[pronut-hiv] abrupt cessation of breastfeeding; balancing the risk; the impact of rolling out ART for eligible mothers

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

Local policy on the infant feeding component of PMTCT tends to be made by people with very little if any expertise on infant feeding. Ever since research began to focus on the reduced risk of HIV transmission linked with exclusive breastfeeding, "mixed feeding" began to get demonized. 
   
  But the three or four studies that have looked at the impact of mixed feeding all looked it in babies < 3 months of age. At that age the infant gut and immune system are very immature. After several months of exclusive breastfeeding it is likely that the hygienic addition of solid foods will not lead to the high rates of HIV transmission seen in newborns who are mixed fed. For example, in the ZVITAMBO study, the rate of HIV transmission was 0.22% per month for the first six months among mothers who basically only did 3 months of exclusive breastfeeding. Presumably it would be lower still if they had managed for all six. If babies were partially breastfed (milk or solids added), the rate of transmission was 0.73% per month. But from 6-18 months, those who had been exlcusively breastfed for 3 months did not return to this 0.73 figure, they transmitted at a rate of 0.57% per month.
   
  In any case, what really counts is maximizing rates of HIV-free survival. Sadly, very little research has focused on this, since the emphasis, at least in the early years of PMTCT, was on reducing postnatal transmission--sometimes seemingly at all costs. 
   
  Rates of HIV transmission need to be weighed against risk of death in different settings and at different ages so that counsellors have an idea how to discuss the issues with they kinds of mothers they see. 
   
  The most recently published simulations providing relevant data guide this kind of balancing of risk (Piwoz EG, Ross JS. Use of population-specific infant mortality rates to inform policy decisions regarding HIV and infant feeding. J Nutr. 2005 May;135(5):1113-9) suggest that it does not make sense to avoid breastfeeding altogether rather than exclusively breastfeeding in a setting where the infant mortality rate is > 25 per 1000 live births. In Africa, outside South Africa, that can only be found in rich areas of some cities. This does not mean that NO mothers in such settings should avoid breastfeeding, just that on average exclusive breastfeeding will lead to better overall outcomes. Where infant mortality rates are over 100/1000 (which they are in poorer African countries) outcomes will actually be better if one does nothing about infant feeding. Shortening breastfeeding dramatically in such settings, especially rapid cessation, is simply too dangerous to lead to any
 improvement in HIV-free surival rates.
   
  Again, there will be some mothers for whom avoidance of breastfeeding or early cessation will be better options, but infant feeding counsellors in such settings need to realize that these mothers will be rare--basically the richer and better educated ones. In fact, in health centers I have visited in Rwanda and Cote d'Ivoire health workers tell me they never see such mothers. One suspects that they may visit private practitioners rather than waiting for hours to see a health worker in a public clinic. 
   
  Thus individual counselling is not done in these health centers. Mothers are informed in group information-sharing sessions of what the infant feeding options are if one has HIV. Then in individual counselling of mothers who have tested positive they are simply asked how they want to feed the baby and, except in the rare centers offering free formula, virtually all mothers say they want to breast feed. In the best cases exclusive breastfeeding is then discussed. Sadly, there is little understanding for the need to then later do some kind of AFASS assessment with the mother to help her decide when is the right time for her to stop breastfeeding. In Ivory Coast she is pressured to stop in a two-week period. In Rwanda, she is asked to do it over a two-month period. 
   
  No one is arguing that exclusive breastfeeding prevents all illness, let alone all HIV transmission. But as ART is rolled out, most of the mothers who know they are HIV+ and are most at risk of transmitting HIV are now being put on HAART already in pregnancy (if their CD4 count is < 350). I have seen still unpublished data from two studies suggesting that once this is happening there is very little HIV transmission indeed via exclusive breastfeeding among the mothers with higher CD4 counts. 
   
  Ted Greiner

---- Rachel Stern wrote:

  Setting aside the question of rapid cessation and 
"breast damage", how do 
you react to the recommendation that (exclusive) 
breastfeeding should be 
ended abruptly at 6 months if mother is HIV+, and 
replaced with something 
else?

Thrush, small abrasions, lesions that accompany 
minor colds - these are all common in very young 
infants, infants not yet likely to receive foods 
other than breastmilk.  Isn't transmission across 
such lesions as high as it is through lesions 
elsewhere on the body?

Rachel Stern