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Re: [pronut-hiv] Breast feeding and HIV (4)

  • From: "Rachel Stern" <>
  • Date: Wed, 25 Aug 2010 10:59:07 -0400

Hi Thulani, and thanks for your insights.

But I believe one must be careful in generalizing and in being doctrinaire
on this subject. For example, I understand that Botswana has formula
programs suited to locales within the country, and i remember reading on
this listserve some months ago that their mtct rate has gone down
dramatically. It is wrong, however, to make blanket recommendations about
formula, just as it is wrong to make blanket recommendations about
breastfeeding. In the popular press, the message is coming out that
breastfeeding prevents transmission, and that misinformation is unfair to
mothers and infants.

Whether it be exclusive breastfeeding for 6 months (did I read right? it's
now to be 12 months?) or formula feeding, both require intensive educational
efforts that have generally not been successful.

Rachel Stern

----Thulani Maphosa wrote:

Thanks Tom you summarised the issue very well. I liked the aspect of of
providing adequate counseling easpecially when the two options are being
considered. Key challenges that are indetified are the resource poor
countries do not have adequate health care workers (Health care provider and
patient ratio is high) therefore couseling time is not available.

Above all we have seen the industry pushing its agenda to promote infant
formula, and issues of conflict of interest within health care workers have
also become a major challenge. Code violations and the subsequent WHA
Resolutions have not been fully applied at national level to protect and
support breastfeeding. We need all come together
in this regard because i still believe it will make a difference towards
supporting the new WHO Rapid Advice.

What we need to be discussing is how as countries exclusive breastfeeding
rates can be increased (currently most countries are below 50%)? , scale the
ARV prophylaxis according to the new WHO PMTCT Rapid Advice to make
breastfeeding safer.

Clearly evidence has been provided Tom and it's time to scale up all the
high impact interventions. It is clear as well after the 2006 WHO Consensus
statement there has been no change in the survival of children easpecially
in countries with high HIV prevalence i.e South Africa, Botswana, Swaziland,
Lesotho and unfortunately some of these countries intoduced free formula to
PMTCT children but child survival never improved and as well new infections
in children still remained high. Child survival should be our focus and
simple interventions can make a difference.

I would want to draw attention to all of you to check the progress in Brazil
in-terms of trends towards attaining the MDG's and the facillitating
factors. Clearly they focused on simple programmes that are cheap, manageble
but with high impact towards health and survival.

Great article Tom and it's very clear but we need to agree: On what
interventions can make a difference in improving infant feeding practices?

Thulani Maphosa
Chief Programmes Officer
IBFAN Africa
Tel: 0026824043803
Cell: 00268-6023803

----Annie Buchanan wrote:

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
formula fed have 6 TIMES the mortality as breast fed babies. Of course we
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