July 26, 1998
AIDS Brings Shift in U.N.
Message on Breast-Feeding
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Related Article
* <AIDS
Renews Battle Over Baby Formula
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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.
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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."
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