July 26, 1998 AIDS Brings Shift in U.N. Message on Breast-Feeding ---------------- Related Article * <AIDS Renews Battle Over Baby Formula ---------------- By LAWRENCE K. ALTMAN GENEVA -- Countering decades of promoting "breast is best" for infant nutrition, the United Nations is issuing recommendations intended to discourage women infected with the AIDS virus from breast-feeding. The much-debated step aims at preventing transmission of HIV, the AIDS virus, from mothers to babies in what U.N. officials say is "a runaway epidemic" in many developing countries. Passing H.I.V. From Mother to Child Estimated number of children newly infected with H.I.V. through mother-to-child contact worldwide. ---------------- The New York Times U.N. officials said they were reluctant to issue a blanket warning because the decision should be left to each mother and because no simple message could encompass the diversity of environments where women live. Women may become stigmatized for not breast-feeding in some cultures, and in some places alternatives like formula can be unaffordable or unsafe, but the United Nations wants that to change. In its directive, the United Nations said it was deeply concerned that advising infected mothers not to breast-feed might lead many mothers who are not infected to stop breast-feeding. To reduce that possibility, it is advising governments to consider bulk purchases of formula and other milk substitutes and to dispense them mainly through prescriptions. The compelling reason for the action is the soaring HIV infection rates in much of the world, said Dr. Tomris Turmen, a U.N. official. As many as 70 percent of women at a prenatal clinic in one city in Zimbabwe and 30 percent of women in major urban areas in six African countries were found to be infected in recent surveys. In desperately trying to deal with a crucial aspect of mother-to-child transmission of HIV, the United Nations is up against a fundamental, even ideological, pediatric practice. It also risks stirring memories from decades past, when international corporations promoted formula, and babies died after it was mixed under unsanitary conditions. "Those who have seen babies die needlessly because they were fed with formula made from dirty water are worried that it might happen again," said Dr. Susan Holck, an expert on breast-feeding at the World Health Organization. But she added in an interview, "Others say it is unethical to deliberately, consciously breast-feed an infant milk that you know has HIV in it." But in the affected areas, some anxious women and families are beginning to demand that their governments provide information about HIV and breast-feeding, and to offer alternatives, the United Nations said. The rights of children to be born uninfected are also being invoked for personal and public health reasons because the overwhelming majority of infected children and adults in developing countries are doomed to die from the lack of anti-HIV drugs and standard health care. The epidemic has altered population demographics in some African countries. The U.N. directive advises that all HIV-infected women be informed of the risks of breast-feeding before deciding whether to let a newborn suckle. That goal, however, is hindered by the fact that about 90 percent of infected people in developing countries do not know they are infected. Worldwide, about one-third of pregnant women receive no prenatal care and 60 percent deliver at home. The new policy has emerged after years of internal debate that has sometimes been as emotional as scientific. Even now, the guidelines are cause for some dispute within the three U.N. agencies that put them out: UNAIDS, Unicef and WHO. The Dangers Presented by a 'Double Message' Dr. Peter Piot, executive director of UNAIDS, the agency that has pushed hardest to discourage infected mothers to breast-feed, said he was deeply concerned about sending to Third World countries a "double message" that tells some women breast-feeding is best for their babies but tells others that breast-feeding could kill their babies. But "we urgently need to find solutions" to the AIDS epidemic and these recommendations are part of that, Piot said in an interview. Dorothy Odhiambo of Nairobi, Kenya, a representative of African nongovernmental organizations, said at the recent 12th World AIDS Conference in Geneva that "it becomes unethical to continue not to do anything about it knowing very well that children are getting infected daily." The directive comes at a critical time in the United Nations' efforts to stop mother-to-child transmission of HIV. A primary objective is applying on a broad scale findings from a study in Thailand made public in February. The study showed that AZT pills taken twice daily from the 36th week of pregnancy and continued through labor halved the rate of transmission of the virus from mother to child, to 9.2 percent from 18.6 percent. For scientific reasons, the study involved only women who did not breast-feed. Studies to determine the effect of the short-course AZT therapy on breast-feeding women and infants are continuing and findings are not expected before the end of the year at the earliest. The use of a drug to prevent mother-to-child transmission has been hailed as one of the rare triumphs in the war against AIDS. However, concern is growing that it could become a hollow victory. The very same babies spared HIV infection during pregnancy and delivery could, just a few months later, become infected through breast-feeding. "That's the elephant in the room," said Dr. Kevin De Cock, an AIDS expert at the Centers for Disease Control and Prevention in Atlanta, which helped pay for the Thai study. In the United States, the use of AZT during pregnancy and delivery has helped to reduce greatly the incidence of HIV-infected babies, and health workers hope to bring down the number to near zero. In 1985, when HIV was first detected in mother's milk, U.S. Public Health Service officials issued recommendations applicable only to the United States that infected mothers not breast-feed. The U.N. directive represents a significant change in policy, De Cock said in a telephone interview. For large agencies that have worked hard and long promoting breast-feeding "to say that women with HIV should avoid it, if possible, has been a very difficult policy pill to swallow," he said. Last year, breast-feeding accounted for up to a third of the 600,000 children in the world who became HIV-infected, said Dr. Bernhard Schwartlander, the chief epidemiologist for UNAIDS. The risk of infection varies with the duration of breast-feeding, which lasts up to two years. Why some babies breast-fed by infected mothers do not get infected is not known. A partial answer is that a baby's risk of becoming infected rises significantly if a woman becomes infected during pregnancy or breast-feeding or has advanced AIDS, said Dr. Philippe Van de Perre of Bobo-Dioulassa, Burkina Faso. He was among the first scientists to recognize the hazards of HIV and breast-feeding. The United Nations has prepared two books of guidelines that Van de Perre and other leading experts developed after they met at WHO last year. They are the first the United Nations has prepared for dealing with breast-feeding and HIV, and they are being sent to all governments. One book is for government and other policy-makers. The other is for health care workers. Books of Guidelines Emphasize the Practical The guidelines spell out the need for training in the nitty-gritty of providing alternatives to breast milk. If commercial formula is not available, the guidelines describe what to do to cow's milk to make it safe for babies to drink and how to avoid mistakes that would endanger a baby. Emphasis is on practical advice, like the need to prepare a new batch every time an infant is fed. For women using formula, the guidelines explain the need to boil water and then not keep the mixed formula in the hot sun for hours. The guidelines reinforce the United Nations' unwavering belief that breast-feeding is the easiest and best source of nutrition for an infant, promotes bonding between the mother and infant, allows for a newborn's natural reflex to suckle, provides longer spacing between births, and protects against many life-threatening infections -- other than HIV -- in the first few months of life. For infected mothers who choose not to breast-feed, the United Nations recommends that all countries make safe, affordable alternatives available. Among them are replacing mother's milk with commercial infant formula; home-prepared formula made from fresh or processed cow's or goat's milk that is diluted with sugar water; HIV-negative wet nurses; breast-milk banks, and mother's milk that has been heated to kill HIV. Although the United Nations has policing powers in battle zones, it lacks them in health matters and thus relies on moral suasion to implement and enforce health directives and guidelines. Success will "depend on the political will" of the United Nations and countries, said Dr. Isabelle De Vincenzi, a UNAIDS epidemiologist. As a start, the United Nations intends to conduct pilot projects in 11 countries in Africa and Asia where women have high infection rates, and it is seeking donations from governments and foundations to pay for them. The aim of the pilot projects is to expand HIV testing and counseling to introduce replacement feeding, short-course AZT therapy and a number of other measures. Financing is a major obstacle. "The cost of providing breast milk substitutes to all women needing them in Tanzania, for example, dwarfs the present health budget in Tanzania and dwarfs all of Unicef's funds in Tanzania for the next two years," David Alnwick, a Unicef official in New York City, said in an interview. He and other officials acknowledged that the recommendations would not immediately save many lives. Dr. James Tulloch, a WHO official, said the United Nations viewed its directive as part of a package intended to have longer-term benefits. Doctors and local health officials will gain leverage to obtain more counseling, testing and resources for women. The hope is that as more women learn they are infected and talk to others in the community, the HIV problem will become more visible and lead to political action to raise the quality of maternal health services. The guidelines also spell out the risks of not breast-feeding, which are particularly great for women in communities where producing babies is considered a woman's obligation and a symbol of status. But many women in Africa and elsewhere have been thrown out of their homes when families have learned that they carry HIV. Thus, a grave concern is the stigmatization of an infected mother who does not breast-feed and is seen using bottles or cups to feed an infant. Experts, while criticizing the lack of strong studies, also worry that not breast-feeding could cause psychological harm to mothers and infants. Dr. Felicity Savage, a WHO official, expressed extreme caution about the new guidelines, citing the risk of contamination of breast milk alternatives in areas that lack clean water and loss of nutrients if a woman mixes water and formula inaccurately. Such hazards could "endanger a lot of lives that would otherwise not have been at risk at all," and could produce more deaths among those receiving replacement feedings than AIDS among those breast-fed by infected women, Savage said. Since 1985, many scientists have documented that HIV can be transmitted through mother's milk, but for years U.N. officials were skeptical about the public health significance of the finding. In 1992, the United Nations first confirmed that mother's milk could transmit the AIDS virus. That year, WHO recommended that, in most developing countries, where malnutrition and infectious diseases remain the paramount threat to infants, "breast-feeding should remain the standard advice to pregnant women, including those who are known to be HIV-infected, because their baby's risk of becoming infected through breast milk is likely to be lower than its risk of dying from other causes if deprived of breast-feeding." From 1992 through last month, up to 1 million babies in the world had become HIV-infected through breast-feeding, Schwartlander said. WHO Expert Cites Paucity of Information Holck, the WHO expert, said she "was struck by how much denial there was around 1990 of the evidence we had that HIV could be transmitted through breast-feeding." Much of the denial, Holck said, "undoubtedly was fed by people who had invested so much in promoting breast-feeding and feared what confirmation of that transmission might do to the gains that were made in breast-feeding." Holck also said that she "was struck then by the lack of information on the risk of not breast-feeding, and that is still the case." Alnwick of Unicef said "it is fair to say that the U.N. did not think that alternatives to breast-feeding were practical in any particular sense.' Scientists are seeking drugs and other ways to make it safe for women with HIV to breast-feed, at least for a time. With such safeguards, Alnwick said, "three months' breast-feeding would be a lot better for an infant than no breast-feeding at all." --