Feature

Mothers in need of courage

HIV-infected women face a grim dilemma in deciding whether to breastfeed, report Rosemary Okello and Felicity Snowsill

A short-course AZT drug therapy that reduces mother-to-baby transmission of HIV by 51 percent has been hailed as a medical breakthrough in the protection of infant health, particularly in Africa and Asia. And the announcement that the pharmaceutical giant Glaxo Wellcome intends to reduce the cost of AZT to approximately $50 per application in developing countries may help bridge the gulf between the haves and the have-nots — the so-called treatment gap. But controversy surrounds advice to HIV-positive mothers not to breastfeed their infants.

The short-course therapy was announced in March after a study conducted in Bangkok under the auspices of the Joint UN Programme on HIV/AIDS (UNAIDS), the Thailand Ministry of Health and the US Centre for Disease Control. Treatment consisted of oral doses of AZT given to a group of pregnant women with HIV.

AZT treatment is not new. Pregnant HIV-positive women and their new-borns in Western countries have been routinely offered AZT since 1994. The drug, when administered intravenously over many weeks, reduces mother-to-baby transmission rates by 68 percent.

Until now, women in poor countries did not have this option. The cost of AZT treatment for mother and baby is about $1,000 — far beyond the resources of developing countries with health budgets of less than $10 per capita. And the fact that it needed to be administered intravenously under regular supervision made it inappropriate for local conditions.

However, a critical — and controversial — component of the therapy’s success, according to researchers, is advising HIV-infected mothers not to breastfeed. The Thai participants gave their babies artificial milk substitutes to prevent HIV transmission through breastfeeding.

Data from developing countries indicate that up to half of all mother-to-child HIV transmission is due to breastfeeding. And international efforts to find a treatment were spurred on by the grim prediction that AIDS may increase infant mortality by as much as 75 percent and under-five mortality by more than 100 percent in the worst-affected regions by the year 2010.

Breastfeeding advocates have an equally grim warning: if African mothers stop natural feeding, the death rate in under-fives could more than double. Breastfeeding is one of Africa’s success stories — its widespread promotion saves infant lives, providing vital protection against deadly childhood illnesses like diarrhoea and respiratory ailments which are far more common than HIV.

For women to switch from breast to bottle is no academic question in African countries where the cost of infant formula is prohibitive and access to clean water lacking. Breastfeeding advocates in Zimbabwe estimate that the cost of providing enough of the very cheapest formula to feed one baby for a year is more than Z$2,500.

Because of such realities — and in the absence of treatment — international health agencies initially advised that women breastfeed regardless of their HIV status, particularly in Sub-Saharan Africa and other regions where childhood infectious diseases are common and HIV testing unavailable.

But following the Thai study, new guidelines on infant feeding for policy makers and health care managers have been issued in April, according to Dr Isobelle De Vincenzi of UNAIDS.

‘It is now recommended that HIV-positive women should make an informed choice on infant feeding on an individual basis, and be supported in their choice,’ De Vincenzi told Panos. ‘However there should be strong promotion of breastfeeding for women who are not HIV-positive and do not know their status for sure,’ she added.

UNAIDS will promote confidential HIV testing and counselling for women, and the use of short-term AZT. Women will be advised to use replacement feeding since breastfeeding may significantly reduce the efficacy of the short AZT regime. And ‘treatment will not be withheld to women if they choose to breastfeed,’ De Vincenzi added.

The experience of Kenyan mother Naomi Atieno (not her real name) is typical of how many women discover they are infected, and the often conflicting advice they receive about infant feeding before and after their HIV status is confirmed.

Atieno only learned she carried the virus when her sickly nine-month-old-daughter was found to be HIV-positive. She then received a double blow: clinic workers, who had earlier advised her to breastfeed to ensure her baby’s health, now told her that she had infected the child through breastfeeding and she should switch to baby milk, which she cannot afford.

Confusion over infant care is widespread. But as early as 1996, advocacy groups like Zimbabwe’s Women and AIDS Support Network were questioning the presumption that women could only ‘handle a single message’ regarding HIV and child feeding practices.

Lynde Francis of The Centre, a Harare-based organisation providing information, support and counselling for people living with HIV/AIDS, believes that blanket statements that ignore individual situations are ‘patronising.’ But, she says, fears that breastfeeding will now be abandoned are unfounded.

The Centre’s client Sipho confirms this: ‘If you are told that breastfeeding may pass the virus on to your child, and you are told ways to feed that child to reduce risk, it gives you courage as a mother.’

How baby milk companies will react to the new guidelines is as yet unknown. Tessa Martyn of UK Baby Milk Action is worried. ‘There are signs that the commercial baby milk companies are waiting to jump on the bandwagon, and are using the HIV/breastfeeding debate to promote their products,’ she says.

Perhaps anticipating the many unresolved issues, UNAIDS Executive Director Dr Peter Piot told the press earlier this year that delay in implementing the new drug therapy can only lead to ‘significant deterioration. The question is no longer when or if we should act, but simply how,’ he said.

© Panos Features: www.oneworld.org/panos/