[pronut-hiv] Balancing infant feeding risks for mother and child

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

Dear Rachel,
   
  Yes, per person over the long run formula would be cheaper than HAART, though in one program I know of that provides both, the budget for each is about the same because so many fewer patients receive HAART.
   
  The proportion of infants who die from formula feeding can easily be far above the proportion that becomes infected from breastfeeding. The worst documented case is infants under 1 month in Pakistan where 21 times as many died if not breastfed. 
   
  In Pakistan, Brazil and the Philippines, 5 times as many died if not breastfed at 6 months of age among mothers in the lowest education tercile compared to almost no excess death among those in the highest education tercile.
   
  For HIV+ mothers, AFASS assessment for whether to breastfeed, and again, when to stop for those who choose to breastfeed, should be based on the individual because, as you say, there can be exceptions. 
   
  But for a donor interested in improving public health and utilizing scarce resources in a cost-effective way, purchasing infant formula will come very far down on any priority list of interventions. For those seeking to improve equity (which is a goal for most donors), giving formula alone, with no benefit to the women who choose breastfeeding, will actually increase inequity. 
   
  While it is reasonable to assume what you say about breastfeeding being tiring to HIV+ women, nature has worked out clever ways to ensure that breastfeeding is a "win-win" proposition for women. More intensive breastfeeding on average delays the return of menstruation, and this is particularly protective for those women who tend to lose more than the average amount of blood monthly in menstrual bleeding. And they are the ones most vulnerable to anemia. Anemia tends to be pretty exhausting as well. Not only will non-breastfeeding women be more subject to anemia, unless they quickly start to practice modern contraception, they are likely to get pregnant again quickly, and short birth spaces are by far the most exhausting and dangerous situation for women of reproductive age, let alone those with HIV. In my experience, few PMTCT sites offer adequate family plannning support and services to overcome this risk. There are now three studies finding no excess morbidity or
 mortality among HIV+ mothers who breastfeed, including one from Malawi in the latest issue of WHO Bulletin, full text articles from which are available free online. 
   
  Ted Greiner
---Rachel Stern wrote:

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