Sarah
Thank you for your further response on the international and US and
UK guidance on whether HIV+ mothers should be
allowed/encouraged/recommended to breastfeed.
We seem to have reached something of an impasse. We are both citing
and quoting from the same guidance documents. You are emphasizing
certain passages and I am emphasizing others. I've said that the
first recommendation of both organizations is for formula-feeding,
but that both also allow/permit breastfeeding when HIV+ mothers
really wish to do so, and I think you've said that too, although you
also seem to say that although that's what's written, they don't
really mean it.... We seem to differ only in the _interpretation_ of
the AAP and BHIVA guidance.
I receive queries from HIV+ mothers from all over the world, and from
IBCLCs and others who are concerned that the baby's health/well-being
should be the first concern. They ask, in light of the most recent
research, if breastfeeding might not be the safest infant feeding
option in the context of HIV, and they ask if HIV+ mothers who have
their hearts set on breastfeeding might, if possible, be enabled to
do so. As an IBCLC I may not make recommendations, nor give medical
advice. But I can, and should, share the most current research that
I can find, as well as the most up to date guidance/recommendations
from various international/national bodies for mothers to discuss
with their doctors, their babies' paediatricians and their HIV
clinicians. For example there is a case history here: Morrison P and
Faulkner Z, HIV and breastfeeding: the unfolding evidence,
Essentially MIDIRS, Dec/Jan 2015;5(11):7-13,
<http://www.midirs.org/em-decjan-hiv/>http://www.midirs.org/em-decjan-hiv/
I'm sure you're aware that in the UK, a few HIV+ mothers _are_
breastfeeding with their healthcare providers' endorsement and
support. Hopefully when their clinicians have a large enough sample
to assess local results they will be published. Until that happens
we only have the results from mainly African studies because
breastfeeding was effectively banned in industrialized countries from
1985 onwards.
It could be that we disagree on the finer points due to our different
backgrounds. I'm an IBCLC and committed breastfeeding
advocate. I've been looking for the rationale and research to back
various HIV and infant feeding policies and guidelines since 1995 and
some of them have not been based on the best science, but on
prejudice and half-truth and - I suspect - on commercial interest. I
live in England now but I spent most of my life in Eastern and
Southern Africa where breastfeeding was necessary to keep babies and
young children alive. Over 99% of all mothers initiated and over 90%
maintained breastfeeding well into the second or third years of life,
and there are many social, cultural and tribal beliefs which serve to
preserve and protect breastfeeding. Although mixed feeding was
common, formula was never used by African mothers prior to 2000. Not
to breastfeed at all was unthinkable because if her baby would not
accept the breast it showed that a mother had been unfaithful to the
baby's father, and she would risk ostracism, violence, abandonment
and even murder. Thus each act of public breastfeeding affirmed her
value as a woman, a virtuous wife and a good mother.
All this only started to change, with much soul-searching and
distress, when UNICEF gave out freebies to HIV+ mothers and taught
healthcare workers how to teach them to formula-feed from 2000
onwards, ostensibly to "save" their babies from HIV, but without
recording the results - neither the numbers of babies who ended up
HIV-free nor numbers who didn't survive formula-feeding. The
Botswana story is instructive, but these disasters were happening in
all the African countries where the PMTCT pilot projects had started
and where other researchers carried them on. We kept hearing of
"babies dying like flies" due to formula-feeding long before the
journals dared to publish the results. As you may know, 78% of HIV+
mothers now living in the UK are born in these same countries, and
they bring with them (as I do) their own home-grown cultural beliefs,
taboos and fears. Some of their stories, of hiding in their bedrooms
formula-feeding because their doctors here say they may not
breastfeed, yet they dare not show their neighbours and friends that
they're not breastfeeding, would make you weep, (see Ayugi de Masi,
J, Becoming an African mum, NAM/AIDSMAP blog 19 September 2012,
available at
<http://www.aidsmap.com/Jackies-back-and-shes-a-mother/page/2512977/?utm_source=NAM-Email-Promotion&utm_medium=hiv-weekly&utm_campaign=hiv-weekly>http://www.aidsmap.com/Jackies-back-and-shes-a-mother/page/2512977/?utm_source=NAM-Email-Promotion&utm_medium=hiv-weekly&utm_campaign=hiv-weekly
)
It's for these reasons that I welcome the change in the international
HIV and infant feeding guidance which recognizes that maternal
antiretroviral therapy can not only reduce the mother's viral load to
undetectable and prolong her life to almost normal, but that maternal
ART and exclusive breastfeeding can result in extremely low rates of
mother-to-child transmission in utero, during birth and during
breastfeeding. These findings have been described by WHO as
"transformational", and they form the basis for the relaxation in the
AAP and the BHIVA guidance.
With regard to the possibility that an HIV+ breastfeeding mother
might just do mixed feeding or might forget to take her ART, your
thoughts are similar to at least one researcher who says we can't
promote breastfeeding with ART because depressed mothers don't take
their meds. This is nonsensical - are prescriptions for antibiotics
or statins or anti-depressants simply not prescribed "in case
patients forget to take them"?? Of course not. I believe that it's
my job to explain very very carefully why exclusive breastfeeding and
medication adherence are so important. And I've had some very very
sweet confirmations from all sorts of places that mothers do indeed
understand and are _highly_ motivated to keep themselves healthy for
their babies, and keep their milk as HIV-free as possible so that
their babies are can survive and thrive. So they are very determined
to withstand cultural pressure to feed little mouthfuls of "porridge"
or give sips of water, and they know that their ART has to be taken
religiously every single day.
IMHO the _most_ important aspect is safety. Which infant feeding
method is likely to be safest for a particular baby living with a
particular mother in her unique environment? For most HIV+ mothers
in most countries there is no doubt - as WHO recognize - that EBF +
ART is safest. But even in industrialised countries, with their much
more efficient health-care systems, this can also be true, and while
the AAP and BHIVA make a first recommendation for formula (which
covers them from making a recommendation which has for so long been
considered unsafe) they have also looked carefully at the research
and the mothers and babies who will be affected by their
recommendations - and fortunately they've at last relaxed the total
ban on breastfeeding. I think it's marvelous. And, to echo the
words of a trainer at the WHO/UNICEF HIV and infant feeding course,
who taught me how to prepare formula, working on newspaper on the
floor of a Harare Hospital outbuilding in 1999, to mimic the
conditions most African HIV+ mothers would be experiencing, "I didn't
set the policy, I'm just responding to it." It's nice that things
have now turned full circle.
Pamela Morrison IBCLC
Rustington, England
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