HIV Prevention

Debate on whether breast is best

Doctors, researchers as well as nutrition and child health experts have warned that a decision to offer free formula feed to HIV positive mothers could be doing more harm than good, especially for those infants living in rural settings or poor peri-urban poverty. But those who have been dispensing formula feed in the urban areas warn that the debate should be placed in context with different solutions for different areas, depending on issues such as access to water, health services and levels of poverty.

Doctors, researchers as well as nutrition and child health experts have warned that a decision to offer free formula feed to H

Doctors, researchers as well as nutrition and child health experts have warned that a decision to offer free formula feed to HIV positive mothers could be doing more harm than good, especially for those infants living in rural settings or poor peri-urban poverty.

In the 18 prevention of mother-to-child transmission (PMTCT) test sites, government has been offering formula milk to HIV positive mothers and encouraging those with access to clean running water to forego breastfeeding in favour of the formula.

A government commissioned report written by the Health Systems Trust provides an overview of the 18 sites and warns that with all the publicity surrounding government’€™s position on nevirapine, the more important and serious issue of its policy on infant feeding and providing free formula has been neglected.

“The current policy needs to be reconsidered, as there is a danger that it may do more harm than good in many communities.

“When one looks at overall child health as an outcome, instead of just HIV transmission, the benefits and advantages of promoting free formula become questionable,” said Dr David McCoy, programme director at HST and lead author of the report.

He said that although the long-term aim should be to enable all HIV positive women to provide safe and affordable exclusive formula feeding, under the current circumstances, the policy may lead to higher rates of mortality and morbidity due to other diseases, as well as higher rates of mixed (formula plus breast) feeding.

His views are backed up by leading nutrition experts at the University of the Western Cape’€™s School of Public Health, Drs David Sanders and Mickey Chopra.

“The risk of an HIV positive mother infecting her infant is approximately one in three cases. Breastfeeding can be responsible for one third of those infections only. In other words, most HIV positive mothers do not infect their children and of those that do, most do not do so through breastfeeding. Breastfeeding is responsible for 1 to 2% of all HIV infections,” the academics pointed out.

Sanders and Chopra said that if all HIV positive women elected to bottle feed, all of their infants would be susceptible to the dangers attendant thereto, with increased risk of death from other infections especially diarrhoea, one of the commonest causes of child death in South Africa.

They pointed out that there was very little known about the psychosocial effects on a HIV positive mother when she is told that she might infect her child by breastfeeding.

A study in Cape Town found that two thirds of HIV positive mothers had not disclosed their HIV status to the father of the child and 94% did not want to tell members of their household they were not breastfeeding because they were HIV positive. This often resulted in mixed feeding both bottle and breast – which has shown in one rigorous study to be the most dangerous mode of feeding.

Infants who are breastfed plus given other foods and liquids (mixed feeding) are at a significantly higher risk of MTCT through breastfeeding. This is attributed to the lower exposure of exclusively breastfed infants to bacterial contaminants and food antigens, which can damage the gut lining.
Other liquids and foods may compromise intestinal integrity, resulting in small lesions in the immature gut through which HIV can pass to infect the infant.

Professor Ted Greiner of the Department of Women’€™s and Children Health at Uppsala University in Sweden agrees that mixed feeding is the most common form of feeding in the world.

Greiner, who has been working in the breastfeeding field for the past 27 years, said serious harm had been done to breastfeeding and that there had been no effort to establish what impact formula feed has had on infant morbidity and mortality.

“Where there is evidence she can use it safely, such as a peri-urban setting with running water and electricity it could work,” Greiner said.

He said that only Nestle stood to benefit from Government’€™s policy to make formula feed universally available. He said the question remained as to what would happen to the babies when the formula feed has run out at six months and they have not been breastfed.

Professor Jerry Coovadia, paediatrician and Head of Research at the Nelson Mandela Medical School at Natal University, also believes that government should not be providing formula milk ‘€“ the most expensive aspect of its PMTCT programme ‘€“ but rather encouraging women to breastfeed exclusively.

“I believe government is being badly informed by poor science. It shouldn’€™t be providing the formula,” said Coovadia. “Formula food is a killer. It doesn’€™t provide babies with the protection against disease that breastmilk does. If it’€™s mixed with contaminated water, babies can die of diarrhoea or pneumonia.”

According to a study done by the University of Natal, the risk of HIV transmission from exclusive breastfeeding for six months and then rapid weaning was “less than 5%”, said Coovadia.

Sanders said there was little doubt that those women who opted for formula feed were nearly all providing mixed feeding.

“In the poorest communities it is the wrong thing to promote formula feed. Presently, health workers are very confused as to how they should advise patients,” Sanders said.

Head of the HIV/AIDS programme in the health department, Dr Nono Simelela confirmed that in places where women don’€™t have access to clean running water, they have been advised to exclusively breastfeed ‘€“ “and exclusively means just that ‘€“ no water, no tea, just breastmilk”.

“Many women are not comfortable to tell their partners that they are HIV positive, so they don’€™t take the formula,” added Dr Simelela. “Or they might breastfeed when their hubby and family is around and use the formula when they are alone. Unfortunately, research shows that this mixed feeding is more dangerous for transmission of HIV to the baby.”

Sanders, Chopra and Dr Jon Rohde of the Equity Project in the Eastern Cape, supported the call in the HST report for a national commission of experts to be urgently set up to review the current policy and guidelines on infant feeding and mother-to-child transmission.

It was suggested that the so-called national commission of experts should incorporate experts from the field of nutrition, HIV and child health, and not just HIV.

Health minister Dr Manto Tshabalala-Msimang recently recognised the issues in the HST report while addressing parliament.

She said she was particularly interested in the HST assertion that the key policy issue that confronted government was not the provision of anti-retrovirals, but the question of infant feeding.

She said it broadened the debate from an HIV issue to a general public health issue. “The challenge is not only to reduce HIV rates among the babies, but ultimately to reduce the overall infant mortality and morbidity rates.

“We must find ways to avoid substituting one set of health risks ‘€“ diarrhoeal diseases, malnutrition and infections ‘€“ for another, namely HIV/AIDS.”

The report added that: “One option that must receive serious and urgent attention is the post-natal administration of short-course anti-retroviral treatment to mothers and/or babies as a strategy for making breastfeeding safe.”

Finally, the imperative to save babies from HIV should provoke a broader and urgent response from government and civil society to address child poverty, the unacceptable levels of child care and child mortality from easy-to-prevent causes, the report added. ‘€“ Health-e News Service

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Anso Thom