Push to allow HIV-infected mothers to nurse sparks outcry

By Rosie DiManno

Toronto Star 12 July 2000

Durban -- To breastfeed or not to breastfeed: That is the question.

Certainly suckling was the most emotional debate yesterday at the 13th International AIDS Conference, and the seminar which drew the keenest interest - or skepticism, even alarm - among the 12,000 delegates in attendance.

"I came here thinking I knew at least one thing for sure, that HIV-positive women should not breastfeed their babies,'' complained Dr. Steve Thomas, from the University of Pennsylvania, after listening to the much-anticipated presentation of South African researcher Dr. Anna Coutsoudis, who strongly favours breastfeeding.

"Now I feel like I know nothing at all.''

Thomas wasn't alone. There was befuddlement and consternation among the delegates, be they scientists or physicians or health-care workers. This controversy has enforced the suspicion by lay people, especially here in Africa, that the experts may not know very much.

"What are you telling us?'' Thomas continued, after rising to speak from the audience. "And how can we now prevent this from turning into another international controversy about AIDS? There's already been enough of that at this conference. I promise you that this disagreement about breastfeeding will be on the front pages of newspapers all over the world tomorrow.''

Along the west-east or north-south divide between developed and developing nations, the issue of breastfeeding by HIV-infected mothers has suddenly turned into an area of impassioned debate among scientists. This after it had been roundly agreed in the past decade that women with HIV, the virus that causes AIDS, should definitely not nurse their babies with mother's milk.

There's no doubt the HIV virus can be transmitted from mother to child through breastfeeding, with women aged 15-49 now representing 43 per cent of all new HIV infections.

Breastfeeding has been one of the most common means of infection for infants who come into the world healthy, despite being born to afflicted mothers. Having avoided infection in the womb or while emerging through the birth canal, these babies have been immediately and exclusively put on formula.

Studies of HIV-positive women have shown that if the mothers are given a four to five week course of the anti-retroviral drug AZT and provided with safe alternatives to breast milk, the risk of mother-to-child transmission can be reduced by half, from around 18 per cent to 9 per cent.

Further, the largest clinical trial ever undertaken in the area of transmission during birth or in the womb concluded the risk of infants becoming infected can be reduced by 37 per cent if women are given anti-retroviral drugs at the time of delivery. With no anti-retroviral drugs, there is a 20 per cent risk of the mother passing on the virus at birth.

These findings prompted UNAIDS, UNICEF and the World Health Organization, two years ago, to negotiate with pharmaceutical companies for the donation of anti-retroviral drugs that are now propelling health projects for pregnant women in 11 pilot countries.

It was one of the few feel-good breakthroughs in the global HIV/AIDS crisis. And in affluent Western countries, where cost is not a problem and proper health coverage exists, mother-to-child transmission has been largely eradicated.

That's not the case in Africa, Eastern Europe, South and Central America or Asia, where breastfeeding (or a combination of breastfeeding and formula) is the cultural norm and where drugs are out of reach for impoverished women.

The pro-formula undertaking in Third World countries, in this era of AIDS, has also reversed the impetus of all those years that health-care workers and feminists fought against the multinational baby formula producers. Those companies had weaned poor mothers away from their own milk - by offering free samples - even though the women were routinely mixing the formulas improperly or used contaminated water, thus spreading illness.

Mother's milk was good. Mother's milk was healthy.

But not, alas, if mother had HIV. That was the consensus, until now.

"Breastfeeding now lies in a conundrum of complexity,'' said Isabelle de Zoysa, who moderated yesterday's debate. "There has been an intensive public health effort to promote and protect breastfeeding. Now our hard-achieved efforts are threatened by HIV and AIDS.

"Affluent women can safely turn to other forms of feedings. But poor women are expected to make difficult choices in deciding how to feed their infants. The science here is evolving and the choices are wrenching.''

Coutsoudis, a scientist with the Department of Pediatrics at the University of Natal, conducted a trial involving 551 mother-and-child pairs. Of those, 157 were formula feeders, 118 were breastfeeders and 276 mixed both.

The women and babies were tracked over a two-year period, but exclusive breastfeeding ceased when the infants reached about six months. This is the customary age when mothers who breastfeed begin feeding their babies other liquid nourishment or solid food.

Coutsoudis said her study showed a 44 per cent reduction in transmission among women who breastfed exclusively for six months, even though the mothers had HIV and were not taking drugs.

`Breastfeeding now lies in a conundrum of complexity'

But infection among those babies jumped once other food was introduced to the babies' diet. She suggested the introduction of "allergy or contaminants'' created a more fertile environment in the infant's system for the HIV virus to take hold, perhaps supplanting whatever natural immunity existed.

It was left to Dr. M. G. Fowler, from the Centres for Disease Control and Prevention in Atlanta, to carry the other side of the debate: the predominant anti-breastfeeding view for infected mothers.

"Anna's findings are very compelling but the study was quite limited. We just don't know enough yet,'' she said.

"I am very much in favour of breastfeeding, in general. But with HIV-infected mothers, we shouldn't let our hearts lead us with dogma.''