Christine - apologies for the delay in replying to your query which a kind
colleague has just alerted me to.  You quote from a medscape article,

".....Slightly better results are achieved when newborns are formula fed
rather than breast-fed.[4] In light of these
findings, the World Health Organization (WHO) and the Joint United Nations
Programme on HIV/AIDS (UNAIDS) recommended that developing countries
provide this short-course perinatal antiretroviral therapy and advise
HIV-infected women not to
breastfeed infants, if possible.[5]:",

and ask

"I was unaware of this WHO recomendation in developing countries. Is this
true?"

You sound a little incredulous, and rightly so.  But yes, my understanding
is that the WHO/UNICEF/UNAIDS recommendation *is* that - if possible - all
HIV+ mothers should be encouraged to make a decision NOT to
breastfeed.  Or, if they do breastfeed at all, the duration should be as
short as possible.

There is a little table in a paper written by Kevin de Cock which is often
quoted to show how western countries (who recommend that HIV+ mothers
should not breastfeed) have more appropriately responded to the pandemic
compared to developing countries, where breastfeeding is still nearly
universally practiced.  It apparently demonstrates that the risk of
mother-to-child transmission (with antiretroviral drugs and NO
breastfeeding) has been reduced to 2 - 3%, whereas with no ART AND
breastfeeding the risk is 25 - 40%.  Breastfeeding itself is shown to be a
major risk factor for HIV.

However, what is *not* really highlighted (above, and in the
WHO/UNICEF/UNAIDS recommendations) is that in the absence of ART (and which
developing country can afford to provide it to up to 20% - 40% of its
pregnant women?) about 20% of the babies of HIV-infected women will be born
already infected.  Nevirapine (single dose to mother and baby) or
zidovudine (longer doses) appears to reduce the risk of transmission during
birth.  Babies already infected survive about twice as long if breastfed
than if not breastfed because the risk of opportunistic infections is
reduced.  However, the general consensus is that ART is wasted if
transmission during birth is avoided but then babies "saved" from this risk
are then exposed to virus in breastmilk.  Also what is *not* highlighted is
that where really exclusive breastfeeding is practiced, the risk of
transmission of HIV from virus in the breastmilk, as well as the risk of
mortality from the other major killer diseases such as pneumonia and
diarrhoea, is vastly reduced.

Why are these important facts touched on in passing, but mostly glossed
over?  Well, that is indeed the question we should all be asking.  On the
continent hardest hit by HIV, and where the poverty has to be seen to be
believed - sub-Saharan Africa - breastfeeding is one of the few resources
that are left.  Since exclusive breastfeeding is life-saving against *all*
infections, including HIV, which actually poses a much smaller risk in the
general scheme of things (only 4%) than pneumonia and diarrhoea, the only
benefit which would seem to follow from any recommendation to disrupt the
cultural norm of an entire continent, would be for commercial
gain.  However, when the recommendation is dressed up in human rights
wording (HIV+ women themselves should be encouraged to decide which method
of infant feeding they would like to use .....) then the underlying
intention certainly becomes less discernible - especially to good people in
industrialized countries where *all* women are expected to exercise their
right to choose their infant feeding method.....

Pamela Morrison IBCLC (in Australia from Zimbabwe)
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