[pronut-hiv] Most HIV positive women choose to breastfeed their infants

["Mundi Stella" <smundi2005@yahoo.com>]

Thanks Ted, this is very hepful. 
  I agree partially with the recommendation to counsel HIV positive women so that they can choose the most appropriate feeding option for their infants. From my experience, only wealthy HIV positive women can make that choice. Most HIV positive women attending antenatal clinic choose to breastfeed their infants because they cannot afford breastmilk substitute. 
   
  Stella


--- Ted Greiner wrote:

    Dear Stella,
   
  Thank you for this question, which raises important issues.
   
  First, if the family cannot afford milk, I do not think it is appropriate to stop breastfeeding before about a year of age. With no milk or other animal foods (such as liver and eggs) it is impossible to provide a nutritionally acceptable diet that will allow an infant to survive and be healthy.
   
  Second, the rate of transmission of HIV during exclusive breastfeeding is so low that the most recent published simulation study (Piwoz and Ross) suggested that it makes no sense to do replacement feeding in a setting where the infant mortality rate is likely to be higher than 25/1000 live births. (You do not say what country you are writing from but I do not believe that anywhere expect possibly wealthier urban areas of South Africa has such a low IMR in Africa.) Thus stopping exclusive breastfeeding before six months is hardly advisable in such a case.
   
  Third, in 1998 the Coutsoudis study showing that exclusive breastfeeding resulted in a lower HIV transmission rate (later confirmed by data from the ZVITAMBO study in Harare and the DITRAME study in Abidjan) resulted in an inappropriate assumption that mixed feeding after six months of exclusive breastfeeding is as dangerous as it was shown to be by those three studies in the first three months of life. While no research has been done on this, I greatly doubt this is true, if only because the infant gut is completely different in a newborn compared to a healthy six month old. Honey or nitrate-rich water can kill newborns but not older babies; newborns' guts are so immature that they can absorb entire proteins instead of breaking them into amino acids as six month olds do; until about 8-9 months of life, some of the lighter proteins in cow milk appear to cause occult gut bleeding unless the milk is boiled for some time before being fed to the baby--not just pasteurized. 
   
  Interestingly, infants who were exclusively breastfed in the first three months of life in the ZVITAMBO data transmitted HIV at a lower rate during the 6-18 month period than those who were mixed fed during the first three months (5.6% versus 9.6%), though I was informed that this was not a statistically signficant difference.
   
  In most of Africa, the risk of death from not breastfeeding is likely to be quite high. Bahl et al, using combined data from Ghana, India and Peru, recently found the death rate to be 10.5% higher in the period 6 weeks to 6 months. This is 2-3 times as high as the rate based on old studies in one city each in the Philippines, Brazil and Pakistan used in the Piwoz and Ross simulation. The proportion likely to get HIV during breastfeeding during the period 1.5-6 mo varies from about 1.5% to 5%, depending on whether the breastfeeding is exclusive. Thus stopping breastfeeding would make sense only if the infant mortality for that 1.5-6 mo period was under 5/1000, which one sees only in industrialized countries. 
   
  Another factor to consider is Jane's health and immune status. If she has a high CD4 count (or if you do not know it, if she has not lost much weight in the past year or so), then her chances of transmitting HIV are less than if her CD4 count is below say 350 (or if her BMI<19 or her weight loss >5% recently), when the risk of transmission goes up.
   
  Regards,
   
  Ted Greiner, PhD
  Senior Nutrition
  Director, Ultra Rice Program
  PATH
  1800 K St. NW, Suite 800
  Washington DC 20006 USA
  +1 202 822-0033
  Fax +1 202 457-1466
     
  Message: 2
Date: Mon, 17 Apr 2006 07:00:44 -0700 (PDT)
From: "Mundi Stella" <smundi2005@yahoo.com>
Subject: [pronut-hiv] Help with transition to 
replacement feeding
To: pronut-hiv@healthnet.org
Message-ID: 
<20060417140044.54298.qmail@web38410.mail.mud.yahoo.com>
Content-Type: text/plain; charset="iso-8859-1"

Dear colleagues,
   
  I am a midwife in antenatal service in the 
district hospital and will 
be meeting with a 21 year old young woman (Jane) 
who delivered three 
months ago in the maternity. Jane is HIV positive 
and decided to 
exclusively breastfeed her baby. 
  I will be meeting with Jane in two weeks to 
counsel her on abrupt 
cessation of breastfeeding and how to transition 
to replacement feeding. 
Jane lives with her parents and does not have any 
income. Jane?s parents 
do not know about her HIV status. They cannot 
afford to buy milk. The 
only replacement feeding is available is ?family 
foods?. I am very 
challenged by Jane?s situation. Jane?s parents 
may become very suspicious if Jane stops 
breastfeeding their grand child. Family foods may not be 
well tolerated by Jane?s baby. 
   
  Any idea or suggestion on how to go about this 
situation will be much 
appreciated
   
  Thanks 
   
  Stella