Saviours or culprits? HIV, infant feeding, and commercial interests Tessa Martyn, Health Campaigns Coordinator, Baby Milk Action This article appeared in The Health Exchange, April 2001, magazine of The International Health Exchange (info@ihe.org.uk). "Breastfeeding carries risk of HIV" the headlines shout. The 'era' of HIV has now cast doubt on the suitability of what for centuries has been a life-saving normal physiological process - breastfeeding. Breastfeeding provides infants with the best immunological and nutritional start in life - something which a 'dead' or inert substance like artificial baby milk just cannot do. The first reports of transmission of HIV through breastfeeding appeared in 1985. This information was based on case studies involving 3 women . It was years later before a randomised controlled trial or prospective cohort study confirmed this. As early as 1989 baby milk companies started undermining breastfeeding with the assumption that mothers who tested HIV positive should not breastfeed. For example, in 1989, NestlŽ representatives, in a talk to school children, said that up to 50 % of women in Africa should not breastfeed because they were infected with HIV. Later in 1992 the umbrella organisation for the artificial baby milk companies (the IFM) told delegates at the World Health Assembly that mothers could not breastfeed if they tested positive for HIV. This was despite promises they made not to exploit the HIV crisis . Protectors or profiteers? For the artificial baby milk companies the link between HIV and breastfeeding created an important opportunity to reposition themselves as 'savours' rather than 'culprits' in the baby milk issue. They now had the chance to expand their existing markets in traditionally breastfeeding cultures. Artificial baby milk companies (and drug and other companies who have a vested interest in promoting the HIV 'market') have been offering donations of products and services to NGOs to use in programmes to reduce transmission, and at the same time lobbying governments to weaken legislation concerning the marketing of breastmilk substitutes. While many agencies, desperate to halt the pandemic, have jumped at such offers, important factors have been ignored or pushed aside. Firstly, HIV aside, not a single study has shown artificial baby milks to be superior to breastmilk in terms of morbidity or mortality. For example, the relative risk of death from diarrhoea for non-breastfed infants in resource-poor areas is known to be significantly higher than for exclusively breastfed infants. A recent analysis by WHO shows that infants who are not breastfed have a 6-fold greater risk of dying from infectious diseases in the first 2 months of life than those who are breastfed . UNICEF estimates that in the last 20 years up to 1.7 million children may have contracted HIV through breastfeeding ; disturbing figures undoubtedly. But, during this same period of time 30 million children have died because they were not breastfed . (At this point perhaps it is wise to remember that even in countries where conditions for artificial feeding are optimal there are numerous health disadvantages associated with artificial feeding.) Secondly, the very same companies who are trying to promote their products as the solution to HIV transmission are those who have taken out patents on certain components of breastmilk, such as lactoferrin, because it is known to have anti-viral properties which denature HIV. In recent years even more discoveries have been made about the rich make-up of breastmilk. For example, it is now known that breastmilk comprises proteins (called lysozymes) which destroy HIV. The researcher in this particular study even speculated that pregnancy prompts a woman's body to make more virus-killing proteins in order to protect her developing infant . The Coutsoudis study In August 1999 ground-breaking research by Anna Coutsoudis and her team in South Africa was published (ref 1). Her research, a prospective cohort study, found that those mothers who exclusively breastfed their infants had no higher rates of transmission than those infants who were artificially fed. This was crucial as it was the first time researchers had looked at the effect of exclusive breastfeeding. Previous studies had used the term breastfeeding to mean mothers who mainly breastfed but may also have used water, teas, other milks and foods. Coutsoudis (along with other researchers) found that mixed feeding, ie partial breastfeeding and the inclusion of other substances in the infants diet, gave rise to the highest rates of transmission. As Coutsoudis noted, the reason for the protective effect of exclusive breastfeeding, and the increased rates in mixed fed infants may be due to "ingestion of contaminated water, fluids, and food may lead to gut mucosal injury and disruption of immune barriers". Prior to this new research it was estimated that approximately 15% of infants of HIV positive mothers were at risk of contracting HIV through breastfeeding ; so, even in an area with a relatively high HIV prevalence of 20%, within a population of 100 mothers and infants only 2 or 3 will be at risk of contracting HIV through breastfeeding. 97 will not. If these women exclusively breastfed this rate would be even lower. In February 2001 the results of Coutsoudis's follow up study were published (ref 2). This clearly showed that "infants exclusively breastfed for 3 months or more had no excess risk of HIV infection over 6 months than those never breastfed". There is an urgent need for more research (independent of company interests) to look at the effect of exclusive breastfeeding. If Coutsoudis's findings are replicated, then the consequences for all are enormous. Even now policy makers should re-examine policies which advocate artificial feeding, especially in resource poor settings, and see if instead support can be given for exclusive breastfeeding. In settings where breastfeeding is already the norm it is surely easier to continue to promote breastfeeding but with an emphasis on exclusive breastfeeding, rather than to re-educate whole populations about artificial feeding, especially if it is to be exclusive (ref 3). Advocating artificial feeding is fraught with difficulties: who will supply the safe water? Who will pick up the health care costs for treatment of diarrhoea and other diseases? How will the woman explain to her family why she is not breastfeeding? How will she afford the powdered milk? How will she store it safely? How easily will she be able to stop herself from nursing her child in the night? Programmes promoting artificial feeding have gone ahead long before solutions to these problems have been found. Inform and support Of crucial importance is that in all further research the health outcomes of the infants is monitored - not just their HIV status. A study by Nduati found that mortality rates at two years of age were similar for all infants of infected mothers, regardless of how they were fed. Health workers have a responsibility to inform women of the social, economic and health advantages and disadvantages of different feeding methods, including both exclusive breastfeeding and artificial feeding. For example, perhaps it is no longer correct (if it was ever) to say 'breastfeeding transmits the virus'. Partial, or non-exclusive breastfeeding may transmit the virus. We should now say 'for infants of mothers diagnosed HIV positive exclusive breastfeeding can offer as much protection, possibly more, than artificial feeding'. Health workers are in the key position of guiding women to making a decision which will be the most suitable for them; but all women should be supported in their chosen method of infant feeding. Infant feeding decisions should not be influenced by commercial considerations, particularly those made by women infected with HIV. Baby milk companies should not advise, or have contact with, mothers. The aim of the WHO International Code of Marketing of Breastmilk Substitutes and subsequent Resolutions is to ensure that mothers receive only objective and sound information - not advertising from companies. The Code allows for breastmilk substitutes to be used as and when appropriate. Indeed, both WHO and UNICEF have called for a greater compliance with this Code in the HIV 'era' The subject of HIV and infant feeding is complex, as is the dilemma it poses. This article has touched on only a fraction of the issues involved, but it has suggested that the most affordable and culturally appropriate solution may also give rise to the best health outcomes. References 1. Coutsoudis, A., et al (1999). 'Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study.' The Lancet 354 (471-476). (Available on http://www.thelancet.com/ - register and search for Coutsoudis to find the paper). 2. Coutsoudis, A., et al (2001). 'Method of feeding and transmission of HIV-1 from mos to children by 15 months of age: prospective cohort study from Durban, South Africa.' AIDS 15 (379-387). 3. Haider, R., et al (2000). 'Effects of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised, controlled trial.' The Lancet 356 (1643-1647).