the cultural frenzy in the resource rich west of the spectre of the 'dangerous breast' infecting innocent babies.

I've appended the report in full at the bottom of this post: do read it. Foot notes are on the original link above.

Now, I've said this is about culture, as much as anything, and have really only spoken about medical research and statistics. Where is the culture? Well, I'm willing to bet it's in the heads of some of the people reading this, who are saying.... "well yes,that's probably okay in those poor places... but the rich West can't afford those 4 babies to be infected, so let's formula feed them when we know the formula is safe."

And the culture there... is... that formula is safe as long as the water and preparing areas are clean.

And this isn't so.

Not only is powdered infant formula not a sterile substance, it can carry bacterial contamination from manufacture, it is potentially harming to the newborn stomach. Simply, newborn gut lining is not designed to ingest cow's milk, no matter how modified it is. The newborn gut is a route of infection, for many infections, if it is compromised by having anything else other than human milk poured into in the first six months of life. It takes six months for the gut to mature on its own, and develop immunities to strange proteins (such as cow's milk) coming into contact with it.

A gut that has had anything other than mother's milk in it, for those first six months, is compromised. That's why formula fed infants, in the resource rich West, with its seemingly stringent hygiene conditions, still have far higher rates of vomiting, sickness, diarrhea and serious stomach infections that those babies who are breastfeeding. Their immune system is compromised by lack of breastfeeding, the formula itself compromises their stomach lining and it often carries bacterial contamination.

But culture states this can't be true... because formula is nice and safe and sterile and scientific, and breastmilk comes out of not nice, unsafe and not scientific female breasts. Infected breasts. Well, they may be infected with HIV, but the milk coming out of them protects and builds the lining of the baby's stomach, and there is evidence to suggest the proteins in human milk destroys HIV. So HIV+ mothers are still doing the best they can by their infant, by letting them breastfeed exclusively. Fewer will die from contaminated formula. Fewer will die from infections taking hold in their compromised gut.

Culture says not, of course. News headlines, campaigns by formula marketeers, everyone who's scared of HIV.. the voices against breastfeeding seem to crescendo when an HIV+ mother enters the room. Science, rational and evidence based research, leaves through the back door. Fear based instinct rules, and the 'obvious' and 'safe''conclusion - prevent the mother from breastfeeding at all costs - emerges. Remove her right to make an informed choice on behalf of her baby, and tell her she cannot nurture her baby at the breast. She isn't allowed to decide which set of risks she wants to apply to her feeding choices: she must choose formula.

My argument is that she requires support, proper information and the freedom to choose for herself and her baby. She may choose formula, particularly in the West, where practices may reduce the transmission rate of HIV to zero. Equally, she may choose to be treated by anti-viral drugs and to breastfeed. The point is, the choice is hers, and we should be doing our damnedest to support each woman in that choice. To make sure their babies can have access to the breast, if the mother wishes it, and that every mother - rich or poor - has the freedom to choose what's best for her and her baby. And that's a choice free from bigotry that demands that HIV+ status automatically means that mother's cannot allow their babies to breastfeed. Today's report finally makes that clear to all and updates the data previously being used to build arguments that deprived breastfeeding babies of their mother's body.

In the wider issues around this, the twentieth World AIDS Day, you may also like to have a look at Nelson Mandela's 46664 site. Self determination is the best way forward for everyone, not just breastfeeding babies! :-)

- - - - - -

WABA World AIDS Day Statement
Press Release
Embargo: 1 December 2007


A decade of uncertainty has fuelled an agonizing dilemma about the least risky way to feed HIV-exposed babies.

Research presented in 2007 finally points conclusively to the need for renewed protection, promotion and supportof breastfeeding. The Final Report of the 2006 World Health Organization HIV and Infant Feeding Technical Consultation1 provides welcome revised recommendations. New evidence clarifies that the most appropriate infant feeding option should continue to depend on a mother’s individual circumstances, her health status and the local situation, but should take greater consideration of available health services. HIV-positive mothers should breastfeed their babies exclusively for the first 6 months of life, and continue partially breastfeeding after 6 months unless conditions are already in place to show that replacement feeding is safe.

Commenting on the dilemma of competing risks between HIV transmission through any breastfeeding vs no breastfeeding, Dr Hoosen Coovadia was quoted this year as saying, “If you choose breastfeeding, you would of course have HIV infection. You would have about 300,000 per year in the world. But if you avoided breastfeeding, the mortality would be about 1.5 million per year. So on the balance of probabilities for poor women in the developing world, there is no other choice than to breastfeed their infants. You shouldn’t devise policies for the rich few. There are some, but the majority of HIV infected women are poor.” 2

His subsequent paper showed that HIV transmission through 6 months’ exclusive breastfeeding by South African mothers was 4%.3 Cumulative 3-month mortality due to replacement feeding was 15.1% vs 6.1% for breastfeeding. Early weaning vs continued breastfeeding substantially increased morbidity and mortality of infected and uninfected babies in Uganda 4, Malawi, 5 Kenya,6 and Zambia 7. Researchers concluded that the risks should be anticipated and PMTCT programmes should strongly encourage breastfeeding into the 2nd year of life. .

Specific HIV and infant feeding counselling was less effective than group information, videos and pamphlets in achieving exclusive and extended breastfeeding in Zimbabwe.8 Intriguingly, 84.5% of mothers recruited into the ZVITAMBO study did not wish to learn their HIV-status, 9 thus avoiding a recommendation for early weaning for HIV-exposed babies, leading instead to an extremely high rate of HIV-free survival.10

Finally, providing antiretroviral therapy (ART) to mothers only during pregnancy and birth begs further scrutiny. While only ~1% of HIV-infected mothers currently receive it, ART for eligible mothers could reduce MTCT in resource-poor settings by over 75%.11 In Rwanda12 and Tanzania13 triple-therapy dramatically reduced transmission of HIV during 6 months exclusive breastfeeding to 0% and <1% class="blsp-spelling-error" id="SPELLING_ERROR_25">iral therapy (HAART) for mothers recruited into the DREAM study in Mozambique, Tanzania and Malawi.14 Acknowledging the difficulty in telling a woman that she can avoid transmitting the infection to her child, but that little can be done for her own health, researchers provided HAART to mothers from the 25th week of pregnancy through 6 months exclusive breastfeeding.

Cumulative HIV transmission to infants was similar to rates reported in high-income countries and lower than those of formula-fed babies, being 2.2% and 2.7% respectively, with postnatal rates of 0.8% and 1.8%.

Political will and strong leadership are needed to reverse the decade-long erosion of breastfeeding accompanying the global PMTCT effort. <BR>

Characterization of formula-feeding as a safe infant feeding option can no longer be justified; contamination of powdered infant formula can occur intrinsically from raw materials, during manufacture 2/2 or from extrinsic sources.15 16 Its cost has been very high in terms of infant malnutrition and mortality, and indisplacement of funding away from treatment for HIV-positive mothers. Rational and humane strategies are needed to simultaneously

o improve the health and survival of HIV-infected women,
o lift the burden of an impossible choice from mothers as they contemplate how best to feed their babies,
o prevent transmission of HIV to exposed infants, and
o protect food security for young children.

WABA calls on national and international leaders to close the gap between rich and poor countries regarding access to treatment, and to use current evidence to enact universal public health measures fostering overall child survival, both within and outside the context of HIV.

For more information, kindly contact:

Pamela Morrison IBCLC
Co-coordinator WABA Breastfeeding and HIV Task Force
Rustington, England


Sarah V. said...

You left out the references to the WABA post. Could you post them, please?

Morgan said...

I'm not sure what you mean? The link is contained in the text.