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Re: [pronut-hiv] Breast feeding and HIV (2)

  • From: "Annie Buchanan" <>
  • Date: Tue, 24 Aug 2010 03:53:02 -0400

Thank you Tom for summarizing our current best evidence. The only thing I
would add is the magnitude of risk associated with formula feeding over
breastfeeding in resource poor settings. The evidence shows that babies who are formula fed have 6 TIMES the mortality as breast fed babies. Of course we want to keep them HIV-free, but first we want them to survive.

Annie Buchanan

Annie Buchanan
KCMC-Duke Collaboration
Box 3010
Moshi, Tanzania

---- Schaetzel, Tom wrote:

> Thanks to all who have contributed to the lively discussion prompted by our
> World Breastfeeding Week posting on 9 August. Choice of feeding option for
> HIV-infected mothers obviously continues to be a contentious issue, with
> strong opinions promoting both formula and breast feeding. Since everyone
> wants what is best for the HIV-exposed child and her/his mother, however,
> it's important to base our opinions on the evidence.
> Several have mentioned the need to ensure that babies born to HIV-infected
> mothers do not become HIV infected. No one would dispute this. I'd like to
> submit, though, that it's equally important for babies born to HIV-infected
> mothers to survive. The evidence shows that in many settings the number of
> excess infant deaths resulting from formula feeding exceeds the number of
> HIV infections that it avoids. The key issue thus is not just keeping babies
> free of HIV--the issue is maximizing HIV-free survival, or minimizing the
> combined risk of non-HIV death and HIV infection.
> If we focus on reducing the risks of both death and HIV-infection, what
> feeding method is best? As some have pointed out, the answer depends on the
> context. We have decades of evidence that formula feeding greatly increases
> the risk of death in settings where infant mortality is high. We also know
> that breast feeding is best for infant survival, growth and
> development--especially when mothers practice exclusive breastfeeding for
> the first six months. Even though breast feeding carries a risk of
> HIV-transmission, whenever formula feeding increases the risk of infant
> death so much that it exceeds the risk of HIV transmission from breast
> feeding, breast feeding is the safest and best option.
> Several posts have questioned the efficacy of exclusive breast feeding for
> reducing HIV transmission, and the feasibility of promoting it. The evidence
> is overwhelmingly clear, however: for an HIV-infected mother who breast
> feeds the risk of HIV transmission is greater if she practices mixed feeding
> than if she practices exclusive breast feeding. Additionally, the survival
> advantage that exclusive breast feeding offers over mixed feeding is
> well-established. For the HIV-exposed child who is breast feeding, exclusive
> breast feeding both reduces the risk of HIV transmission and improves the
> chance of survival. While it may be difficult (but certainly not impossible)
> to achieve high rates of exclusive breast feeding, this is no reason to
> abandon efforts to promote it.
> The main problem with choosing an infant feeding option is determining when
> the death risk of formula feeding out-weighs the HIV transmission risk of
> breast feeding. Communicating both of these risks clearly to HIV-infected
> mothers, so they can make an informed choice, has proven overwhelmingly
> difficult. Several posts mentioned the need to avoid minimizing the
> HIV-transmission risks of breast feeding when communicating with mothers. In
> most countries affected by the epidemic, conveying the risks of breast
> feeding is not a problem. Rather than not being aware of the MTCT risks,
> mothers (and providers) more often exaggerate these risks, even assuming
> that all or nearly all HIV-exposed infants who breast feed will become
> infected. At the same time, many mothers and providers ignore or do not
> understand the mortality risk of formula feeding.
> Fortunately, we now have evidence that ARV prophylaxis for the mother or
> infant (or HAART if the mother is eligible) drastically changes the risk
> equation for making the feeding decision. Whereas before, without
> intervention, the risk of HIV transmission from breast feeding was around
> 14%, ARV prophylaxis can reduce it to less than 2%. With ARV, in most
> low-resource settings the mortality risk of formula feeding will be far
> greater than the HIV transmission risk of breast feeding.
> This is a huge opportunity. With the risk of MTCT through breast feeding
> reduced by ARV, HIV-exposed babies can get optimal feeding just like
> non-exposed babies. Health systems can focus on making ARVs available and
> promoting adherence. And, rather than struggle to provide bias-free
> counseling about the risks of different feeding options, they can provide
> infant feeding advice that is basically the same for all mothers. Perhaps
> most importantly, HIV-infected mothers in resource-poor settings no longer
> need to anguish over whether they have chosen the safest feeding option for
> their baby.
> With the new guidelines from the WHO on infant feeding in the context of
> HIV, we are in a situation that, for once, offers a clear way forward. In
> countries that decide to promote breast feeding (with ARV) as their national
> recommendation, we can leave these nuanced arguments about formula and focus
> our efforts on providing ARVs, supporting adherence, and promoting breast
> feeding to give babies the best start in life.
> Thomas T. Schaetzel, PhD
> Technical Director
> Infant and Young Child Nutrition (IYCN) Project