May I very respectfully suggest again that UNICEF's announcment that it
will begin to distribute ABM for babies of HIV+ mothers in Uganda,
Rwanda, Zambia etc. is a watershed event, and call for discussion other
than the "slander the messenger" approach (on Dana Raphael, or Glenda
Gray, who is NOT funded by industry).  UNICEF's decision, I believe,
calls for thoughtful reflection and an examination of the primary
research.

Someone asked me by email questions about the 1997-1998 research, and I
thought I would reply to the group, as I have received many similar
requests for information about primary research.  As Kathy Auerbach
reminded Lactnet readers on this topic, there is a big difference
between primary research reports and secondary articles.  It is far
easier to find secondary sources on HIV & breastfeeding, in which the
author(s) opine that breastfeeding isn't really a bad risk for
transmission.  I don't think that UNICEF would plan to distribute
formula unless there were significant cause to do so.

As far as primary research reports are concerned, Laura Guay's data from
Uganda show the lowest rate of transmission (only 26% of babies breatfed
by HIV+ mothers became HIV+).  I always list Guay, but I also always
list the other primary authors, who have found different rates of
transmission in their populations of breastfeeding HIV+ mothers.

These include 25% in Rwanda, 26% in Zaire, 30% in Sao Paulo Brazil, 39%
in Zaire, 35% in Malawi, 38% in South Africa, 40% in Congo, 43% in
Kenya, 46% in Soweto, 48% in India, 49% in Rio de Janeiro Brazil,52% in
Central African Republic, 57% in Spain, 63% in Italy, 90% in Zambia,
100% in Saudi Arabia.

From the 1998 and 1997 medical journals come more reports.  I will refer
to four,which are typical.  There are *no* primary reports showing that
breastfeeding is realtive risk-free.

1)  Lewis et al.  1998.  Cell-free Human Immunodeficiency virus type 1
in breast milk.  Journal of Infectious Diseases 177: 34-39.

In previous research, HIV-1 DNA had frequently been detected in
breastmilk cells.  In this study Lewis at el described the quantity of
*cell-free* HIV-1.  It was higher in mature milk than in colostrum. For
infants consuming 700 mL HM/day, the oral exposure is more than 630,000
copies of HIV-1 RNA/day.  This is a substantial exposure.  Lewis et al
also refer readers to research on simians that showed that oral exposure
can readily lead to infeciton.  Adult rhesus monkeys could be infected
by the oral route with 6000 times less virus than was needed for
infection by the non-traumatic rectal route.

2)   Becquart et al. 1998. Early postnatal Mother-to-childl transmisison
of HIV-1 inBangui, Central Africa Republic. Presented at the Fifth
Conference on Retroviruses & Opportunistic Infections, Chigago February
105.  All babies were breastfed by HIV+ mothers; 52% of babies beame
HIV-infected.

3)   Bobat et al. 1997. Breastfeeding by HIV-1-infected women and
outcome in their infants: a cohort study from Durban, South Africa.

The HIV transmission rate was 39% in those exclusively breastfed, 32% in
those mixed fed and 24% in those formula-fed.   The longer babies were
exclusively breastfed, the higher the risk of transmission.  Among
babies exclusively breastfed for one month, 45% became HIV-infected.
Among those exclusively breatfed for two months, 64% became
HIV-infected.  Among those exclusively breatfed for three months, 75%
became HIV-infected. Mortality was 19% in those exclusively breastfed,
13% in those mixed fed and 0% in those formula-fed.

4)  Maguire etal. 1997.  Potential risk factors for vertical HIV-1
transmission in Catalonia, Spain: the protective role of cesarean
section.   AIDS 11:1851-1857.

In Spain, 57% of babies breastfed by HIV+ mothers became infected,
compared to 17% of bottle fed babies.

I know that older studies such as the work in Haiti & Malawi showed
lower rates.  In older studies,babies who died beore a year of age were
sometimes excluded from analysis (truly).  ALso, older studies stopped
testing babies once they had one HIV-negative test result.  All babies
of HIV+ mothers would be HIV-antibody-positive for awhile (maternal
antibodies in babies).  Then many babies revert to negative - i.e.
HIV-antibody-negative by test.  But when babies of HIV+ mothers continue
to breastfeed, they continue to risk HIV infection.  In the Nairboi
cohort, out of 90 children who were eventually HIV-positive - 40 of them
went through a period of months of being HIV-negative.  These children
then were HIV+, HIV-, then HIV+.  Children who convert to positive in
the later months or years are very likely to have been infected by
breast milk.   Other possible means of HIV infecition were excluded
(blood transfusions, scarification etc).   Ref = Datta et al 1995
Journal  of Infectious Diseases 172:1419.  Also Datta et al 1994 Journal
of Infectious Diseases 11:974-976.

Edith White, IBCLC since 1985