[pronut-hiv] The requirements and problems with providing free formula in Africa

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

Dear Rachel,
   
  If intuition had proven to be good enough, we wouldn't need evidence-based medicine. 
   
  Formula feeding CAN work in Africa, but it requires provision of free formula, clean water, and fuel for a long time (Family Health International gives it for 18 months in two districts in Rwanda). FHI also asks the mothers to come for the formula every 2 weeks, when a qualified health worker checks the child, someone with access to the drugs needed to save those who come down with the numerous diseases artificially fed infants always suffer from, but need not die from if and when good health care is available close to home. (Like AIDS patients, non-breastfed infants are immune-incompetent.) So, while definitely possible, the cost of getting free formlua to work and NOT having it actually decrease HIV-free survival rates is high indeed. 
   
  However, when scaled up, even in the better resourced countries of southern Africa, free formula is not working very well. In South Africa, the recently completed (still unpublished) Good Start study found that nearly all women on free formula had periods of time when the formula ran out and they were not yet eligible to get more or there was none to be had when they travelled to the health center for their monthly ration because it had run out there too. Bergstrom, in a sub-study done in Durban, found that even among mothers with some high school education and a fridge at home, 2/3 had fecal bacteria in the bottles they were giving to their babies. Her thesis is freely available at http://www.hst.org.za/publications/564.
   
  In Botswana, the other African country providing free formula to HIV+ mothers, a recent rise in the water table contaminated the usually reliable water supplies and over 10,000 infants, mainly those receiving free formula under their national PMTCT program, were hospitalized with diarrhea. About 500 died. Like you say, it's nice to avoid HIV transmission, but it's very dififcult in most African environments to avoid paying too high a price for doing so by avoiding breastfeeding.
   
  Meanwhile, as HIV testing, CD4 testing and HAART availability expand, much if not most postnatal transmission will disappear, as it is mainly HIV+ women with a low CD4 who transmit though breast milk.
   
  Cheers,
  Ted

--- Rachel Stern wrote:
   
  Ted - I'd have to read these reports in order to 
respond. I'm wondering, for example about the 
Pakistani report: Were these mothers HIV+? Did these 
mothers reconstitute powder, reconstitute 
concentrated liquid, or use 
ready-to-feed formula?  Did these mothers have to 
purchase their own 
formula, thereby putting the infants at risk of 
inadequate intake?  I'm just not sure that the 
experiences you cite would be relevant to the safety 
of a formula-feeding program, carefeully targeted 
to prevent HIV transmission.

I don't think there's any doubt that formula 
feeding was a diseaster, as it was probably practiced 
in Pakistan, Brazil, the Phillippines, and many 
other countries during the period when formula 
gained a foothold. The superiority and other 
benefits of breastfeeding and of breastmilk, including 
its contraceptive effects, are well known. But so 
are the benefits of HIV prevention, and perhaps 
at least in some regions an innovative and 
carefully crafted formula program could save infants 
from a lifelong HIV infection.

The poorest, most poorly educated women may have 
a surprising capacity to 
take this kind of prevention measure, if provided 
with the right resources.

As for anemia and menstruation, nutrional 
depletion as well as breastfeeding (and in this case, 
the two are probably interrelated) cause a delay in 
return of menstruation and fertility. Unintended 
pregnancies often occur when fertility returns 
before menstruation returns. I agree with you on 
the importance of family planning services. I'll 
try to find the WHO Bulletin articles you mention, 
although intuitively, their conclusions don't 
sound reasonable.

Again, thanks for your thoughtful response.

Rachel