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Sent: Friday, 3 November 2000 6:06
Subject: Update on HIV and breastfeeding
Dear Colleagues,
Here is an update in the evolving policy climate in relation to HIV and
breastfeeding.
WHO just issued a book called "Management of the child with a serious
infection or severe malnutrition." Its HIV chapter actually goes further
than the original UNAIDS/WHO/UNICEF guidelines, saying that a mother
"suspected" to be HIV-positive should be counselled about the risk of HIV
transmission through breastfeeding. This is an example of the unfortunate
way in which this whole thing is blowing up out of proportion, especially
in the African context. In some countries many health workers are likely to
suspect nearly any thin or sick mother of being HIV-positive.
On October 25, UNAIDS and WHO issued a press release regarding a technical
consultation they held in Geneva from 11-13 October. It reflects some
lessons learned about drug treatment but not much regarding infant feeding,
given all the pilot trials that have been going on during the two years
since the new guidelines were issued. Exclusive breastfeeding "for the
first months of life" is now given more emphasis for HIV positive women who
choose to breastfeed. Instead of referring to the average assumed rate of
transmission of HIV that infants born to HIV-positive mothers acquire
through breastfeeding (15%), it says "up to 20%," a well-worn strategy
among lobbyists, since it is not incorrect. One is left wondering who
decides on these press releases, who they are lobbying and what they hope
to achieve.
Even more depressing is the summary of Durban published in Lancet (Sept 30,
p. 1204) by M Merson (former head of the AIDS program in WHO) and A
Rosenfield. In an other wise good review that emphasizes prevention, the
only lesson they seemed to have learned about breastfeeding was
"Unfortunately, it now appears that their (antiretroviral drugs) benefit
may be lost if infected mothers breast-feed their infants."
The Government of South Africa issued new guidelines on HIV on Oct 24,
including the following statement:
"Breastfeeding, safer sex, nutritional supplements and vaginal cleansing
with an antiseptic solution are part of the policy recommendations to cut
the risks of mother-to-child HIV transmission."
Though many of us have doubts about some stances that government has taken
regarding HIV, let us hope that this particular statement can inspire other
African countries to recognize the risks involved in rapidly changing their
stance toward breastfeeding even in the face of the HIV threat. UNICEF's
regional office in Africa has initiated a study in four countries into what
is being done to protect, support and promote breastfeeding. If many of our
perceptions are correct, little is being done, due to inappropriate fears
that their pre-existing breastfeeding promotion efforts (including support
for the Code and the BFHI) will lead to higher rates of MTCT.
While the findings of Coutsoudis et al (Lancet 354:471-6, 1999, that 3
months of exclusive breastfeeding did not lead to higher MTCT, but mixed
feeding did) are gaining acceptance, there is a good deal of complaining
now in the "HIV establishment" that exclusive breastfeeding is rare and
difficult to promote. Amazingly, the implication seems to be that it is
wiser (and somehow simpler) to train an entire continent not to breast feed
at all than to make the changes necessary to enable a shift to exclusive
breastfeeding. Admittedly much remains to be done, but promotion of
exclusive breastfeeding to the entire society would probably do more to
reduce maternal to child transmission (MTCT) than the current pilot tests
and promotion of voluntary counselling and testing. They reach few women
and it is estimated that 90% of those infected do not know their status.
And as we have pointed out so many times, a shift to EBF would have many
positive "side effects" for all babies. How sad that each vertical program
is so uninterested in helping achieve any other health outcome besides the
one they deal with.
We need rapidly to expand our knowledge about how effectively to measure
"exclusive breastfeeding from birth" (rather than using a 24-hour recall
that overestimates how many are likely to have received effective
protection against HIV transmission). An article by C. Aarts et al in the
forthcoming December 2000 issue of the International Journal of
Epidemiology suggests such an indicator and shows how it differs from the
existing WHO indicator when applied to the situation in Sweden. A
forthcoming article in Public Health Nutrition by Shirima et al
illustrates its use in data from rural and urban Tanzania. (If you would
like a copy of Aarts et al, write to
[log in to unmask]; I can provide copies of Shirima et al.)
We also need rapidly to learn more about how to promote exclusive
breastfeeding, especially in Africa. The BFHI needs to be expanded, no
doubt, especially to rural hospitals. It's 10th step, links with the
community, needs a lot more work. We also need to give more attention to
the other Innocenti goals, including the breastfeeding rights of working
women. Keep an eye on the WABA website
(http://www.waba.org.br/ilopage.htm), as more information will continue
coming out on the new ILO Maternity Protection Convention 183 and
Recommendation 191, including action and strategy ideas and case studies of
what the Maternity Protection Coalition
and others are doing in various counties. These new international
instruments offer an important opportunity to advocate for longer paid
maternity leaves and other needed workplace support.
Regards,
Ted Greiner, Coordinator
WABA Research Task Force
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