HIV and Infant Feeding:
New UN policies raise critical issues

WHO, UNAIDS, UNICEF Guidelines on HIV and Infant Feeding(1), the long-awaited three part guide for health practitioners and policy makers, has finally been released. Although the report is timely and it is recognized that carefully thought out policies and practices need to be there for those faced with the dilemma of the AIDS epidemic, the recommendations raise a number of important questions. These include the rights of the HIV positive mother and the donation of formula in environments where the use of artificial feeding may actually increase mortality risk beyond the risk presented by HIV.

As a policy document, HIV and Infant Feeding has as its central objective the prevention of vertical transmission of HIV while continuing to protect, promote and support breastfeeding. The objectives are:

• Breastfeeding remains the most important means to feed infants.
• The human rights of the child are central to decisions made regarding treatment and feeding.
• Preventing the transmission of HIV to women of childbearing age is of high priority.

HIV and mother-to-child transmission
Even though considerable variation exists in reported rates, analysis of reports conclude that the highest rate of transmission is in Africa, 20-42%, and lower in Europe and North America at 14-24%. Transmission during pregnancy: mother-to-child transmission rates are estimated at 15 to 25% in industrialized countries and 25-45% in developing countries. The majority of HIV positive infants -- approximately two thirds -- become infected via the placenta or during delivery and possibly one third through breastfeeding.

Infant feeding options
A number of infant feeding options are suggested by the report. Although breastfeeding is normally the best way to feed babies, “however if a mother is infected with HIV, it may be preferable to replace breastmilk to reduce the risk of HIV transmission to her infant”, the report suggests. Considerations such as the infants nutritional requirements, risks of contamination when formulas are used, increased risk of death due to diarrhea, as well as cost of artificial feeding, losses in fertility protection, the loss of optimal mother-infant bonding and the social cultural patterns of breastfeeding need to be taken into account.

For those under six months, the guidelines lists a number of breastmilk substitutes -- commercial infant formulas, home-prepared formulas, modified animal milks, dried milk powder, evaporated milk and unmodified cow’s milk. Options for the infant to receive breastmik are also listed – early cessation of breastfeeding, expressed and heat-treated breastmilk, banked breastmilk and wet-nursing.

Free or subsidized formula
The recommendation that national authorities -- governments – negotiate with the formula industry to make breastmilk substitutes available at subsidized costs or free of charge is where the UN guidelines become controversial. The report defends this position on the basis that it is sustainable, does not create a dependency, does not undermine breastfeeding for the majority, does not promote breastmilk substitutes to the general public, and assures adequate supplies for the duration needed.

Organizations working on the protection of breastfeeding have not seen fit to endorse the UN report and have raised questions ralating to the practical aspects of ensuring safety.

What are the problems
A major problem is the use of artificial feeding products in areas of the world where conditions are contraindicated for their safe use. The risk of transmission of HIV through breastmilk is relatively small and one cannot predict who will become infected with the virus and who will not, yet the blanket recommendation to provide free formula to HIV positive mothers will most certainly increase the mortality rate due to diarrheal and other infectious diseases. This additional health care responsibility of sicker and dying babies will be yet another burden on severely inadequate health care services in areas where HIV is endemic. Replacement feeding has its place, when reliable testing and counselling is available, but must be used with utmost discretion. Formula must not be seen as the champion of this tragedy. According to the same UN agencies, formulas and breastmilk substitutes are responsible for 1.5 million infant deaths per year.

Why are UN agencies supporting formula procurement procedures instead of placing increased emphasis on prevention measures for women of childbearing age? The portrayal of providing free formula as the solution to decreasing the mother-to-child transmission is a subtle and dangerous message by the UN about the safety of infant formula.

Will mothers who receive the “free” formula be stigmatized as being HIV positive? Will a mother’s confidentiality be compromised when she is given UN formula to feed her child? What about the needs of the mother? Putting the emphasis on “saving” her child reduces the emphasis on preventing transmission to the mother in the first place. Or is it just easier for the UN to tackle breastfeeeding than the more difficult prevention through sexual contact?

More research should be placed into alternatives to breastmilk such as limited breastfeeding; heat treatment of expressed breastmilk, banked breastmilk and wet nursing by adequately screened mothers. Infant formula is the least desirable of all the infant feeding options available to poor countries with poor mothers. Research is also needed to determine the impact of strictly defined exclusive breastfeeding compared to the usual mixed feeding that may be practised.

Global priorities need to shift so that adequate resources are available to deal with this epidemic in an equitable and humane manner. Europeans spend $11 billion on ice cream and $50 billion on cigarettes annually. Pet food expenditures in Europe and the United States are $17 billion per year. Globally $400 billion are spent on narcotic drugs and military spending is $780 billion annually.

References
1 UNICEF, UNAIDS, WHO. HIV and Infant Feeding. WHO, Geneva 1998 BACK