By Rupa Chinai

The Times of India 25 Jan. 2000

Mumbai -- In a striking change of position United Nations health agencies now uphold the role of "exclusive breast feeding" by HIV positive mothers. They also advocate the need to "protect, promote and support in all populations irrespective of HIV prevalence". Earlier, these same agencies had been against such breast feeding by HIV positive mothers.

The policy directive, reaffirmed in the in the 'program instructions' of UNAIDS, dated November 23, 1999, and supported by WHO and UNICZEF, is likely to clarify the prevailing confusion on this issue with in the medical community in cities like Mumbai. According to UNICEF's project officer (health in Mumbai, Dr Prakash Gurnani the need to emphasise the importance of 'exclusive breast feeding' by all mothers, including those who have tested HIV positive, is based on the findings of a recent study conducted in Durban, South Africa, and considered to be a 'landmark'. (Exclusive breast feeding implies that a baby is fed nothing but mother's milk in its first three months.) Dr Gurnani says the Indian government is likely to accept the initial findings of the study in its own policy guidelines and initiate similar studies in India.

The Durban study, reported in the Lancet issue of August 7, 1999, indicates that 'exclusive breast feeding' reduces the risk of HIV transmission from the mother to the baby. According to the authors of that study, the widely held view that HIV transmission takes place through breast milk is based on "faulty analysis".

This analysis, they say, failed to take into account the effects of different types of breast feeding practices. Babies that received 'mixed breastfeeding' with or without water, other fluids and foods that might contaminate and injure the immature gastrointestinal tract are likely to suffer a higher incidence of HIV transmission compared to babies who were 'exclusively breast fed' for the first three months. The later were observed to have a significantly lower risk of HIV transmission.

Thus mother-to-child HIV transmission through breast milk is dependent on the pattern of breastfeeding, the authors of this study say. The virus acquired during delivery could have been neutralised by immune factors present in breast milk, but not when it is accompanied with formula feeds. Mixed feeding carries a high risk because the beneficial immune factors of breast milk are probably counteracted by damage to the infant's gut by contaminants in the mixed feeds.

The ingestion of contaminated water, fluids and food may lead to gut mucosal injury and a disruption of the immune barriers, they add. Since mixed feeding is unlikely to involve hygienic food preparation practices, bacteria and other contaminants may be introduced into the gut and result in inflammatory responses and subsequent damage to the mucose. HIV -1 is less likely to penetrate intact and healthy gastrointestinal mucose than damaged mucose.

Meanwhile, R.K Anand president of the Association for Consumers Action on Safety and Health, confirms the significance of studies indicating the need for exclusive breastfeeding. While clarifying that HIV transmission from the mother to the baby could occur during pregnancy, or at the time of delivery, or through breast feeding, he says, 'exclusive breastfeeding' carries a significantly lower risk of HIV transmission than mixed feeding.

According to Dr Anand, clinical studies have already shown that the lack of breast feeding in industrialised as well as non-industrialised countries result in significantly high mortality and morbidity, especially in relation to gastro-intestinal and respiratory infections.

Keeping these facts in mind, Dr Anand says that if the mother is HIV positive and formula feeding (artificial food) is not affordable and safe, ensuring exclusive breast feeding is required for about six months.

If the mother is HIV positive, has access to health care and can afford safe formula feeding, she can be helped to make an informed choice, Dr Anand says. If the mother choose to breast feed, current studies indicate that the infant should be exclusively given breast milk for three months and then switched over to formula feeding. Further studies are likely to confirm that breast feeding can be safely given for uo to six months, he adds.