Naomi you wrote, "I imagine that transmission
of HIV in women with cracked nipples is through blood, not
breast milk, which leaves us with the question of whether, how
and under what circumstances breastmilk can transmit HIV."

The question of hiv transmission through breastmilk is complex and reading
what the experts have to say in regard to it is often frustrating.  We seem
to have reason to believe that MTCT (mother-to-child transmission) of the hiv
virus occurs mostly through pregnancy, labor, and birth (about 3/4's) and the
other 1/4 is attributed to breastfeeding.  So in order to protect that 1/4 of
infants, we have instituted policies of breastfeeding avoidance in developed
countries and in developing countries--if the mother has access to adequate
resources (clean water, access to medical care, economic ability to purchase
infant formula, etc.).

The foundation of these MTCT policies on breastfeeding and hiv transmission
rests on the accuracy of the hiv testing that was done in the late 80's and
90's. Testing of infants is rendered incredibly difficult because maternal
antibodies to hiv can still be circulating in the infant's bloodstream for
the first 18 months of life.  In the early years the research and studies
that were done on hiv and breastfeeding used the ELISA (enzyme immunoassay
EIA) and Western Blot serum tests.  They now know that "Because maternal
antibodies can be detected in an infant's blood for up to 18 months after
birth, the ELISA and Western blot serum tests will be positive, regardless of
whether the infant is infected."  [HIV Nursing Curriculum, Baylor College of
Medicine 2001, page 19]  It has only been in the second half of the 90's that
the new standard has been used--the PCR.  That standard is expensive to use
and is why in Africa the ELISA is often used or diagnosis is often by
symptoms only.

All the studies that were used to damn breastfeeding as a mode of
transmission of hiv were based on tests that the medical community no longer
uses on infants because they are so erronous.  According to the Baylor
College Nursing Curriculum on HIV Diagnosis in Infants, "the infant needs two
positive PCR serum tests taken at two separate times to be considered
infected.  The first DNA PCR should be performed after one month of age..."

This information leads me to believe that until we do better studies using
correct testing procedures, we cannot possibly know for sure that hiv is
transmitted by breastfeeding.  Thus the debate about sore nipples and
mastitis causing transmission is a moot question and may never be settled
unless they find a reliable test for infants under a month.  Valerie W.
McClain, IBCLC

A good place to find information on hiv and breastfeeding is
http://www.anotherlook.org  There are position papers there by Magda Sachs,
Pamela Morrison, and others.






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