Kristen

It is really very gratifying to read another thoughtful post from the
University of North Dakota.  I think I can speak for all Lactnetters when I
say how much we appreciate the very careful background research which the
nursing students share with us.

The question of whether an HIV-1-infected mother living in a resource-poor
setting should breastfeed her baby is, as you have discovered, the subject
of much controversy. The situation is really one of competing risks, whether
the risk of death from HIV transmitted through breastmilk exceeds the risk
of death from other diseases.  Your tentative opinion, expressed in your
first paragraph,
"is that although there is evidence connecting a higher rate of HIV-1
transmission to infants through breast milk, it may be more beneficial to
advise the mother to breast feed if they are in a low-resource environment"
just about sums it up.  The topic is extremely complex, with many blind
alleys, and a maze of possibilities which can lead you round and round in
circles!

Breastfeeding Review in Australia were kind enough to publish, in two parts,
a long article which I wrote in 1999, where I attempted to look at this very
vexing subject from every angle. The refs are quoted below.

Since 1999 several important papers have been published which add to our
understanding.  I attempt to keep up with the most relevant research and am
pasting below my latest summary, unpublished, which I use as a quick
hand-out. If you can paste it into a Word document it fits front and back on
a single A4 sheet.  Please feel free to copy it if you you think it might be
useful.
               ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
   MOTHERS AND BABIES AND HIV:  WHAT IS THE RISK OF BREASTFEEDING?
        PAMELA MORRISON, IBCLC      (Updated: January 2002)

1.  The exact frequency of breastmilk HIV transmission during the course of
lactation remains unknown.  Current international guidelines [UNAIDS 1998]
state that the additional risk of mother to child transmission of HIV
through breastfeeding (over and above that occuring in utero or during
labour/delivery) is "about 15%".  This figure comes from a meta-analysis
[Dunn et al 1992] of 42 women with new infections and 1772 women with
established infection. The majority of the women had breastfed for only 2 -
4 weeks and only l06 women breastfed longer than 6 months.  The additional
risk of transmission from breastmilk was estimated at 14% with established
infection and 29% among newly infected women.

2.  The limits inherent in current testing techniques prevent identification
of the HIV-infected infant at the time of birth.  It remains speculative to
say that breastfeeding provides the route of transmission in a breastfed
baby who subsequently tests positive in the early postpartum [Black 1996]
particularly since a baby who is not breastfed may test negative on PCR at
birth and yet test positive any time in the next 90 days [Bagasra 1998].

3.   The degree of exclusivity of breastfeeding in many case reports is
unknown and the definition of "breastfed" children, even in populations
where breastfeeding is routinely practised, almost certainly means babies
who were, in fact, only partially breastfed.  The protective effects of
breastfeeding against ANY disease are known to be enhanced by increased
exclusivity and longer duration of breastfeeding.  Exclusive breastfeeding
facilitates enterocyte junction closure of the intestinal mucosal barrier.
This decreases  exposure to dietary antigens and environmental pathogens
which occur with premature introduction of other foods and liquids (and
formula), which in turn cause intestinal irritation and inflammation, to
allow direct contact of the virus with the infant's bloodstream [Smith &
Kuhn 2000, Morrison 1999].    Studies conducted in South Africa [Coutsoudis
1999,  2000,  2001(c)] confirm that at 3 months the overall rate of
transmission of HIV to babies who had been exclusively breastfed was 14.6%,
whereas 18.8% of babies who had never been breastfed had become infected.
Babies who received both breastmilk and formula had the highest rate of
transmission (24.1%).   By  6 months,  babies who had been exclusively
breastfed for 3 months still had lower rates of infection (18%) than never
breastfed (19%) or mixed fed babies (26%).

4. Re-analysis of the infant mortality risks associated with not
breastfeeding in the first year of life in three developing countries, [WHO
Collaborative Study Team, 2000]  found that the risk of death for infants
under 2 months from infectious disease was 6 times as likely if they were
not breastfed; 4.1 times as likely from 2 - 3 months, and 2.6 times as
likely from 4-5 months. The relevance of these risk estimates for HIV+
mothers was identified.

5.  An East African study showed that mortality at 2 years between babies of
HIV-infected mothers randomized to breast or formula feeding  was 24% and
20% respectively,  a difference that was not considered to be statistically
different, demonstrating that there was no child survival advantage when
breastfeeding was withheld.  [Nduati et al, 2000]

6.  The same East African group recently reported that the maternal
mortality rate of HIV-infected breastfeeding mothers exceeded that of the
formula feeding mothers [Nduati 2001].  However close scrutiny of the data
shows that although randomization was generated by computer, more mothers
assigned to the breastfeeding arm had STDs, particularly syphillis, and low
levels of vitamin A. They were also more likely to have had C-sections,
episotomies, rupture of membranes greater than 4 hours before birth, have
suffered miscarriages or stillbirth, and a higher percentage of their babies
were shown to be already infected at birth.   No difference in mortality
rates between mothers who were breastfeeding, mixed feeding or not
breastfeeding at all were found in the South African study [Coutsoudis 2001(d)].

SUMMARY: Although early research appears to show that breastfeeding
increases the risk of mother-to-child transmission of HIV, more recent
studies which clearly define "breastfeeding" show no additional risk of MTCT
of HIV through exclusive breastfeeding over not breastfeeding at all.  In
addition, there is no difference in the overall mortality rate at 2 years
between children of HIV+ mothers randomized to breast or bottle feeding.
Since infant morbidity and mortality are greatly enhanced whenever
breastfeeding is abandoned, particularly in resource-poor settings, it
follows that public health measures which seek to maximize child survival
should continue to promote exclusive breastfeeding for the first half year
of life, and continued breastfeeding with the addition of household weaning
foods for up to two years or beyond, notwithstanding maternal HIV status.

REFERENCES:

Bagasra O,  Is infection with HIV-1 possible during delivery and
breastfeeding? Guest Editorial AIDS Newsletter 1998 13(2): 1-2.

Black RF, Transmission of HIV-1 in the breast-feeding process.  J Am Diet
Assoc 1996;96:267-274.

(a) Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM.  Influence of
infant feeding patterns on early mother-to-child transmission of HIV-1 in
Durban, South Africa:  a prospective cohort study. Lancet 1999;354:471-476.

(b) Coutsoudis, A. Promotion of exclusive breastfeeding in the face of the
HIV pandemic. Lancet 2000;356:1620-1621

(c) Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai W-Y, Coovadia HM for the
South African Vitamin A Study Group.  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 2001;15:379-387. (Table p 383)

(d) Coutsoudis et al.  Are HIV infected women who breastfeed at increased
risk of mortality? AIDS 2001;15:653-655

Dunn DT, Newell ML, Ades AE, Peckham CS, Risk of human immunodeficiency
virus type 1 transmission through breastfeeding, Lancet 1992;340(8819)585-588.

Morrison P. HIV and infant feeding: to breastfeed or not to breastfeed: the
dilemma of competing risks,
Part 1. Breastfeeding Review 1999;7(2):5-13
Part 2. Breastfeeding Review 1999;7(3):11-19.

Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha  A,
Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J. Effect of
breastfeeding and formula feeding on transmission of HIV-1: a randomized
clinical trial. JAMA 2000;283:1167-1174

Nduati R, Richardson B, John G, Mbori-Ngacha D, Mwatha A, Ndinya-Achola J,
Bwayo J, Onyango FE and Kreiss J. Effect of breastfeeding on mortality among
HIV-1infected women: a randomised trial. Lancet 2001;357:1651-55

Smith MM & Kuhn L.  Exclusive breastfeeding: does it have the potential to
reduce breastfeeding transmission of HIV-1? Nutrition Reviews 2000;58:333-340.

UNAIDS/UNICEF/WHO 1998 HIV and Infant Feeding: A review of HIV transmission
through breastfeeding, WHO/FRH/NUT/CHD/98.3

WHO Collaborative Study Team. On the role of breastfeeding on the prevention
of infant mortality, effect of breastfeeding on infant and child mortality
due to infection diseases in less developed countries:  a pooled analysis.
Lancet 2000; 355:451-55.
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