Breast is best but what about HIV?
By Prof MICKEY CHOPRA

'Breastfeeding is best.'

This is a phrase that every mother should know. It is strongly promoted by health experts, Government and international health agencies - and not without reason.

Research by the World Health Organisation (WHO) found that, in developing countries, an infant that is breastfed - even just a little - is more than twice as likely to survive its first year than one that isn't breastfed at all.

This is because breastfeeding is an extension of maternal protection. It supports the young infant during its introduction to the outside world with its many diseases. And this protection is especially important in developing countries, where infectious diseases are more common.

Recently, research has also shown that the benefits of breastfeeding increase the more it is practised, and exclusive breastfeeding - where an infant receives nothing but breastmilk - has been proved to give the best protection against infection.

A study of infants living in the overcrowded and poverty- stricken slums of Dhaka in Bangladesh found that the risk of death in the first six months was more than halved when infants were exclusively breastfed.

Even in settings where diarrhoea and pneumonia are less common, breastfeeding has been found to hold significant benefits for the infant in terms of better cognitive and intellectual performance, as well as reduced allergies and ear infections. It is also important for the health of the mother - breastfeeding assists with birth spacing and reduces the risk of breast cancer.

But the landscape changed in 1985: HIV was discovered in breastmilk and it was found that the virus can be transmitted to baby via breastfeeding. Further research has shown that, on average, about 7% of babies born to HIV- infected mothers will become infected if they are given a mixture of breastfeeding and other liquids and foods for 12 months.

In first- world countries, the way forward was clear - women were advised to give their babies formula only. But what about mothers in developing countries, where depriving infants of breastmilk significantly increases the risk of serious illness and death?

In August 1999, South African researchers based in Durban published ground- breaking research on HIV- positive women. They found that those mothers who exclusively breastfed their infants for the first three months had much lower rates of transmission of HIV than those who mixed breastfeeding with other liquids, formula feeds or semi- solids.

This study underscores what has long been known: that exclusive breastfeeding protects against a number of infections in early infancy - including HIV.

Even so, it might seem safer to advise a mother with HIV not to breastfeed at all, but rather to use formula or replacement milk and bottle feed her infant exclusively - thereby avoiding contact with the virus. However, in order for bottle feeding to be a safe alternative to breastfeeding, and not put the infant at even greater risk of illness and death, the following criteria must all be met for the entire period that bottle feeding will take place:

• Replacement milk must be accessible and affordable, and it must be possible to prepare it safely with clean water and utensils
• Adequate health care must be available and affordable
• The community and household must be accepting of the fact that a woman doesn't breastfeed her child.

If these conditions can't be met, exclusive breastfeeding provides the best alternative.

Of concern is the fact that, although exclusive breastfeeding is deemed the ideal practice for infants up to about six months of age, even in the general population this behaviour is practiced rarely, with only 10% of infants in South Africa being exclusively breastfed at three months of age.

Women who choose to exclusively breastfeed - especially those who are HIV- positive - require constant and vigorous support and protection.

Without it, HIV-positive women may find it necessary to mix their feeding methods, which will increase their infants’ risk of infection with HIV.

The South African situation
Advising HIV-positive mothers about the safest infant feeding options forms part of the Department of Health’s prevention of mother-to-child transmission (PMTCT) programme.

The programme provides free breastmilk replacement formula, and offers counselling to help HIV-positive mothers choose the feeding method that is best for their particular situation.

The MRC’s Health Systems Research Unit (in collaboration with the Health Systems Trust and the University of the Western Cape) has been working closely with the department to examine the practical challenges of the programme. Results from these studies suggest the following:

• The complex nature of the decision an HIV positive mother has to make about infant feeding means that good counselling support is vital.
• There are still gaps in the knowledge of health workers, many of whom are not comfortable counselling women experiencing infant feeding difficulties.
• Health workers need ongoing supervision and support after receiving training in order to enhance their application of recently learnt skills and knowledge.
• There have been numerous operational problems with the provision of free formula milk as part of the PMTCT programme in South Africa. These problems include erratic supplies, poor training of mothers in safe formula preparation and inadequate storage facilities in many clinics. Furthermore, there is evidence that the provision of free formula milk does not guarantee exclusive formula feeding.
• There is evidence of high rates of mixed feeding in the general population, and given the inadequate infant feeding support provided, this is likely to be the same for HIV positive women. Given the current knowledge on exclusive breastfeeding, this would increase the risk of HIV transmission through breastmilk.
• Infant feeding is considered to be the most challenging component of PMTCT for policy makers, health workers and mothers.

A study has just been completed that followed up over seven hundred HIV-positive mothers who had been through the PMTCT programme in three provinces. The full results will be released shortly. The research team is now evaluating the effectiveness of a community-based infant feeding intervention to improve the rates of exclusive breastfeeding and exclusive replacement feeding for HIV-positive mothers who choose not to breastfeed.