HIV/AIDS and Breastfeeding
It is nearly impossible to know if HIV is transmitted from mother to child in the womb, during delivery, or by breastfeeding. All babies with HIV+ mothers have the mother’s antibodies in their system and will test positive initially. According to researcher Anna Coutsoudis, about 20 babies out of 100 born to HIV+ women will be infected. With no special breastfeeding management practices, an additional 5 babies will become infected through breastfeeding. One study frequently cited is Dunn (1992) which found a rate of transmission of about 14% by comparing breastfed infants to non-breastfed infants. Another study (Nduati 2000) studied formula-feeding versus breastfeeding. The formula-feeding group was given extensive instruction and support whereas no special instruction was given to the breastfeeding group. This study concluded that the increase in transmission due to breastfeeding was 16.2%. However, only 70% of the formula-feeding group was considered compliant, and at 24 months, child mortality was the same for both groups. Both studies have been criticized for the vague definition given breastfeeding. If the women in these studies followed their cultural norms, they were actually providing a mixed feed.
In underdeveloped countries, poor sanitation may preclude formula and/or bottle feeding. Increased mortality due to the lack of breastfeeding negates any reduction in HIV transmission rates. Some studies even indicate that exclusive breastfeeding protects against HIV transmission.
Another study using subjects from South Africa, Coutsoudis (2001), divided the mother/infant pairs into 3 groups, exclusively breastfed, exclusively formula-fed, and mixed feeding. At 3 and 6 months, the exclusive breastfed and exclusive formula-fed groups had identical transmission rates of 19.4%. The mixed feed group was higher at 26.1% rate of transmission. What this means then is that even though HIV can be transmitted through breast-milk, the protective properties of breast-milk can negate this effect. Mixed feeding may contribute to the increased rate in transmission by allowing tiny fissures in the baby’s gut or by the mother missing a feeding, putting her in a state of sub-mastitis and opening her up to infection. (I have personal experience that a regularly missed feeding can bring on infection.) This has led some to recommend exclusive breastfeeding for six months with optimal breastfeeding management to avoid mastitis and nipple damage, and then quickly weaning to other foods. Note that this group had higher rates of transmission than some other studies due to the poorer health status of the subjects.
There are several factors that affect HIV transmission:
The stage of the mother’s infection (transmission rates are highest at the early and late stages of the disease)
The type of birth (vaginal births have a higher rate of transmission)
The viral load
The duration of breastfeeding
Mastitis and nipple damage
Thrush (yeast) in the baby
Use of antiretroviral medications
I have discovered that exclusive breastfeeding rates are unusually low in Africa. Breastfeeding is the traditional and normal means of feeding infants, but it is a common practice to provide foods other than breastmilk to very young infants. I did not find out what kind of food is offered or the motivation for doing so, so I don’t know if it is simply a common food, or if infants are regularly left with caregivers who must supply alternate food. In addition, some women believe they are diluting the effect of the virus by providing a mixed feed, though the research indicates an increased risk with mixed feeding. Some may artificially feed in private and breastfeed in public. In some societies, a woman who cup feeds or bottle feeds her baby is suspected of being HIV+ and may be abused or ostracized.
Another safe way to provide breastmilk is to pump and heat the milk to boiling. This has been shown to kill the HIV virus and is similar to the pasteurization used for human milk in milk banks. This is an option in developed countries, but in an area without reliable electricity, pumping and storing milk would be nearly impossible. Milk can be hand-expressed on occasion, but exclusive pumping requires a costly electric pump in order to maintain the milk supply. Unless the milk is to be given within the next few hours, it must be refrigerated or frozen.
In summary then, the options for an HIV+ woman include the following:
Exclusively breastfeed for 6 months and then switch to alternative feeding.
Exclusively formula feed.
Antiretroviral therapy.
Express and boil breast-milk to kill the virus.
Use a healthy, HIV- woman to wet-nurse.
None of these methods is as simple as taking your baby in your arms and nursing him when he’s hungry, comforting him when he’s upset, or soothing him to sleep. I would sooner cut off my right arm (and I seriously considered this – if my arm had gangrene I would cut it off), than give up the physical, mental, and emotional benefits of nursing to both me and my baby.
Thus, many recommend that women in undeveloped countries breastfeed their children exclusively, but counsel women in developed countries to formula feed where it is deemed safer. Others feel that that this is discriminatory – that where a woman lives should not determine the feeding method, especially if they feel strongly that breastfeeding is best for babies' health and protects against HIV/AIDS. We get into a situation where the government tries to mandate a health policy without sufficient scientific knowledge and then enforces this policy through heavy-handed tactics. That is why I would counsel a woman – and now I am talking about my opinion - who has no reason to suspect that she would be HIV+ to decline the test and keep well-meaning over-zealous government officials out of her life. If a woman is seriously concerned about her status, I would recommend she be tested anonymously or go to a doctor in a neighboring town. If the test came back positive, she can inform herself and make her own decision without interference. If a woman already knew she was HIV+ but had a low viral load, I would provide her with the latest research that indicates she can breastfeed exclusively for at least 6 months. If a woman in the highly infectious stages of the disease found herself pregnant, depending on the severity of the condition and her prognosis, she may need to consider formula-feeding, the long-term care of her child, and even end-of-life choices.
Part of the reason I feel this way are the stories I read in Mothering magazine showcasing HIV+ mothers' difficult dealings with health and social service agencies . Here is a link to their article. Also check out the links to the sidebars at the top, one of which discusses the same studies on breast-milk and HIV transmission, and the other on avoiding government interference.
Safe and Sound Underground
Mothering has several other interesting articles on HIV/AIDS. Just enter “HIV” in the “find” field.
Here is a website with several presentations and position papers on HIV/AIDS and breastfeeding:
anotherlook.org
Here is a review and fact sheet of the program presented on HIV/AIDS and breastfeeding at the 2003 La Leche League International Conference:
LLLI Session Notes
I will be attending the 2005 La Leche League International Conference where I am scheduled to take a session entitled "Pressures on HIV Positive Mothers' Infant Feeding." I hope to add any new findings at that time.
In underdeveloped countries, poor sanitation may preclude formula and/or bottle feeding. Increased mortality due to the lack of breastfeeding negates any reduction in HIV transmission rates. Some studies even indicate that exclusive breastfeeding protects against HIV transmission.
Another study using subjects from South Africa, Coutsoudis (2001), divided the mother/infant pairs into 3 groups, exclusively breastfed, exclusively formula-fed, and mixed feeding. At 3 and 6 months, the exclusive breastfed and exclusive formula-fed groups had identical transmission rates of 19.4%. The mixed feed group was higher at 26.1% rate of transmission. What this means then is that even though HIV can be transmitted through breast-milk, the protective properties of breast-milk can negate this effect. Mixed feeding may contribute to the increased rate in transmission by allowing tiny fissures in the baby’s gut or by the mother missing a feeding, putting her in a state of sub-mastitis and opening her up to infection. (I have personal experience that a regularly missed feeding can bring on infection.) This has led some to recommend exclusive breastfeeding for six months with optimal breastfeeding management to avoid mastitis and nipple damage, and then quickly weaning to other foods. Note that this group had higher rates of transmission than some other studies due to the poorer health status of the subjects.
There are several factors that affect HIV transmission:
The stage of the mother’s infection (transmission rates are highest at the early and late stages of the disease)
The type of birth (vaginal births have a higher rate of transmission)
The viral load
The duration of breastfeeding
Mastitis and nipple damage
Thrush (yeast) in the baby
Use of antiretroviral medications
I have discovered that exclusive breastfeeding rates are unusually low in Africa. Breastfeeding is the traditional and normal means of feeding infants, but it is a common practice to provide foods other than breastmilk to very young infants. I did not find out what kind of food is offered or the motivation for doing so, so I don’t know if it is simply a common food, or if infants are regularly left with caregivers who must supply alternate food. In addition, some women believe they are diluting the effect of the virus by providing a mixed feed, though the research indicates an increased risk with mixed feeding. Some may artificially feed in private and breastfeed in public. In some societies, a woman who cup feeds or bottle feeds her baby is suspected of being HIV+ and may be abused or ostracized.
Another safe way to provide breastmilk is to pump and heat the milk to boiling. This has been shown to kill the HIV virus and is similar to the pasteurization used for human milk in milk banks. This is an option in developed countries, but in an area without reliable electricity, pumping and storing milk would be nearly impossible. Milk can be hand-expressed on occasion, but exclusive pumping requires a costly electric pump in order to maintain the milk supply. Unless the milk is to be given within the next few hours, it must be refrigerated or frozen.
In summary then, the options for an HIV+ woman include the following:
Exclusively breastfeed for 6 months and then switch to alternative feeding.
Exclusively formula feed.
Antiretroviral therapy.
Express and boil breast-milk to kill the virus.
Use a healthy, HIV- woman to wet-nurse.
None of these methods is as simple as taking your baby in your arms and nursing him when he’s hungry, comforting him when he’s upset, or soothing him to sleep. I would sooner cut off my right arm (and I seriously considered this – if my arm had gangrene I would cut it off), than give up the physical, mental, and emotional benefits of nursing to both me and my baby.
Thus, many recommend that women in undeveloped countries breastfeed their children exclusively, but counsel women in developed countries to formula feed where it is deemed safer. Others feel that that this is discriminatory – that where a woman lives should not determine the feeding method, especially if they feel strongly that breastfeeding is best for babies' health and protects against HIV/AIDS. We get into a situation where the government tries to mandate a health policy without sufficient scientific knowledge and then enforces this policy through heavy-handed tactics. That is why I would counsel a woman – and now I am talking about my opinion - who has no reason to suspect that she would be HIV+ to decline the test and keep well-meaning over-zealous government officials out of her life. If a woman is seriously concerned about her status, I would recommend she be tested anonymously or go to a doctor in a neighboring town. If the test came back positive, she can inform herself and make her own decision without interference. If a woman already knew she was HIV+ but had a low viral load, I would provide her with the latest research that indicates she can breastfeed exclusively for at least 6 months. If a woman in the highly infectious stages of the disease found herself pregnant, depending on the severity of the condition and her prognosis, she may need to consider formula-feeding, the long-term care of her child, and even end-of-life choices.
Part of the reason I feel this way are the stories I read in Mothering magazine showcasing HIV+ mothers' difficult dealings with health and social service agencies . Here is a link to their article. Also check out the links to the sidebars at the top, one of which discusses the same studies on breast-milk and HIV transmission, and the other on avoiding government interference.
Safe and Sound Underground
Mothering has several other interesting articles on HIV/AIDS. Just enter “HIV” in the “find” field.
Here is a website with several presentations and position papers on HIV/AIDS and breastfeeding:
anotherlook.org
Here is a review and fact sheet of the program presented on HIV/AIDS and breastfeeding at the 2003 La Leche League International Conference:
LLLI Session Notes
I will be attending the 2005 La Leche League International Conference where I am scheduled to take a session entitled "Pressures on HIV Positive Mothers' Infant Feeding." I hope to add any new findings at that time.
posted by Mary Joan | 10:39 PM
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