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- From: "Rachel Stern" <email@example.com>
- Date: Wed, 11 Aug 2010 13:13:17 -0400
Probably everyone on this listserve agrees that breastfeeding is the best way to feed a baby. We all know the many benefits.
But for the HIV-infected mother, I believe it is important to be accurate and forthright about risks of breastfeeding vs formula, so she can make the feeding decision that is best for her. All options carry risk, and how great each risk is depends on her individual circumstances.
- Breastfeeding plus antiviral prophylaxis may be the best option for many. There are the benefits of breastfeeding, its nutritional superiority, its safety etc, and the risk of HIV transmission is very low with prophylaxis. However, the infant has prolonged exposure to powerful medications, and we don't know if there are long term adverse effects. The drugs do have immediate side effects for many people as well. There are compliance issues, and there are cost issues as funding gets harder to come by. For health care providers, there are also concerns about resistance.
- Formula is the safest as far as preventing HIV transmission. In the US, a physician who discouraged formula when the mom is HIV-positive, probably would get sued for malpractice if the baby gets infected. However, formula has clear disadvantages in resource-poor regions - cost, compliance, logistics, and of course, safety. (It is puzzling to me, though, that concerns about water safety, are never translated into guideline goals. Clean safe water is also important for breastfed babies at 6 months when other items are added to the diet, and later at weaning). Mortality rates with formula can be as high as HIV infection rates plus mortality rates in breastfed babies.
- Breastfeeding without prophylaxis is risky, and that risk should not be downplayed to mothers. I know that there are studies showing that 6 months exclusive breastfeeding lowers transmission, but those transmission rates remain high - about 12% a year, as I remember. Mothers should know that the most important determinant of transmission is her viral load. The antibodies in breastmilk help prevent infectious disease, but it is doubtful that HIV is one of those diseases; the healthiest, fittest adults in the US - people with mature immune systems - became infected with HIV in the 80's and 90's. Also, we know that HIV enters the body where epithelial tissue is disrupted, and babies often have sores in their mouths - from thrush, from a fingernail cut, sore throat, cutting teeth - leaving a portal for entry. I believe it is wrong to downplay the risks of transmission via breastmilk.