and HIV/AIDS: is there a conflict?
Prof. R. V.
Department of Obstetrics and Gynaecology, University of Melbourne
Royal Women’s Hospital, Carlton, 3053
August 1st, 2003 marked the beginning of World Breastfeeding Week, and
in a circular to commemorate the event Gro Harlem Brundtland, the former
Director-General of the World Health Organization said:
“The HIV pandemic and the risk of mother-to-child transmission of HIV
through breastfeeding continues to pose unique challenges to the
promotion of breastfeeding, even among unaffected families. Accurate
information, disseminated widely, about breastfeeding’s benefits for the
majority of children and mothers is essential for preventing baseless
doubts in this connection. Support for HIV-positive women should include
counseling about appropriate infant-feeding options”.
That is a perfect summary of our dilemma. Speaking in Paris on July
14th, 2003, at the United Nations Global Fund to fight AIDS, Nelson
Mandela said that AIDS was “The greatest health crisis in human
history”. He went on to point out that “we have failed to translate our
scientific progress into action where it is most needed, in the
developing world”. How right he was.
In some Southern African countries, e.g. Botswana and Lesotho, over 40%
of pregnant women are HIV-positive; in Swaziland, Zambia and Zimbabwe,
over 30% are HIV-positive (UNAIDS, 2002).
When considering mother-to-child transmission of HIV, this ranges from
14-32% in Europe and the United States, to 25-48% in Sub-Saharan Africa,
and the difference is thought to be due to breastfeeding (De Cock et al,
2000). 1,600 HIV-positive children a day are born in Sub-Saharan Africa.
Globally, at the end of 2001, there were 14 million AIDS orphans under
the age of 15 who had lost one or both parents to AIDS. (UNAIDS, 2002).
Since about 40% of mother-to-child transmission of HIV is thought to be
due to breastfeeding, the simple solution might appear to be to
recommend that no HIV positive mother should breastfeed. But in a
developing country, such a recommendation would have disastrous
consequences. In the first place, many women will never know whether
they are HIV positive, so you would have to recommend that no woman
breastfed her baby. But the risk of an infant dying from infectious
diseases in the first two months of life is six times greater for
infants who are not breastfed. Thus the promotion of infant formula
feeding to reduce HIV infection may increase overall infant morbidity,
mortality and malnutrition.
A recent analysis of mother-to-child transmission in mothers
breastfeeding for 18-24 months suggests that intrauterine infection
accounts for 5-10% of transmissions, 10-20% occur during the birth
process, and can be reduced by caesarean delivery, or antiretroviral
treatment (e.g. Nevirapine) of the mother and the neonate, 5-10% occurs
in the first 2 months of breastfeeding, and a further 5-10% during
subsequent breastfeeding, giving an overall mother-to-child transmission
rate of 25-50% (De Cock et al, 2000).
Why Breast is
The situation has now changed for the better, with the exciting
discoveries made by Prof. Coovadia and his team from Durban, South
Africa (Coutsoudis et al, 2001). In a large prospective study of
HIV-positive women who chose to either breastfeed or bottlefeed their
babies, 118 infants that were exclusively breastfed for the first 6
months of life had NO increased risk of acquiring HIV infection compared
to 157 infants not given any breastmilk. However, 276 infants who were
on mixed breast and bottle feeding from birth had a significantly higher
rate of HIV infection.
After 6 months, when the exclusively breastfed babies started to go on
to mixed feeding, their rates of HIV infection started to rise
significantly when compared to babies who were never breastfed. The
explanation for this surprising finding appears to be related to the
viral load in the breastmilk, which determines its infectivity.
With the approach of weaning, or if there is any sub-clinical mastitis,
the white cell count in the milk and hence the viral load is increased,
making it much more infectious to the baby (Willumsen et al, 2003).
The conclusion is obvious. In a developing country setting, all mothers
should be encouraged to breastfeed exclusively for at least the first 6
months, regardless of their HIV status, and then to wean the baby
rapidly. Research needs to be done to see what would be the cheapest and
most available weaning food to use.
Of course, the central issue remains – how to protect the mother from
becoming infected with HIV in the first place. Here there is a sad twist
to the tale that involves breastfeeding. In West Africa, and maybe
elsewhere, there are cultural taboos on intercourse during the first 6
months of lactation. Unfortunately this means that this is the time when
male partners are most likely to seek satisfaction from extra-marital
sex, and hence become infected with HIV. Since viral titres are
extremely high during the early stages of the infection, this means that
the men may be highly infectious once they resume intercourse with their
lactating partners, who in turn will be much more likely to infect their
babies in the early stages of their own infection. Thus men need to be
made aware of the fact that extra-marital sex whilst their partners are
lactating puts three lives at risk – their own, their partner’s, and
their baby’s. If ever there was a time for men to practice Safe Sex,
surely this is it.
A Counsel of
Perfection for the HIV+ Mother
We can now begin to summarize the situation. Leaving aside the key
question of how to avoid HIV infection, what should a woman do about it
once she is infected?
The first thing is to consider very carefully the issues around
parenting. Since HIV infection is in effect a death sentence for the
mother, even in developed countries, is it right to bring a new child
into the world, only to become an AIDS orphan when the mother dies?
If the HIV positive mother does not wish to become pregnant, and wants
to minimize the risk of infecting her partner if he is HIV negative,
what contraceptive should she use? This is a question that is seldom
addressed, and there is no easy answer. If she becomes pregnant against
her wishes, then perhaps she should seriously consider having an
If she decides to continue with the pregnancy, she can minimize the
chance of infecting her baby at birth, the time of greatest risk, when
the baby may swallow infected maternal blood and secretions, by having a
Caesarean delivery. Alternatively she can have antiretroviral treatment,
e.g. Nevirapine, for herself antenatally and for the baby immediately
after birth. The chances of being able to afford a Caesarean, or having
access to antiretrovirals in the developing world are minimal.
The mother should breastfeed her baby exclusively for the first 6 months
of its life as this will give it the best possible protection against
diarrhea and respiratory infections, and there is little or no further
risk of HIV transmission. But if she develops mastitis, she should cease
breastfeeding immediately. After 6 months, the baby should be abruptly
weaned from the breast, and introduced to solid food. By adopting this
all-or-nothing breastfeeding policy, mother-to-child HIV infection
should be drastically reduced.
The HIV pandemic is destined to get much worse before things start to
improve. At the end of 2001 there were 40 million people living with
HIV/AIDS, 2 million of whom were women. There were 5 million new
infections, and 3 million deaths from AIDS, including 580,000 children (UNAIDS,
Although Sub-Saharan Africa is the epicenter of the epidemic, with
28,500,000 infections, South and South East Asia come next with
5,600,000 infections. It seems likely that India will soon become the
new epicenter, and by 2050 some estimates suggest that globally, over 1
billion people will be infected.
Stopping HIV infection must be the world’s first priority, and reducing
mother-to-child transmission should be high on the list; here it seems
that the promotion of exclusive breastfeeding has an important role to
De Cock et al (2000). Prevention of mother to child HIV transmission in
resource-poor countries. J. Amer. Med. Assocn. 283, 1175-1182.
Coutsoudis, H. M. et al (2001). Method of feeding and transmission of
HIV-1 from mothers to children by 15 months of age: prospective cohort
study from Durban, South Africa. AIDS 15, 379-387.
UNAIDS (2002). Report on the global HIV/AIDS epidemic. Geneva.
Willumsen, J. F. et al (2003). Breastmilk RNA viral load in HIV-infected
South African women: effects of subclinical mastitis and infant feeding.
AIDS 17, 407-414.
ABC TV - The World Today - August 4, 2003
HIV positive mothers in Africa encouraged to breastfeed their children
While Africa battles to contain the AIDS pandemic, there's new research
about the impact of breastfeeding on the rate of mother-to-baby
infections. The research concludes that it's vital that women who are
HIV positive breast feed exclusively, rather than provide bottle formula
to their newborns, as Toni Hassan reports.
It's a staggering statistic: In Africa today, 40 per cent of all mothers
reported to hospitals and clinics are HIV positive. Mother-to-child
transmission rate ranges between 25 and 50 per cent.
Up to 10 per cent of those infections occur in the womb – something
practitioners can't do anything about. Another 10 to 20 per cent occur
at birth, probably due to blood-to-blood contact.
Caesarean delivery can reduce that, but that's not an option for women
in the developing world. New mums and their babies could also be given
anti-retroviral drugs, but again it's often not an option.
Another 10 to 20 per cent of transmissions occur during breastfeeding.
But that, according to Roger Short, a specialist in reproduction and
AIDS at Melbourne University that does not mean advocating a ban on
Dr Short has been liasing with colleagues in Durban, South Africa who've
done some ground breaking research in the area. The conclusion: breast
milk, exclusively offered, is still best.
Mothers who breast feed exclusively and don't give the baby any food
other than breast milk – none of them become infected through the breast
feeding. But if the mothers start to introduce supplements and infant
formula, then up goes the transmission rate, and this completely
unexpected result is explained by the fact that once you start partially
breastfeeding and topping up with supplements, the load of virus in the
breast milk shoots up.
And so the recommendation we've now got to make is that we should
reinforce the World Health Organisation's recommendation that all
mothers should breast feed for at least six months exclusively, giving
nothing else. And then, when you decide to wean, you must wean very
rapidly, because it's the process of weaning that, paradoxically, is
infecting the babies.
WHO's initial recommendation that women in the developing world are
encouraged to breast feed – is that even being heard?
Well, I think it's not, unfortunately. The obvious response when people
heard there was infection occurring through breast milk was oh, right,
we've got to go onto 100 per cent infant formula.
But when we actually look at the statistics, I mean it leaves absolutely
no doubt that putting babies onto exclusive infant formula kills them,
because they going to die of diarrhoea.
Because there's a bigger problem isn't there, that women in the
developing world are tempted to use formula because it's seen as
something developing women use, despite the fact that the water is
obviously more unsafe and therefore the chance of passing on any sort of
infection is greater.
The difficulty of making up infant formula safely in a developing
country setting is enormous, and sadly there's a new twist to that. When
I was in South Africa at the end of last year, they told me that because
of the enormous deforestation that's occurred, chopping down trees to
make coffins, there's no firewood left – the coffins for the babies and
adults who had died of AIDS.
So water isn't even being boiled?
Well, the challenge is huge, isn't it.
Indeed it is. Professor Roger Short, a specialist in reproduction at
Melbourne University speaking to Toni Hassan.