sources : medscape pediatric
Sanjay Lala, MB, ChB
The second day of the XIII International AIDS Conference in Durban, South Africa, hosted an important and eagerly anticipated debate on the feeding options that are available to infants born to mothers infected with HIV.[1,2] Although many delegates had hoped that some consensus could be reached regarding feeding recommendations, the debate highlighted numerous limitations and gaps in our current knowledge regarding HIV transmission through breast-feeding. The audience and participants remained divided over the complex issue of breast-feeding, and concern was raised that a single, unified message was not being delivered to infected mothers and healthcare workers. Dr. Glenda Gray, a pediatrician working in Soweto, aptly described feeding options as a “a conundrum of complexities.”
The controversy regarding feeding options for infants born to HIV-positive mothers in poor countries was sparked by a recent report in The Lancet, which suggested that infants who were exclusively breast-fed had similar HIV transmission rates as those infants who received only formula feeds. It was therefore appropriate that Dr. Coutsoudis, whose Durban-based group had reported these findings, argued in favor of the debate topic: “HIV-positive women should be encouraged to exclusively breast-feed.”
Dr. M. Fowler opposed this view and cautioned not enough is known from the available data. The transmission of HIV through breast milk feeding was universally accepted.
Dr. Coutsoudis reported on new data available from the Durban study. Previously reported data described HIV transmission rates in 3-month-old infants as 18.8% in infants fed formula (no breast milk), 14.6% in infants exclusively breast-fed (breast milk only), and 24.1% in infants who had mixed feeds (breast milk and other liquids/solids). The new data were the HIV transmission rates for these infants at 15 months.
These new data appear to negate the effects of exclusive breast-feeding over formula, but emphasized the superiority of exclusive breast-feeding over mixed feeding. The HIV transmission rates at 15 months were 19.4% in formula-fed infants, 24.7% in infants exclusively breast-fed, and 35.0% in mixed-fed infants. Whether these differences were significant or not was not mentioned. The limitations of the study (ie, not being a randomized controlled trial) were stressed again, although Dr. Coutsoudis presented analyses to suggest that the initial findings were not due to the effects of reverse morbidity. Dr. Coutsoudis went on to recommend that exclusive breast-feeding be the feeding option of choice for HIV-infected women in developing and developed countries.
Dr. Fowler stated that the Durban study was the only study that had found lower HIV transmission rates in breast-fed infants compared with formula-fed ones, but he conceded that other studies had not (or to a limited extent) analyzed the effects of exclusive vs mixed breast-feeding. An important issue, thus, is the acceptability of exclusive breast-feeding to women in developing countries. The participants agreed that exclusive breast-feeding is uncommon, and that social and cultural norms promote the use of mixed feeding. For example, in the Durban cohort, only 26% of the women who chose to breast-feed fed their infants with breast milk exclusively.
The promotion of exclusive breast-feeding for HIV-infected mothers who choose to breast-feed their infants remains an urgent priority, especially in developing countries. Dr. M. Chopra presented data regarding the impact of mother-to-child transmission programs on the breast-feeding counseling practices of healthcare workers in Khayelitsha, South Africa.[4,5] Healthcare workers (in this instance, professional registered nurses) were inadequately trained regarding knowledge of feeding options available to HIV-infected mothers. Worryingly, HIV-infected mothers were not given a choice regarding breast-feeding. All mothers were told not to breast-feed and all complied with this advice. Mothers were not provided with sufficient information regarding the safe preparation of formula feeds, and feed quantity and frequency were not discussed. Interestingly, bottle-feeding was not associated with detrimental social effects and most fathers were supportive of this practice.
In Khayelitsha, 62% of HIV-infected mothers were aware of the risk of HIV transmission through breast milk. However, the majority of mothers who breast-fed their infants introduced other liquids. Other milks were introduced by 52% of mothers within the first month of feeding. Within 3 months, 82% of mothers had introduced other milks to their infants. Clearly, infant feeding practices in these communities need to be improved.
Dr. Chopra’s group assessed the attitude of 11 HIV-infected mothers regarding feeding their infants breast milk exclusively. All mothers insisted on not breast-feeding and 10 of 11 mothers refused to believe the results of the Durban study. HIV-infected mothers all believed that they would definitely transmit the virus to their infant if they breast-fed, and they were clearly not prepared to do so.
Dr. Desclaux described the enormous difficulties facing West African HIV-infected mothers.[6,7] These mothers are given ambiguous messages regarding breast-feeding because the country’s health services universally promote the message that “breast is best,” irrespective of the mother’s HIV status. Tremendous social and economic limits also undermine the choice of feeding options for these women. The cost of formula and the negative attitudes of fathers and families toward formula feeding are major contributors to this limitation.
In communities where HIV-infected mothers have very limited options other than breast-feeding, pasteurization of human milk may be an option. Dr. Jeffery has described a simple home-based method of pasteurization of human milk by passive heat transfer. Preliminary data from 17 HIV-infected mothers who have had their milk pasteurized were presented. The milk was tested for the presence of HIV by RNA viral loads and p24 assay. The p24 assays were all negative in the pasteurized human milk and RNA viral loads were dramatically reduced in the pasteurized milk compared with controls. Although these initial results are encouraging, further investigation is necessary to provide another feeding option to HIV-infected mothers and their infants.
It was clear from the proceedings that feeding options available to HIV-infected women in developing countries is limited. A large social and cultural variability influences feeding practices within individual communities, and feeding recommendations must take this into account. What is clear, though, is that women should be clearly informed about all available feeding choices. Healthcare workers must be adequately trained in feeding options available to these mothers, and they should lend their full support to these mothers irrespective of the feeding option that they choose.
- Moodley D, chair. Mother to child transmission: issues in breastfeeding transmission. Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Session D05.
- de Zoysa I, Karim QA, chairs. HIV-positive women should be encouraged to exclusively breastfeed. Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Session Db05.
- Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM, for the South African Vitamin A Study Group. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet. 1999;354:471-474. [Abstract]
- Chopra M, Schaay N, Piwoz E. What is the impact of an AZT programme on breastfeeding and infant care counseling and practices amongst health providers and HIV-infected women in Khayelitsha, South Africa? Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Abstract MoOrD203.
- Chopra M, Piwoz E. What are the barriers to offering exclusive breastfeeding as an option in an already existing AZT programme? Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Abstract MoOrD206.
- Desclaux A, Taverne B, Alfieri C, Querre M, Coulibaly-Traore D, Ky-Zerbo O. Socio-cultural obstacles in the prevention of HIV transmission through breastmilk in West Africa. Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Abstract MoOrD205.
- Desclaux A. Is HIV prevention incompatible with the medical culture of breastfeeding in West Africa? Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Abstract TuPeD3721.
- Jeffery B, Webber L, Mokhondo R. Determination of the effectiveness of inactivation of HIV in human breast milk by Pretoria Pasteurisation. Program and abstracts of the XIII International AIDS Conference; July 9-14, 2000; Durban, South Africa. Abstract MoPeB2201.
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