ted with a three- to fourfold decreased risk of HIV transmission compared to infants who were breastfed and also received other milks or foods.
Instrumental in guiding the new recommendations were two major African studies that announced their findings in July 2009 at the fifth International AIDS Society conference in Cape Town. The WHO-led Kesho Bora study found that giving HIV-positive mothers a combination of antiretrovirals during pregnancy, delivery and breastfeeding reduced the risk of HIV transmission to infants by 42%. The Breastfeeding Antiretroviral and Nutrition study held in Malawi also showed a risk of HIV transmission reduced to just 1.8% for infants given the antiretroviral drug nevirapine daily while breastfeeding for 6 months.
In spite of these findings it will be a challenge to change the ingrained culture of formula feeding in South Africa. Existing attitudes have been influenced by the country’s high HIV-prevalence – 18% of the adult population is HIV positive, according to 2008 estimates from the Joint United Nations Programme on HIV/AIDS. The 2003 South African Demographic Health Survey found that fewer than 12% of infants are exclusively breastfed during their first three months and this drops to 1.5% for infants aged between three and six months.
Some health workers themselves are yet to be convinced of the benefits of breastfeeding, even for mothers who aren’t HIV positive. “There exists the general idea that it is not important, that there is no critical reason to breastfeed, especially when you can formula feed,” says Linda Glynn, breastfeeding consultant at Mowbray Maternity Hospital in Cape Town. “Some [health workers] think breastfeeding is a waste of time and an inconvenience.” Yet, the risks of not breastfeeding often go unrecognized. Most children born to HIV-positive mothers and raised on formula do not die of AIDS but of under-nourishment, diarrhoea, pneumonia and other causes not related to HIV. Breastfeeding not only provides babies with the nutrients they need for optimal development but also gives babies the antibodies they need to protect them against some of these common but deadly illnesses.
WHO recommends that all mothers, regardless of their HIV status, practise exclusive breastfeeding – which means no other liquids or food are given – in the first six months. After six months, the baby should start on complementary foods. Mothers who are not infected with HIV should breastfeed until the infant is two years or older.
Penny Reimers, of the Department of Nursing at Durban University of Technology, says the greatest declines in breastfeeding have taken place in countries where formula milk has been distributed at no cost, South Africa being a prime example. Infant formula was distributed by national and local authorities and by local nongovernmental organizations to prevent the transmission of HIV from mother-to-child, an initiative which inevitably undermined breastfeeding. An unforeseen consequence of the campaign was that even mothers who were not HIV positive turned to formula, says Reimers.
One reason for the switch was a belief that formula was in some way superior to breast milk, a perception that Coutsoudis believes derives, at least in part, from “strong and dishonest” marketing campaigns that make unfounded claims that the formula milk contains special ingredients that improve baby’s health. “Mothers are not told the truth, that breast milk is infinitely better [for the infant] and that formula milk can be dangerous; that it is not always a sterile product and is easily contaminated,” Coutsoudis says.
But even without formula producers’ marketing campaigns, other pressures are at work. One is the changing role of women in South African society. More women are in paid work than 20 years ago and many struggle to fit breastfeeding into their routines. When Pato Banzi, an administration officer at the Magistrates’ Court in Wynberg, Cape Town, had her second son she was granted four months’ maternity leave in accordance with South African labour law, but then struggled when t