For those of you that could not access the site on my last post - here is the
article: re HIV and Breastfeeding:
Donna Kimick
Intern LC
Long Island NY
Dear Colleagues, Several recent publications may be of interest to you who
are on the WABA email list. The NMAA journal "Breastfeeding Review" has
published a long review by Pamela Morrison of the issues, somewhat more from a
breastfeeding point of view than has previously been available in the literature. The
title is "HIV and infant feeding: to breastfeed or not to breastfeed: the
delemma of competing risks." Part 1 is in BR 7(2):5-17 and part 2 is in BR
7(3):11-19. The editors asked me to put together some complementary information (and
I wrote at a later date than Pamela and thus had access to more recent
publications) which they published as "The HIV challenge to breastfeeding" which is
in BR 7(3):5-9. It is also available on my personal website:
http://www.welcome.to/breastfeeding. Lancet published an exciting and relevant publication of a
WHO team's findings pooling data on mortality and breastfeeding. (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
infectious diseases in less developed countries: a pooled analysis. Lancet 2000; 355:
451-55) In order to decide whether it makes sense to avoid breastfeeding to
reduce the risk of HIV transmission through breast milk, we must know the risk of
the non-breastfed child's dying from other causes. It was impossible for the
team to determine this from the three data sets they had from Africa (Ghana,
Senegal and Gambia) because virtually all babies were breast-fed well into the
second year. But for three other countries with less intact breastfeeding
cultures they could come up with better estimates than we have had previously.
They make the following statement: "This question exceeds the scope of our
analysis, but our results suggest that it will be difficult, if not impossible, to
provide safe breastmilk substitutes to children from underpriviledged
populations." It makes one wonder if the ongoing pilot studies that give free infant
formula to HIV+ mothers too poor to afford it, mainly in Africa, can be
considered ethical. We have mentioned previously the Coutsoudis et al (Influence of
infant-feeding patterns on early mother-to-child transmission of HIB-1 in
Durban, South Africa: a prospective cohort study. Lancet 354:471-6) findings that
exclusive breastfeeding appears not to transmit HIV at all or do so much less
than the more common mixed model of feeding (where water and other things are
given the baby and may lead to damage of the mucosal lining, increasing the risk
if HIV transmission from infected breast milk). A series of letters in
response to this article have now been published (Correspondance on Infant-feeding
patterns and HIV-1 transmission. Lancet 354 (27 November):1901+). Some
challenged it and demanded additional information. The authors provided this and did
so in a manner that to me strengthens their findings. Another recent study
suggest that neveripine can at low cost ($4 per mother-child pair) reduce
perinatal transmission, including from early breastfeeding, by about half.
(Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention
of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012
randomised trial Lancet 354:795-802. Cost effectiveness of single-dose nevirapine
regimen for mothers and babies to decrease vertical HIV-1 transmission in
sub-Saharan Africa Lancet 354:803-9. Correspondence: HIVNET nevirapine trials.
Lancet 354:1816+.) Together these studies suggests that the very dangerous practice
of avoiding breastfeeding in the early months of life may not make sense in
many poor areas of the world, even for women with HIV. So far UNAIDS, WHO and
UNICEF have said in the mass media that their policies need not be changed
based on these new findings. We hope that quietly behind the scenes they are
shifting gears toward greater promotion of exclusive breastfeeding for all babies
(which might reduce postnatal mother to child transmission among the majority
of the HIV+ mothers in the world who in fact do not know their HIV status) and
toward advising poor mothers to exclusively breastfeed, use nevirapine, and
then chose among the various possible alternative means of feeding (described
well in Pamela's articles) once the infant is older. Ted Greiner, PhD
WABA Research Task Force Coordinator
"It's the lucky baby, I feel, who continues to nurse until he's two."
Antonia Novello, MD, MPH, DrPH
Surgeon General 1990-1993
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