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R.R.
Frerichs Posting
The breastfeeding debate has captured the attention of SEA-AIDS members,
similar to other groups in developing countries. The issue is, should
breastfeeding be discouraged among HIV infected women? While mother's milk is
important for the development of the offspring, as has been strongly encouraged
by agencies and experts alike, feeding milk contaminated with virus has a
counter price that all too often is met with death. But how often? This point is
addressed in an article published in the current Journal of the American Medical
Association (Vol. 282, pp. 744-749, August 25, 1999).
To address the breastfeeding issue, decision-makers need to know what
percentage of infants of HIV infected women become infected by breastmilk,
separate from infection coming from the blood of the mother during the
intrauterine or birth period. The authors of the JAMA study were able to make
such a determination. They did a prospective cohort study (i.e., followed a
group forward in time) in Malawi, Africa of 672 infants. This specially-selected
group was born to HIV infected women, but was free of apparent HIV during the
first weeks of life (i.e., all were at risk when breastfeeding got underway).
None of the women in this group had been treated with retroviral drugs during or
after pregnancy. After one month of being breast fed, 3.5% of the infants were
infected due to breastmilk. The cumulative percentage of being infected due to
breastmilk rose to 7.0% at the end of 11 months, and finally to 10.3% after 23
months of breastfeeding. These estimates are lower than the full impact of
breastfeeding since infants who were infected during the first few weeks of life
were excluded from the cohort. Nevertheless, they provide a clear picture of the
rising risk with time, as the duration of breastfeeding continues.
The Malawi results provide vital data for public health and medical
decision-makers and add to our current knowledge. Several years earlier,
investigators had summarized the findings of five studies in a meta-analysis.
They estimated that 14% of births to HIV infected women would become infected
through breastfeeding (The Lancet 1992;340585-588).
Missing at the local level throughout the developing world is information on
what happens to births of HIV infected women who are not breast fed. Some will
receive supplemental milk, as is done in Thailand. Others will try sugar water
or similar poor solutions, and face the risk of death from enteric pathogens.
Here more assistance is needed from SEA-AIDS members on low-cost, but healthy,
alternatives to breastfeeding for HIV infected women in Asia. What has been
tried in various countries of the region? What level of infection or infant
death has been associated with the alternative feeding schemes? How do these
negative health outcomes compare to the "HIV- due-to-breastfeeding"
percentages reported by the Malawi study?
Once such answers are known,
appropriate solutions will be easier to derive.
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