Thirty years old and four months pregnant, Margaret was told that she was HIV positive. Margaret would have given way to despair, but she had to think of her two daughters of ten and twelve years old as well as her unborn child.

Margaret was told by the nurses at her local clinic in Khayelitsha to bottle-fed her child, Sipho, rather than risk transmitting the HIV virus to him via breastmilk. But exclusive bottle-feeding is frowned upon as an unnatural practice by many in Khayelitsha, a township outside Cape Town. And nowadays, people also know that HIV-infected mothers can transmit the virus via breast milk and often suspect that a mother who never breastfeeds her baby has HIV.

Luckily, the misconception that people infected with HIV look sickly and thin has allowed Margaret to keep her diagnosis a secret — despite the fact that she never breastfeeds Sipho.

“People ask me why I’m not breastfeeding and I say that my milk is no good. They have no idea it’s HIV because people think that if you have HIV, you lose weight and are very sick. So, if you are happy and fine, they don’t think you could have HIV.”

Apart from the persistent questions, Margaret has no problem bottle-feeding because Sipho’s father provides financial support and she can afford to buy formula and has access to clean running water.

But if she didn’t have HIV, Margaret says she would have breastfed Sipho just as she breastfed her other two children. “Breastfeeding is better,” she says, “BreastMilk has all the vitamins. And if you are not rich, you have no money to buy milk.”

Like Margaret, Prof Anna Coutsoudis, a well-renowned expert on antenatal care from the Department of Paediatrics and Child Health at the University of Natal, is a firm believer in the advantages of breastfeeding for mother and child.

“It breaks my heart to see a child being bottle-fed,” says Coutsoudis. “It seems like a terrible pity that all HIV positive mothers and their babies should be deprived of the nutritional and psychological benefits of breastfeeding.”

Coutsoudis is also concerned that formula-feeding exposes babies to the contaminants and allergens in water and other foodstuffs that cause diarrhoea and pneumonia, two of the biggest child killers in Africa.

“In the West, bottle-feeding is an easy decision to make. They haven’t seen babies dying from bottle-feeding,” says Coutsoudis.

Coutsoudis’s misgivings about the promotion of formula -feeding for HIV positive mothers led her and her team of co-researchers to do groundbreaking new research into the risk of HIV transmission from mother to child via breastmilk. Her initial research was conducted in Durban, where HIV infection rates of approximately 32.5% are among the highest in the country.

Until Coutsoudis’s findings were released late last year in the respected British medical journal, the Lancet, it was universally accepted by experts that breastfeeding increases the risk of mother-to-child transmission of HIV by about 15%. But Coutsoudis argues that these statistics were flawed because they failed to distinguish between exclusive breastfeeding and mixed breast- and bottle-feeding. (Exclusive breastfeeding means that the infant is given no food or drink other than breastmilk.)

Coutsoudis’s study showed that exclusive breastfeeding for the first three months actually results in no greater risk of HIV transmission than exclusive bottle-feeding. These findings contradict the current global trend towards bottle-feeding to prevent mother-to-child transmission of HIV.

Coutsoudis and her team found instead that it was mothers who combine breastfeeding with formula-feeds and other foods (mixed feeding) who were more likely to transmit HIV to their babies than those who exclusively breastfed.

In fact, mixed feeding was twice as likely to result in mother-to-child HIV transmission than either exclusive breast or exclusive bottle-feeding.

Coutsoudis says that these findings can be explained by the fact that, although breast-milk contains the HI virus, it also contains HIV-antibodies which neutralise the virus.

On the other hand, formula and other feeds may introduce contaminants and allergens which damage a new-born’s sensitive gut-lining and make it easier for the HI virus to cross into the bloodstream. Mixed feeding therefore makes the child especially vulnerable to the risk of HIV transmission via breast milk.

Coutsoudis advises HIV positive mothers who choose to breastfeed to wean abruptly and completely after a minimum of three months, as from this age the health hazards for the child and the social stigma associated with exclusive bottle-feeding are fewer.

Coutsoudis’s study still needs to be replicated by other comparable studies, as no study on its own is ever completely conclusive. There is always the possibility that the group of 549 women studied by the Durban researchers was not representative of all HIV-infected women and that the findings of the study are some sort of anomaly.

After Coutsoudis’s findings were released, the World Health Organisation, UNAIDS and UNICEF, the three main international agencies responsible for global health policy planning, issued a joint statement to the effect that they would not revise their infant feeding recommendations on the basis of Coutsoudis’s “interesting and important” findings.

The report acknowledges Coutsoudis’s point that previous studies on which existing estimates of a 15% risk of transmission via breastmilk failed to distinguish between infants who are exclusively breastfed and those, usually the majority, who are both breastfed and receive other foods or drinks. However, it argues that further research is required before firm conclusions can be drawn.

Coutsoudis and Prof Jerry Coovadia, head of the Department of Paediatrics and Child Health at the University of Natal, have already started preparing another study at Cato Manor and Mtubatuba in KwaZulu-Natal. A larger group of women, as well as closer and more sophisticated monitoring, will be used to ensure the validity of the findings. Unfortunately, research such as this takes time and the results of the second study will only be available in two or three years.

In the meantime, Professor James McIntyre, director of the HIV perinatal clinic at the Chris Hani Baragwanath Hospital in Soweto, feels that it’s premature to change infant-feeding practices for HIV positive mothers on the basis of the Durban study alone.

The South African Breastfeeding Guidelines for Health Workers released by the Department of Health in January recommends that HIV positive mothers are given enough information to “balance” the risks and make an informed decision, to breast or bottle-feed, for themselves.

But the evidence from Coutsoudis’s initial study is seen to be robust enough by the Health Department for policy makers to feel confident about strongly advising HIV positive women against mixed feeding.

Prior to Coutsoudis’s study, there was already a general consensus that HIV-positive women who choose to breastfeed should be advised to breastfeed exclusively to minimize the risk of other childhood infections such as diarrhoea. Coutsoudis’s findings reinforce this approach because they suggest that mixed feeding may in fact result, not only in other infections, but in an increased risk for HIV infection as well.

The advantages and disadvantages of breast and bottle-feeding are complex and there are many factors to weigh up.

The health-related advantages of breastfeeding are the nutritional and immunological benefits, the psychological benefit of bonding between mother and child, and the fact that bottle-feeding can carry other serious and life-threatening health risks, like diarrhoea, especially if access to clean running water is not ensured.

Exclusive breastfeeding also has the advantage of being more socially acceptable than exclusive bottle-feeding in many communities. And since all women, except HIV positive women, are currently advised by health care professionals to breastfeed, exclusive bottle-feeding is now further stigmatised as a sign of HIV infection.

“If they see you coming out of the clinic with formula milk, you are HIV positive,” says Laetitia Mdani, a counsellor who works with HIV-infected mothers in Khayelitsha.

Another consideration is that most South African women can’t afford to buy formula. To make the formula stretch further many mothers dilute it and as a result, bottle-fed babies are often malnourished.

On the other hand, exclusive bottle-feeding means all risk of HIV transmission via breastmilk is removed. (Since HIV is transmitted through breastmilk, the best way to avoid this is simply not to breastfeed.)

But Prof McIntryre, who has worked with HIV-infected mothers in Soweto since 1991, argues that if formula is affordable and access to safe water is ensured, exclusive bottle-feeding provides a much better balance of risks.

Toby Kasper of Medecins Sans Frontieres, an independent medical aid agency with a project in Khayelitsha, agrees. He adds that exclusive bottle-feeding has been tried and tested by doctors such as James McIntyre and Glenda Grey at Chris-Hani Baragwanath, and has been very successful in preventing mother-to-child transmission.

Rachel Jewkes, head of the Women’s Health Division of the Medical Research Council, also points out that exclusive breastfeeding in today’s world is often impractical. Exclusive bottle-feeding is a more feasible option for many women, especially working mothers. She also argues that “it may be dangerous to tell HIV-infected mothers that it’s okay to breastfeed rather than bottle-feed, as this may result in more mixed feeding rather than less.”

The new Health Department guidelines mean that HIV-infected mothers must weigh up the relative risks of breast and bottle-feeding for themselves and choose which of the two options they think will work best for them. But what is clear is that whatever choice is made by an HIV-infected mother breast or bottle it must be adhered to strictly for at least the first three months of life. It can be breast or bottle, but not both.

“What is certain, says Kasper, is that either breast or bottle is better than both. The Durban data shows this clearly.”

Unfortunately, however, most South African women still believe that it is best to give mixed feed to their babies, including water, infant cereals and herbal teas. This is despite the risk of exposure to contaminated and unhygienic water and foodstuffs. According to a recent survey conducted by the Medical Research Council, only 10% of infants in South Africa are exclusively breastfed in the first three months of life.


Approximately 25% to 30% of HIV-infected mothers in South Africa transmit their HIV infection to their child. But another way of looking at this is that 60% to 75% of infants born to HIV positive mothers will not contract the virus.