Thanks to Valerie and Magda, Jennifer, Denise, Cathy and others for raising
the issue of HIV testing of babies.

It seems certain that *some* HIV transmission occurs through breastfeeding,
but that really exclusive breastfeeding significantly reduces the risk as
Cathy explained so well.  But there are still so many questions.

The issue of the HIV tests and how effective they are is one of the key
pieces of the puzzle which we cannot seem to find.  As Valerie points out,
the 1985 recommendation in the US, Australia and some European countries
for HIV+ women not to breastfeed was based on the ELISA test which could
not distinguish maternal from infant antibodies for 18 months following
birth.  My strong suspicion is that a much larger percentage of HIV
infections than we are led to believe, may have actually been acquired
during pregnancy or birth, not breastfeeding, but currently there is no way
to "prove" this because of the limits inherent in the testing techniques.

Valerie mentions that 50% of tests showing a baby to have been infected at
one month are false-positives.  I wonder if she really means
false-*negatives*.  "Late post-natal transmission" is deemed to be
transmission which appears to have occurred after a certain period of time
after birth. A baby might have been infected in utero or during birth, but
because there are insufficient virus in the blood (testing on PCR, which
tests for viral fragments, not antibodies) the baby would test negative at
birth, but might test positive any time in the next 90 days even if never
breastfed at all.  [Bagasra O,  Is infection with HIV-1 possible during
delivery and breastfeeding? Guest Editorial AIDS Newsletter 1998 13(2)]. In
non-breastfed babies, obviously the route of infection can only have been
via the placenta before birth, or from exposure to blood and
cervical/vaginal secretions during delivery.  In breastfed babies late
postnatal transmission is often presumed to have occurred through
breastfeeding - this might be true, but then again, it might not, and
currently we have no way of knowing.

The interesting thing is that different studies move the goal-posts, ie
some of them attribute breastfeeding as the cause of transmission in any
breastfed baby showing negative at birth but subsequently testing positive
at 21 days, 30 days, 45 days or 90 days.  Something I read recently
suggested this window period (between infection having occurred and
sufficient virus being present in the blood to show positive on a test) to
be as long as 120 days.  The Nduati study which randomised babies to
breastfeeding or formula feeding shows that while only 3.1% of babies in
the formula feeding arm first showed positive from 0-2 days after birth,
20.5% were shown to be infected at 24 months.  To be sure, 30% of their
mothers secretly breastfed them, but nevertheless this study is used to
show that a massive 36.7% of babies in the breastfeeding arm became
infected, to "prove" that breastfeeding is responsible for 16% of all MTCT
of HIV in breastfeeding populations and to prove that we are probably
under-estimating the risk of breastfeeding.  Babies in these research
studies are often only tested at 1 month, and 5 or 6 months, and 12 months
etc. so that the *timing* of when the baby first shows positive (which
could give a clue as to the route of transmission - placenta, birth or
breastfeeding) is lost.  Anecdotally I've been told that about 75% of
infected babies will show positive on a test at one month, and about 90% at
6 weeks.  But that still leaves a small percentage who might not yet show
up on the test whose route of infection is being be blamed on breastfeeding
when, in reality, they could actually have been infected at birth.  A study
which shows one of the lowest rates of transmission through breastfeeding -
only 5.4% - (Leroy) excluded all babies showing positive before 75 days in
acknowledgement that these babies could have been infected at the time of
birth.  Even so, there could have been some in the window period from 75 to
90 days.  Even very small percentages are vital when many believe that "if
there is even a one per cent risk of infecting my baby through
breastfeeding, then this is too much".

The sad truth is that we currently have no clue about how much transmission
takes place during early breastfeeding, if any at all. Nor can we know
(because of the window period) how many babies are infected during the 3-6
month period but who subsequently only show positive in the 5-6 to 12 month
period.  And this uncertainty forms the basis of the recommendation for
"early cessation" of breastfeeding even for those who have escaped the net
at birth.

So, based on some very inexact testing techniques, millions of women are
being encouraged not to breastfeed at all, or to stop breastfeeding
prematurely.  The method is to cast grave doubt on the safety of
breastfeeding, to use very politically correct language which apparently
promotes "choice", and then to urge the rest of us to "support" the mother
in her "infant feeding decision". Does this sound familiar?  It makes no
sense to me at all except if viewed from the perspective of boosting sales
of a competitive product.  And thanks to Valerie for keeping track of what
this might be.

One more thing - it is often assumed that if the water can be made safe,
then it will be safer not to breastfeed.  What is often not akcnowledged is
that it is pneumonia, not diarrhoea, which is the leading cause of infant
mortality in the world.  It's not that non-breastfed babies simply lack
clean water - they also lack the immunological components of mother's milk,
for which there is, as yet, no substitute.

Pamela Morrison IBCLC, Zimbabwe
[log in to unmask]

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html