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Breastfeeding and Health
HIV positive mothers in developing countries
advised to breastfeed for 6 months and then abruptly wean.

Breastfeeding best for infant, HIV mothers in Africa told

By STEPHANIE NOLEN

Research shows health benefits for the newborn outweigh the risks of transmitting disease through milk, STEPHANIE NOLEN writes

Globe and Mail Update
Tuesday, January 6, 2004

HARARE -- On health-clinic walls across Africa, the posters have shouted the same cheery message for years now: "Breast is best!"

Breastfeeding passes on crucial antibodies to babies, protects them against allergies, promotes their cognitive development and is much safer than formula that must be mixed with possibly contaminated water.

But then came AIDS. Ninety per cent of people with HIV in Africa don't know they have it and many women first learn they carry the virus when they're already pregnant and are tested at a prenatal clinic.

Half of the children with HIV in sub-Saharan Africa today were infected with the disease through breast milk from their HIV-positive mothers.

Doctors in North America first discovered that a woman with the virus could pass it on in breast milk in 1985. Soon, Western women with HIV were being strongly advised not to breastfeed.

But in Africa, it’s the poorest women -- those least able to afford formula or have access to clean water with which to mix it -- that are statistically the most likely to be infected with HIV.

"You can't just say, ’don't breastfeed.' That’s a death sentence for many babies. Fine, they won't get HIV, but they will die of diarrhea," said Jean Humphrey, who heads Zvitambo, a research project funded in part by Canada that examines HIV and breastfeeding in Zimbabwe.

The issue soon pitted Western scientists against doctors in sub-Saharan Africa. From the West came pressure on the World Health Organization to adopt the policy that HIV-positive women should not breastfeed; from doctors in Africa and elsewhere in the Third World came the reply: So then what?

"It’s a real dilemma, and I’m not pretending it’s easy to solve, but what I resent is the old colonial attitude, 'Look, the U.S. does it and Canada does it, so why don't we do it?' " said Hoosen Coovadia, professor of HIV/AIDS research at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal. "This is a huge cultural question."

African researchers, including Prof. Coovadia, assessed the relative risks of transmitting HIV versus diarrhea, and decided the way forward might be better breastfeeding.

The early results are surprising. They suggest the best thing a mother with HIV can do for her baby is to breastfeed, all the time. "Unicef didn't believe us when we told them the results [of the first studies]," Dr. Coovadia said. "Now, they’ve stopped subsidizing formula."

While the researchers are still puzzling over exactly why this is, they have found that breast milk really is best. Anything else given to an infant -- water, bits of porridge or cooking oil (given in this region to combat constipation) irritate the lining of the gut, increasing the possibility that the baby’s body will absorb the HIV virus. So researchers are now proposing that women practise "exclusive breastfeeding and abrupt weaning." That is, nothing at all except breast milk for six months, and then an abrupt cutoff.

Six months is the current best guess at an optimal length of time that allows babies to get the most important benefits of breast milk while trying to minimize the length of exposure to the virus.

But safer breastfeeding is not as easy as a quick conversation at the clinic. If women are being encouraged to wean abruptly at six months, they must receive intense support from counsellors and their community as it can be deeply traumatic for both mothers and their infants, explained Katherine Semrau, project co-ordinator for the Zambia Exclusive Breastfeeding Study run at a Lusaka clinic. Mothers can end up with breast diseases such as mastitis, and anguished babies can become malnourished.

Mothers also need to be taught the safest possible techniques for breastfeeding to reduce the risk of problems such as cracked nipples, which will increase the possibility of blood being passed to the baby along with breast milk.

Dr. Humphrey said her team has also realized the importance of looking at issues of consent since many rural Zimbabwean women don't make the decisions about child-rearing. Rather, they must follow instructions from their partners or mothers-in-law.

Dr. Coovadia believes that if women with HIV choose to breastfeed and are shown the safest way to do it, and follow the guidelines, their risk of transmission to their babies may be as low as 6 per cent. "Safer breastfeeding is now the only real choice," Dr. Humphrey said.

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