Carole:  Thanks for sharing the new references and bringing up this very
difficult issue, which all of us need to become as knowledgeable about as
possible in order to best help the mothers and babies in our care.  As I'm
sure you found in the discussions in the archives, there is clearly no
consensus on the issue of the best way to prevent HIV transmission through
breastfeeding in the various populations at risk, both in developing and
industrialized nations.

In addition to the question of whether or not an HIV + mother should
breastfeed, there is also the question of how long to breastfeed, as at
least one study suggests that breastfeeding for about 6 months is better
than continuing beyond (of course this is based on the finding of
increasing levels of seropositivity in infants who were breastfed for
longer periods, but in a particular population which may not have had
access to antiretroviral therapy).  This points out the difficulty in
generalizing from a study in one country or population to other
situations.  Another recent study suggests that nipple trauma is high
among breastfeeding mothers whose babies seroconverted, so it's possible
that transmission is more likely in this setting.

I have no particular words of wisdom, nor official recommendations.  In my
own practice, I try to keep up with the latest information and I would
provide my HIV+ mothers with current info to make their decision.  I would
of course urge use of prenatal AZT to reduce the most likely transmission,
(and possibly reduce transmission through colostrum as well, according to
your reference).  I would inform mothers that the greatest risk of
transmission through breastfeeding occurs when a mother seroconverts
while breastfeeding or has a high viral load while breastfeeding, but
that overall the risk of transmission through breastfeeding, although not
zero, is much lower than that in utero or intrapartum.
I would let them know the CDC recommendations
which state that in the USA, HIV+ mothers should not breastfeed.  I would
further individualize my recommendations regarding any individual mother's
decision depending on the mother's immune status and viral load,
consider pasteurizing the mother's milk or using well-screened donor milk
in situations where abm would constitute an increased risk (e.g. a mother
with lower educational or socioeconomic level, a strong family history of
atopy, etc).  If the mother decided to breastfeed, I would be even more
vigilant regarding breastfeeding technique to ensure minimal nipple
trauma.

Here are some more recent references for all of us to study:

Kuhn L, Stein Z.  Infant survival, HIV infection and feeding alternatives
in less-developed countries.  Am Jl of Public Health Jun
1997;87(6):926-31.

Zimmer P, Garza C.  Maternal considerations in formulating HIV-related
breast-feeding recommendations.  Am Jl of Public Health June
1997;87(6):904-6.

Kambarami RA, Kowo H.  The prevalence of nipple disease among
breastfeeding mothers of HIV seropositive infants.  Central African
Journal of Medicine Jan 1997;43(1):20-2.

Tovo P-A, et al.  Mode of delivery and gestational age influence perinatal
HIV-1 transmission.  Journal of AIDS and Human Retrovirol
1996;11(1):88-94.

Nagelkerke NJ, et al.  The duration of breastfeeding by HIV-infected
mothers in developing countries: balancing benefits and risks.  Jl of AIDS
and Human Retrovirol 1995;8(2):176-81.

I will close by paraphrasing one of our beloved Dr. Jack's favorite
sayings:  "Give the mother the information and remember that ultimately
it's her decision."
Regards to all, Alicia Dermer, MD, IBCLC.