Cathy - thank you for a splendid explanation!  I found your case for
exclusive breastfeeding very clear.  And particularly reassuring in view of
something I heard locally very recently suggesting that gut permeability
would make no difference to HIV transmission during breastfeeding.  I think
what I heard was a mis-interpretation of the Willumsen findings.  I like
the phraseology you used - "error of assumption".

Nikki - please send us the refs for the studies you mention.  ("Just to
complicate things, there are at least 3 studies published
showing that subclinical mastitis is a risk factor for HIV
transmission.Warmly,Nikki Lee")

Lara - I see the point you make about the need for screening of milk donors
in spite of pasteurization - because of human error, or failures in the
pasteurization process, mentioning the occasional errors that are made with
screening blood and sterilizing instruments and suggesting that we need to
be realistic about the limits of technology.  The thing is, does this
prevent donated blood being used at all, or surgery taking place, "just in
case"?  No, it doesn't.  Donated breastmilk is not the same as donated
blood which cannot be pasteurized, and should we accept that sloppy
practices in handling and pasteurizing it should prevent us using it at
all?  It just seems that the need for screening is put up as one more
obstacle to the use of donated breastmilk, making it more difficult to
obtain for those who might benefit from it.

For several years I have been trying to suggest the use of the HIV-infected
mother's own home-pasteurized breastmilk - not as a replacement for
breastfeeding, but as a replacement for formula for those women might be
coerced into not breastfeeding.  The resistance to this logical,
physiological, free, healthy alternative is almost pathological.  Responses
have ranged from:

- "It's not possible to express breastmilk long-term"  (so I collected from
Lactnetters 48 separate testimonies showing that this IS, indeed, possible)
- "It's not possible to manually express breastmilk for long, mothers might
get mastitis" (please come and see mothers doing this for days, weeks or
months in neonatal units in Nairobi and Harare)
- "It's not safe" (studies in Puerto Rico and South Africa show that there
are two methods of killing the virus in breastmilk by
home-pasteurization;  flash-boiling, and Pretoria pasteurization - but now
I'm receiving third-hand responses about the latter method that suggest
that the author herself might be retracting her findings because if the
size of the pot holding the boiling water is different, or if the thickness
of the glass in the jar containing the milk is different then this might
invalidate the findings).
- "Oh, but it's not cultural".  (we had someone who came to Zimbabwe and
found that there was *not* a lot of resistance to this idea amongst women
themselves, particularly if communities were to receive education about
this possibility).
- and the last one "But heat-treating breastmilk might de-nature the
protein and destroy the vitamins" (I believe a study is to be done to
ascertain what happens to the components, but it would seem that babies
already receiving banked human milk thrive??)

At the same time formula is being promoted, and in some projects handed out
free, to thousands of African HIV+ mothers in conditions that make the use
of formula very unsafe indeed, notwithstanding that this "option" is
previously unknown, un-cultural, expensive, and contains no immunological
protection at all.  And as we speak there is NO monitoring in place to
check on the mortality of babies who have not been breastfed.  But this is
OK, because at least postnatal transmission of HIV through breastfeeding
will have been prevented?

The rationale we are being persuaded to accept again and again is that
mother's milk is dangerous and that "replacements" for breastmilk are
safe.  It's very depressing.

Pamela Morrison IBCLC, Zimbabwe
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