Breast is always best, even for HIV-positive mothers
Despite emerging evidence that HIV-positive mothers should breastfeed to maximize their babies’ health prospects, South African health workers face a battle to change attitudes and habits. Lungi Langa reports.
Breastfeeding may be natural, but it is not always simple. Professor Anna Coutsoudis, of the Department of Paediatrics and Child Health at the University of the KwaZulu-Natal, Durban, says the problem begins in the first weeks of breastfeeding. “Health-care providers lack the skills needed to offer support and advice,” she says. “So when problems arise – cracked nipples, babies won’t suck and babies don’t seem satisfied – the mothers get bad advice. Then when they become discouraged, they are told to stop breastfeeding altogether and to give artificial substitutes.”
If the mother is HIV positive, more uncertainty is added. “Some counsellors are themselves confused about what is correct practice regarding HIV and feeding practices,” says Thelma Raqa, an antenatal counsellor based in Mowbray Maternity Hospital in Cape Town.
Until recently, the World Health Organization (WHO) advised HIV-positive mothers to avoid breastfeeding if they were able to afford, prepare and store formula milk safely. But research has since emerged, particularly from South Africa, that shows that a combination of exclusive breastfeeding and the use of antiretroviral treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding.
On 30 November 2009, WHO released new recommendations on infant feeding by HIV-positive mothers, based on this new evidence. For the first time, WHO is recommending that HIV-positive mothers or their infants take antiretroviral drugs throughout the period of breastfeeding and until the infant is 12 months old. This means that the child can benefit from breastfeeding with very little risk of becoming infected with HIV.
Prior research had shown that exclusive breastfeeding in the first six months of an infant's life was associated 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 dev