Amal, you asked about this.  I agree with what Valerie has said, the major
thrust of which I would characterise as 'having trust in breastfeeding, and
applying embodied knowledge about breastfeeding to the issue'.  This latter
is something which I feel, from reading the research papers only (ie not
speaking to the researchers) is generally lacking in this field of research.

I would like to come at this from a different angle.  The Coutsoudis AIDS
paper has been out for two days and I can't pretend to have aborbed all of
it yet, however, the group defined as the 'exclusive bf' group' in this
study were women who excluisvely breastfed for THREE MONTHS.  I cannot find
a figure in the paper for the median time of exclusive bf for this group.
the upper limit was 6 months, but there is no discussion of how many babies
taht represents.   What this research shows is that for a cohort of babies
born to women diagnosed as HIV+ and  exclusively breastfed for at least
three months, and then moving at various times -- starting at 3 months and a
day -- mainly to mixed breast and other feeding, the rate of transmission of
HIV to the baby is lower than for exclusively replacement-fed babies, and
certainly for mixed-fed babies (who had a mean ebf time of 3 weeks, by the
way), until 6 months.  At 6 months, those babies who WERE exclusively
breastfed and became mixed fed, start to have hiv-transmission rates above
the erf babies, AS THEY CONTINUE ON MIXED FEEDING.

Still with me?

The question for me is then, if such a group of babies were to be
exclusively breastfed for *6 months*, what would we see?  Would it merely
delay the point at which introduction of mixed feeding 'undoes' the low
transmission rates of ebf compared to erf or mbf?  Or would reaching the six
months' mark of exclusive breastfeeding, which seems to have acheived some
importance in the eyes of WHO, we hope based on some empirical evidence,
confer *later and continued* protection against transmission?

In other words, we have measured early [up to three months] ebf agains mbf
and erf, now it is time to tease out the timings within an ebf cohort.  It
may be that abrupt weaning is going to be a strategy for avoiding
transmission.  It may, however, be that a longer period of ebf results in
different abilities of the baby to withstand the disadvantages of mbf, begun
after 6 months.  And there is, as Valerie points out, the question of
studying the effects of ebf for periods longer than 6 months.

Coutsoudis et al, in this paper, say that exclusive breastfeeding, to work
for HIV+ women, needs to be promoted and supported throughout the
population.  Indeed, this probably needs to happen on a world-wide basis.
So there's a challenge for us -- our work with women needs to move to
include understanding of ebf, in order to support breastfeeding's continued
existence in Africa.  Yet, as Ted Greiner has said, this is an intervention
we can make which should have only benign spillover effects on health.  I
would certainly like to see any discussion of abrupt weaning as only a
possible strategy and keepng this wider picture in mind.  Otherwise early
abrupt weaning could have a spillover effect and start becoming the norm for
all.  Shudder.

Magda Sachs
Breastfeeding Supporter, BfN, UK

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