Re: [pronut-hiv] The issues regarding free formula; how to reduce postnatal HIV transmission rates (2)

["Rachel Stern" <sternworks@verizon.net>]

Thanks Ted, for this point-by-point explanation. This is very interesting 
information. Just a couple of more thoughts in response:  As for cost, this would be a limited time of about a year versus HAART which at the moment seems open-ended. Although the impact of formula is so far unproven, if stix show that 6 or 8 or 15% or whatever babies acquire HIV during breastfeeding, it stands pretty much to reason that formula would prevent that amount of transmission. However, maybe providing formula for those with an AIDS dx, or some other cutoff (as you note), makes more sense.  A woman with AIDS may find breastfeeding adds to her exhaustion, and her milk production may be compromised.

What about cutting teeth? what is recommended during this extensive period?

I'm not sure I agree with you that less educated, less wealthy women could 
not provide formula safely. That would no doubt vary from area to area.

I realize there are many obstacles including cost and hygiene, and it 
certainly goes against what we all understand - that breastmilk and 
breastfeeding are superior. But not always.

Thanks.  Rachel


----- "Ted Greiner" wrote:

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.