1997_4_realistic alternatives



		*Sexual Health Exchange, 1997 - no. 4* Realistic alternatives to breastfeeding in the HIV/AIDS era Geoff Foster "Breast is best" - the promotion of breastfeeding has been one of the most successful child survival initiatives in developing countries. But recent reports suggest an average risk of HIV transmission through breastfeeding by HIVinfected mothers of 1 in 7. It may possibly be twice as high if women seroconvert while breastfeeding. More than onethird of the 300,000-400,000 new HIV infections in children each year result from breastfeeding. Few mothers living with HIV in industrialized countries breastfeed; the opposite is true in the developing world. Consequently, UNAIDS has issued a statement to help formulate policies on HIV and infant feeding: Children of women living with HIV have less risk of illness and death if they are not exclusively breastfed if they have uninterrupted access to nutritionally adequate breast-milk substitutes that are prepared correctly and fed appropriately. When these important conditions are not fulfilled, in particular in environments where infectious diseases and malnutrition are primary causes of death during infancy, artificial feeding substantially increases children's risk of illness and death (Illustration: brochure cover "Pregnancy and AIDS") Women living with HIV need balanced and comprehensive information concerning all aspects of perinatal HIV transmission This creates a dilemma for those involved in the promotion of child health which method of feeding is in the best interests of infants of HIVinfected mothers? The UNAIDS statement proposes that mothers be empowered to make informed decisions about infant feeding and be supported in carrying out their decisions. This is a nice sentiment but difficult to put into practice when even acknowledged experts struggle with the advice they should give infected mothers: the benefitsversusrisks equations associated with breastfeeding and its alternatives are difficult to solve. Little is known about the timing of HIV infection through breastfeeding, or the effectiveness and safety of modified or substitute breastfeeding interventions to reduce HIV transmission. Clearly, it is inadequate for policymakers simply to continue advocating breastfeeding to HIVpositive mothers, regardless of the safe alternatives to breastfeeding that may exist. Reducing HIV transmission Modifying current breastfeeding practices may possibly reduce mothertochild transmission. HIV may be more easily transmitted in the cellrich fluid called colostrum, the mothers' initial milk. Heat treatment of colostrum to destroy HIV or the provision of artificial milk to newborns for the first few days of life may reduce neonatal infection. Another possibility is to limit breastfeeding to the first few months since HIV transmission through breastfeeding occurs throughout the first and second years of life. Introduction of weaning foods in the second or third month of life, though not advocated by health authorities, is widely practised by many mothers. It leads to a reduction in the frequency and duration of breastfeeds and possibly in HIV transmission as well. Studies from Malawi and the US have linked low levels of vitamin A in HIVpositive mothers to increased mothertochild transmission; if vitamin-A administration is found to prevent transmission through breastfeeding, this would be the ideal technological "fix" cheap and no behaviour change required. Active immunization is another intervention that could potentially induce maternal and possibly infant immunity while preserving the substantial benefits of breastfeeding to children and mothers. Work is underway in both of these areas. Mothertochild transmission may also be reduced by feeding infants of HIV-positive mothers with breastmilk substitutes. Where safe alternatives to breastfeeding exist, exclusive formula feeding is advised to prevent postnatal transmission. In a poor urban South African setting, less than one-third of infected women chose to give their infants unsubsidized formula feed; their children grew as well as breastfed babies and there was substantial reduction in HIV transmission. Clearly, some women, when given information, choose not to breastfeed their infants in order to prevent mothertochild transmission. Some countries provide infants of HIVinfected mothers with formula feed since cost is the main factor limiting artificial feeding in these children. To reduce adverse feedingrelated consequences, mothers should be instructed in milk reconstitution and bottle sterilization or be advised to adopt cupandspoon feeding. Reducing costs of breastmilk substitutes The economics of feeding infants with breastmilk substitutes has become an important issue for health workers in poor AIDSaffected communities. Increasingly, grandmothers and aunts are caring for orphaned babies because of rising maternal death rates due to AIDS. The cost of the 22 kg of formula milk required to feed an infant for the first six months of life is more than the annual income of many poor care-givers. An alternative method, which is much cheaper, is to use cows' milk that has been diluted, sweetened and boiled. Some communities are rediscovering traditional alternatives to breastmilk. For example, paps based on groundnuts in Zambia, sorghum in Zimbabwe and beans in India are being given to hungry orphaned babies cared for by poor relatives. HIVpositive mothers seeking lowcost alternatives to breastfeeding may also be instructed in modifying cows' milk or be advised to use locally-based infant feeding recipes. Most women do not know their HIV status and are not infected with HIV. They should be encouraged and supported to breastfeed. Mothers who suspect or know they are HIV-positive should be counselled about HIV infection and infant feeding, especially if they are symptomatic, because an increased viral load facilitates HIV transmission. But most mothers with HIV infection are asymptomatic. Antenatal HIV testing followed by measures to reduce perinatal and feedingrelated transmission by HIVinfected mothers could ensure that a majority of their babies are not unknowingly exposed to HIV infection. Informing mothers The limited knowledge available about the pros and cons of breastfeeding should not discourage discussion of these important issues. If health workers withhold information from women about breastfeeding risks, mothers will make lessinformed decisions when choosing a method of infant feeding. In communities where women who do not breastfeed are the exception, an important issue concerns loss of confidentiality about HIV: mothers who decide to modify or refuse breastfeeding should be prepared to answer difficult questions from their friends and relatives. Whether breastfeeding or not, women need advice and support to help them care for themselves and their babies in the best possible way. Urgent solutions are required to the many unanswered questions about HIV and infant feeding. Infant feeding policies may need to be reviewed in some countries where a projected high proportion, possibly as many as one-third, of babies will be exposed to maternal HIV infection. Geoff Foster, Mutare Provincial Hospital and FACT, 107 Main Street, P.O. Box 970, Mutare, Zimbabwe; Tel: 263-120-61648/67493; Fax: 263-120-65281; email: gfoster@healthnet.zw
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