By Asjylyn Loder
Thursday, August 14, 2003
Mother's milk or formula? Health groups are divided over which to recommend to HIV-positive mothers in sub-Saharan Africa after a study challenged the conventional wisdom that it was best for such women to rely exclusively on formula.
(WOMENSENEWS)--"It's a terrible choice," said Carol Huotari. "The transmission percentage is 14 percent. You don't know if that 86 percent is going to be you or not."
Huotari, manager for the Center for Breastfeeding Information at La Leche League International, is talking about the risks that an HIV-positive mother will transmit her disease to her baby through breastfeeding and whether that mother should feed her baby formula instead.
Worldwide, more than 800,000 children under 14 contracted HIV in 2001. According to the United Nations, 90 percent were infected with HIV through pregnancy, birth or breastfeeding.
For all HIV-positive mothers, therefore, breastfeeding poses a concern. But for women in sub-Saharan Africa the question of whether to breastfeed has become highly charged as a result of an increasingly influential but uncorroborated study that indicates that mothers who exclusively breastfeed might run a lower risk of transmitting HIV to their newborn.
In a region where formula-fed infants are six times as likely to die as their breastfed counterparts, the study raised imposing ethical questions. Should HIV positive mothers be advised and assisted to exclusively breastfeed? Or, despite the potentially decreased risk, should the focus be on reducing transmission by encouraging exclusive formula feeding where that is possible?
Reaction to the study has opened a confusing debate between the powerful breastfeeding lobby La Leche League International and agencies such as the World Health Organization, the United Nations Children's Fund and the Joint United Nations Program on HIV/AIDS.
Women constitute an estimated 58 percent of the 29.4 million people infected with HIV in the region and many women may not even know if they are HIV positive. The region leads the world in mother-to-child transmission of HIV.
The debate is complicated by poverty and cultural norms. The per-capita income in sub-Saharan Africa was $407 in 2001, according to the World Bank, meaning few mothers can afford formula. In addition, a new mother who fails to put her baby to the breast may publicly brand herself HIV positive, a stigma that may cut her off from community support. In addition, formula is expensive, hard to come by, and potentially lethal for infants if mixed with contaminated water.
But a mother trying to exclusively breastfeed faces another set of obstacles, including maintaining a supply of pumped breast milk for when she is away from her infant as well as lessons in how to properly attach her infant and maintain breast health so as to reduce the risk of HIV transmission. Traditional community practices of feeding infants potions and sugar waters will complicate any attempt to encourage exclusive breastfeeding, especially when mothers must be away from their infants in order to work.
The WHO and breastfeeding advocate La Leche League are responding in slightly different ways to the exclusive-breastfeeding study, done in Durban, South Africa in 1999. In light of it, the organizations are either issuing highly qualified advice, or in the case of La Leche League, withholding advice altogether.
Published in the British medical journal The Lancet, the study shook long-held assumptions that exclusive formula feeding--where possible--was preferable to breastfeeding by HIV positive mothers. Conducted by Dr. Anna Coutsoudis, professor of child health at the University of Natal, the study found that exclusively breastfed infants of HIV-positive mothers had a lower risk of HIV infection--perhaps as low as 4.5 percent--than infants fed a combination of formula and breast milk.
Immediately afterward, UNICEF, UNAIDS and the World Health Organization jointly stated that the findings did not warrant encouraging exclusive breastfeeding in HIV-positive mothers. They clarified their position in October 2000, recommending exclusive breastfeeding for HIV-negative mothers and HIV-positive mothers who could not afford to safely sustain formula feeding.
"The main reason for the recommendation to exclusively breastfeed was that the risk of infections (other than HIV) was significantly lower," said Dr. Jose Martines, World Health Organization coordinator for infant and neonatal health in a telephone interview from WHO headquarters in Geneva.
The WHO has approached the 1999 findings with hopeful caution, noting that while the findings are promising, the study is just a single, limited study that has not yet been substantiated by other research.
"It is an area where public policy decisions are made with less information than one would hope to have," said Martines. "At the same time," he said, "we don't want to be too slow when there is an opportunity to save lives."
Their current guidelines mention the Coutsoudis study but stop short of endorsing it because it is just a single, unconfirmed study, Martines said. Two ongoing studies are trying to confirm Coutsoudis' findings, he said.
The WHO guidelines, last redrafted in October 2000, state that the risk of breastfeeding transmission is eliminated only when HIV positive mothers exclusively formula feed their infants where that is "acceptable, feasible, affordable, sustainable and safe." But while coming down firmly on the side of formula feeding under ideal conditions, the WHO also recognized that those conditions are nearly impossible to meet in sub-Saharan Africa.
In reality, most mothers in sub-Saharan Africa, HIV positive or not, will breastfeed some of the time, said Martines. "A woman in extreme poverty would have extreme difficulty to be able to do what we call replacement feeding because she would have difficulty with access to milk, with access to fuel, with access to time to prepare milk feeds and time to keep utensils clean."
La Leche League has been more receptive to the 1999 findings.
An HIV-positive mother calling La Leche League for advice would be informed of Coutsoudis' conclusions, Huotari said. La Leche League International has expressed confidence that Coutsoudis' conclusions will be affirmed by further research. Their 2001 statement expresses concern over the "incomplete understanding of the risk of HIV transmission through human milk." And at La Leche's annual conference in San Francisco in early July--for which the theme was "Creating One Breastfeeding World"--Coutsoudis was a featured speaker.
In July 2001, La Leche League International failed to endorse the WHO guidelines, issuing a statement that declined to make "a recommendation about breastfeeding for HIV positive mothers at this time due to the inconclusive nature of the research and its various interpretations."
A co-founder of La Leche League, Marian Tompson, split off from the group in 1998 to found a new organization, AnotherLook, based in Illinois, to challenge the assumption that mothers transmit HIV through breastfeeding.
"We realized that there really wasn't any hard science backing up the recommendation that HIV positive mothers should not breastfeed," Tompson said. Tompson's group expresses skepticism over whether HIV can even be transmitted through breast milk, a position the WHO brushes off.
"It is very clear that there is no room for doubt anymore, and there hasn't been for quite a while," said Martines, confirming the widely-held conviction that breastfeeding can and does transmit HIV. "The information available is overwhelming," he said.
Asjylyn Loder is a free-lance writer in New York.
AnotherLook at breastfeeding and hiv/aids:
La Leche League International--
LEAVEN Volume 35, No. 1, February-March 1999, pp. 3-5
"Mother-Child Transmission of HIV":
UNICEF--"HIV and Infant Feeding"