Received from Ted Greiner
> Date: March 11, 2000 12:46 PM
>
> To everyone one the WABA mailing list (send us a "remove" reply if you
want
> off):
>
> This is the third time I am writing to you about the issue of HIV and
> breastfeeding. This may seem exaggerated, but it is one of the major
> tragedies of our time. Of course this is particularly the case for the
> individuals suffering from it, especially in poorer countries where drugs
> are out of reach economically, where infant feeding choices for
> HIV-positive women are extremely difficult (and lacking still in a good
> research base), and where all too often both mother and child are
innocent
> victims of cultures which accept male promiscuity and where women have
> little or no power over their own sexuality. My friend Pamela Morrison,
> helplessly
> watching the devastation occurring in her homeland Zimbabwe, refers to
this
> with understandable indignation as "father-child transmission."
>
> There are also broader dimensions to this tragedy. Many of the people
> struggling to combat this terrible AIDS problem seem (incorrectly) to
have
> assumed that the new UNAIDS/WHO/UNICEF policy calls for pressuring
> HIV-positive women to accept artificial feeding or that only in extreme
> cases of poverty would it be "acceptable" for an HIV-positive woman to
> breastfeed. They seem to perceive breastfeeding promotion as an obstacle
to
> implementing the new policy. Increasingly I am coming across calls in the
> AIDS literature for an end to breastfeeding promotion. Frustration over
how
> difficult it is to implement the new policy may also lead to a tendency
to
> exaggerate the magnitude problem. For example, the UNAIDS submission to
the
> ongoing
> Commission on the Status of Women states incorrectly that in 1999 the
"vast
> majority" of children with HIV got it from breastfeeding.
>
> Just at this critical time when many women may be feeling they perhaps
> should not breastfeed in case they have HIV, and government support to
> avoid an overall decline in breastfeeding is most necessary, many
> governments are becoming doubtful about whether they should promote
> breastfeeding. The HIV crisis itself is stretching health budgets to the
> limit. Even within the United Nations agencies, resources that used to go
> toward assisting countries in breastfeeding promotion are now monopolized
> by the HIV crisis. In fact, this decline in UN involvement in
breastfeeding
> outside the HIV issue was the basis for a statement of concern by the
> bilateral donor agencies at the 1999 UN ACC Subcommittee on Nutrition
meeting.
>
> The recently published randomized trial from Kenya (R. Nduati et al,
Effect
> of Breastfeeding and Formula Feeding on Transmission of HIV-1, A
Randomized
> Clinical Trial. JAMA. 2000;283:1167-1174) found that 30% of HIV-positive
> women who were randomized (after informed concent) to formula feed their
> infants, who were provided with free formula and support, did not
"comply"
> completely with formula feeding. That is, they breast-fed in addition.
> Women do not want to artificially feed in public in many countries
because
> of the risk of stigmatization. One small study recently found that 15 of
19
> Indian women who were told they were HIV-positive informed their husbands
> and 11 of them were cast out of the house and family, separated from
their
> children. This kind of tragedy will continue until governments
successfully
> convince
> their people that this issue must be openly discussed and that HIV is not
> something affecting only bad people who somehow deserve it, but also can
> infect good and honorable people. Ironically, this implies that even
> providing HIV-positive women with free infant formula, information and
> support (let alone just recommending they artificially feed) is likely to
> place their infants in the feeding pattern of greatest overall risk:
mixed
> feeding. (Even more so for those who are simply advised to artificially
feed.)
>
> Like other recent papers that have used incomplete or incorrect
definitions
> of breastfeeding and found that breastfeeding transmits HIV in about 16%
of
> cases, Nduati et al got much more media attention around the world than
the
> Coutsoudis et al paper (Coutsoudis A, et al, 1999. Influence of
> infant-feeding patterns on early mother-to-child transmission of HIV-1 in
> Durban, South Africa: a prospective cohort study. Lancet 354:471-6) which
> found that exclusive breastfeeding from birth did not seem to transmit
much
> HIV. As most of you know now, the latter was the first prospective study
to
> define exclusive breastfeeding properly and to inform pregnant mothers of
> its benefits so that many actually put it into practice and could be
> followed up.
>
> Rather than leading to any change in the UN policy, the Coutsoudis et al
> paper has itself been widely criticized and written off by many in the
> "establishment." This is not just unfair, it is unscientific. The proper
> way to criticize a paper is to write a letter to the editor and give the
> authors a chance to defend themselves, add additional information, or
admit
> certain weaknesses (which all studies have). As I mentioned in my last
> message, several letters were published in Lancet (Nov 27, 1999) and
> responded to by Dr. Coutsoudis. Now she has provided us with additional
> information, both on her original study and on the preliminary, still
> unpublished results of the follow up which has taken place since then.
>
> Several of you wrote earlier to ask if things you have received from me
> could be pubished in various newsletters. In the present case, you may
> publish what I wrote above, but nothing from Dr. Coutsoudis letter below
> may be published.
>
> With kind regards to all,
>
> Ted Greiner, PhD
> Coordinator, WABA Research Task Force
> http://www.waba.org.br
> http://www.welcome.to/breastfeeding
>
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