Thought after Chris's post you might like this.  It cheered me up -- though
clearly a long way to go.  If I ever gave a talk where someone who
previously thought they knew 'the answer' came out questioning it (see first
para) I would feel I had acheived something.  I think Anna Coutsoudis has
done a sterling job here....

Magda Sachs
Breastfeeding Supporter, BfN, UK
****************************************************************************
*
07/12/2000

The wait for unequivocal advice on breastfeeding continues

This is one of the controversial issues being debated at the AIDS 2000
conference.
"Over the past ten years of the AIDS epidemic, I thought we had concluded
that HIV positive mothers shouldn't breastfeed", said one Pittsburgh doctor,
"now I'm confused".

This was a popular sentiment at Tuesday's debate on HIV and breastfeeding,
led by Dr GM Fowler of the centre for diseases control in Atlanta, USA, and
Dr Anna Coutsoudis, associate professor of paediatrics at Natal University.

The audience was vocal in its division on the issue that is likely to be one
of the most controversial issues of the Durban conference. As co-chair, Dr
Quarraisha Abdool Karim said, the debate not only clearly "highlighted the
difference between health provision in the North and South, but also between
South and South".

Coutsoudis presented results of a South African study of 551 mother infant
pairs, some of whom fed only formula, some only breastmilk, and some a
combination of the two. The early results of up to three months were
published in the Lancet last year and she was reporting on the complete
results up to 15 months.

This study found that at six months there was no difference in transmission
risk between exclusively breastfed and formula-fed infants but that the risk
was considerably higher in the mixed group. After six months, other foods
were introduced and new infections did occur, but still considerably fewer
in the exclusively breastfed group.

Demographic surveys show exclusive breastfeeding rates to be the lowest in
sub-Saharan Africa, home to 90% of the world's HIV-infected women. Moreover,
urban rates are usually significantly lower than rural rates. In South
Africa, only 5% of infants are exclusively breastfed for up to six weeks.

The Coutsoudis study used the strict WHO definition of breastfeeding. This
requires that the infant receives breastmilk only and no other solids or
liquids, not even water. Most previous studies have referred to a situation
where the only milk given was breastmilk, regardless of whatever else the
baby received.

She made an impassioned plea for all women (not only the poor in developing
countries) to exclusively breastfeed for the first six months. Not only did
this satisfy all nutritional requirements, she argued, but had important
social-psycho benefits if a mother, already traumatised by her HIV status,
was allowed to bond with her child in this way.

Exclusive breastfeeding is moreover associated with proper attachment of the
baby to breast, lowering the risk of transmission through bleeding cracked
nipples and mastitis.

She concluded that entire communities should be involved in discussions of
breastfeeding, that health workers promote the use of condoms for sex during
lactation and encourage working mothers to express their breastmilk so that
a carer could provide regular home feeds.

Consistent breastfeeding strengthens the gut lining whereas allergens and
contaminants in diet supplements can lead to inflammation. Exclusive
breastfeeding also aids the growth of intestinal bacteria that prevent other
more harmful bacteria from taking hold.

Coutsoudis pleaded for HIV-infected women to be empowered to make informed
choices about formula, and if they decide to breastfeed, to be encouraged
and supported to do this for six months and then stop completely.

She questioned whether strong commercial interests had been responsible for
the rush to push for formula feeding.

Coutsoudis said many mothers had been misinformed about the risks. Her data
showed that predominantly mixed breastfeeding had a 4-5% risk within the
first six months and that exclusive breastfeeding might eliminate the risk
almost entirely.

Fowler welcomed the study but said that "we still don't know enough, the
data is inconclusive". Major studies were outdated, methodologically flawed
and often conflicted, Fowler said.

The international community should instead focus resources on providing
short-course anti-retrovirals to prevent mother-to-child transmission, while
larger, longer-term studies on the issue take place.

Conference chair, Professor Jerry Coovadia, said society could not afford
the four or five years it would take to do a proper randomised control
study - too many lives would be lost in that time. He said the R50-million a
year it would cost to provide free formula, was utterly unaffordable and so
society had to find a way to make breast-feeding safer in the developing
world.

Most women, when presented with informed options, choose the breastfeeding
route anyway. In areas where culture dictated that most women breastfeed,
anyone choosing not to may be accused of being HIV positive which may
actually endanger mother and child or cause serious social isolation,
Coovadia said.

Dr Trudi Thomas from the Eastern Cape agreed with Fowler that, regardless of
scientific findings, it remained extremely difficult, in any culture, to get
women to breastfeed exclusively beyond the first few weeks. She said the
insistence on exclusive breastfeeding largely ignored the tough realities of
working women. Food supplementation and anti-retrovirals were the only way
to go, Thomas said.

Janet Howse
South African Medical Journal

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