[pronut-hiv] The issues regarding free formula; how to reduce postnatal HIV transmission rates

["Ted Greiner" <tedgreiner@yahoo.com>]

Dear Rachel,
   
  I agree with you from a nutritional and "care" perspective. Infant formula is the simplest and most practical approach, as well as being nutritionally superior to all options except for breast milk. Where affordable, it should be continued to one year and beyond, the same as is recommended for breastfeeding. The idea that giving it for the first 6 months is enough is absurd and should be soundly rejected.
   
  Providing it for free is however a very expensive option. It will cost the donor about as much as providing HAART. More importantly, its impact is so far unproven. From the relatively poor quality data available so far, there is no evidence that in Africa it results in any increase in HIV-free survival, giving it a very low cost effectiveness. In some settings it may actually result in a decrease in HIV-free survival rates, making most large donors now unwilling to provide it. 
   
  Another problem is that offering an income transfer only to women who choose one option will make objective AFASS-based decision-making impossible. Only women who can use it safely should be choosing it--and yet those are likely to be the better educated, wealthier women. So this is an exceptionally inequitable approach. This constraint could overcome be offering an equally expensive basket of food support to women who choose to exclusively breast feed, but this would of course double the cost of the program, and I know of no countries or donors doing this. 
   
  We do not know the exact mechanism of HIV transmission via breast milk. But there are ways of reducing it:
   
  1. The only relevant data we have, from the ZVITAMBO study in Zimbabwe, found that not only did exclusive breastfeeding reduce transmission rates while breastfeeding was exclusive, but also afterwards. Presumably it protects the infant gut and then as the gut matures and the infants' own immune system kicks in, they are stronger and can better resist transmisison once other foods are added. 
   
  2. Clearly these foods need to be added in a hygienic way. Hygienic preparation, storage and feeding of complementary foods, especially a challenge with animal foods, is a key message for mothers once complementary feeding begins. By the way, in the rare cases in Africa (such as Rwanda) where mothers commonly continue exclusive breastfeeding until 7 or 8 months, I see no value in struggling to get them to start solid foods sooner. There is no evidence that such a delay does any serious harm to the infant.
   
  3. Close observation should be maintained and steps taken to quickly overcome any nipple damage or oral infections in the infant during breastfeeding. In most countries, there is a lack of health workers trained in lactation management who know how best to deal with breast and nipple problems. WHO is about to release a new integrated 5-day curriculum in Infant and Young Child Counselling, which combines three previous courses (5-day course on breastfeeding + 3-day course on HIV and Infant Feeding + 3-day course on complementary feeding). The medium term goal should be for all PMTCT infant feeding counsellors to take this course.
   
  4. Low CD4 count is a major risk factor. In one ongoing study in Zambia, no breast milk transmissions have been seen in exclusively breastfeeding mothers with a CD4 count above 500. In some countries now, HIV+ pregnant mothers are started on HAART once their CD4 count drops below 350 and they remain on it then for life. If measured only during breastfeeding, however, the CD4 count has to be under 200 for the mother to be eligible for HAART. This needs to be reviewed--and should possibly be changed to 350, the same as pregnancy. In any case, putting women with low CD4 counts on HAART will greatly reduce overall rates of breastfeeding transmission. (In one ongoing study of temporary HAART provision to all HIV+ breastfeeding mothers in Rwanda, no postnatal transmission has been seen so far. However, this is still not an approved approach, but a subject for research.) 
   
  I have not seen evidence that ARV levels in breast milk are particularly harmful to infants, but continued study is required. 
   
  Ted Greiner
   
------Rachel Stern wrote:

Thank you, Ted, for this detailed response.

I personally feel that formula should be made 
available to new mothers who 
are willing to use it for their babies from 
birth, and who can prepare it in a reasonably clean 
way. If medications can be subsidized, 
couldn't/shouldn't formula also be subsidized? All the rates 
of mortality and for HIV transmission that you 
cite, remain unacceptably high.

But for those who do brestfeed, and who continue 
past 6 months, do you know the specific route of 
transmission? Is it through a permeable 
intestinal tract? lesions in the babies mouth or lips? 
cutting teeth? Does the route change as the newborn 
baby infant gets older? Maybe there could be a 
way to reduce transmission in younger and older 
infants - I mean, something beyond the "exclusivity" 
thing which I don't find very impressive.

If the mother is taking antiretrovirals and other 
meds, do these pass into 
breastmilk, and is this considered good (by 
limiting transmission) or bad 
(toxicity issues)?

Just curious about these questions.  Thanks.