Document:HIV and Breastfeeding
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Teresa Hansen, HIV-positive, and mother of two who lives near Los Angeles, came home one day to find social workers from the Bureau of Child and Family Services (CFS) waiting for her. An anonymous caller, who Hansen suspects was either her estranged husband or else his family, had informed CFS that Hansen, despite being HIV positive, was breastfeeding her child.
"They told me I had two choices," Hansen recalls. "Either I could go with them and get myself and the baby tested right away, or they would take the baby with them. It was very threatening."
Needless to say, she went along. She left her elder daughter, who is HIV-negative, with a neighbor, and got into the car with the CFS officials. On the way to the testing site, the officials stopped at a supermarket to buy infant formula, demanding that Hansen cease breastfeeding her child then and there. They told her that many studies had shown that HIV can transmit via breastfeeding.
As a conscientious woman who had delivered both of her children at home and describes herself as "very healthy," Hansen was appalled when she read the label. "It was nothing but sugar and corn syrup. That's supposed to keep a baby healthy?"
When the results came back, both Hansen (who at one time had seroreverted to negative) and the baby tested positive for HIV, although the little girl was tested only with an extremely unreliable version of the AIDS test. From that point on, Hansen found herself being cornered by the very social-services infrastructure that was supposedly there to protect her. Her ex-husband, Jack, who remained staunchly orthodox in his views on HIV, AIDS, and medication, took her to court, arguing that Hansen was "in denial" of her illness and hence a dangerous mother. The judge eventually told Hansen she had to put the child on AZT or lose custody. (Jack, who had been taking several HIV medications, died last year.)
But Hansen had little faith in AZT, believing instead that good health requires eating well and avoiding most contaminants, including drugs. For her, breastfeeding represented an extremely crucial element in bolstering her child's immunity, regardless of her HIV status. So she continues to breastfeed secretly (which is why she wished that her real name be withheld), hiding it even from her older daughter, who is occasionally questioned about her mother's activities. "This is all so surreal," says Hansen. "They keep calling me, telling me that they're only here to 'help' me, that I need to plan a will, and all this. I'm perfectly fine."
Protection, intervention, and treatment efforts aimed at beating back HIV have grown much more intensive over the years, culminating today in a barrage of new, high-tech drugs – often as many as eight at one time – that are euphemistically called "cocktails." At the same time, in the name of fighting HIV, several long-established medical practices have been disregarded, chief among them the once-sacrosanct practice of withholding virtually any drug from a woman during her pregnancy. The standard prescription now for a pregnant HIV-positive woman is to take AZT throughout her pregnancy, and to bottle-feed her baby afterward. Some doctors casually claim that "studies have shown" the HIV virus to be transmissible via breastmilk, but this is by no means clear.
The Joint United Nations Program on HIV/AIDS (UNAIDS) claims that 20 percent of babies born to HIV-positive mothers become infected during pregnancy and delivery, while about 14 percent become infected during breastfeeding. Worldwide, it estimates, 300 children are infected each day through breastfeeding, a figure that represents about 20 percent of the 1,500 children infected each day with HIV. 
But if 1,500 children per day are said to be infected with HIV, 33,000 children under the age of five die each day from preventable diseases and malnutrition, "against which breastfeeding can provide an essential defense," according to the International Lactation Consultants Association's Position Statement on this subject.  For mothers and babies in developing countries, breastmilk is not a lifestyle choice, but the difference between life and death.
For this reason, the World Health Organization (WHO) and UNICEF have consistently and strongly recommended breastfeeding in the Third World, even for HIV-positive women, as a first line of immune defense against the scores of health problems and diseases that ravage those populations. WHO recommends that all babies be breastfed for at least two years.
But in a major reversal of its previous position, UNICEF earlier this year announced that it was beginning a new, "stepped-up drive to prevent HIV-AIDS in children," explaining that the agency would henceforth distribute AZT to pregnant women in developing countries and call for access to "safe alternatives" to breastfeeding.  The disadvantages of formula are described in terms of cost, not health.
"The position of UNICEF now is that we want to help HIV-positive women find viable, safe alternatives to breastfeeding," says UNICEF Communications Officer Wing-Sie Cheng.
But, of course, such advice raises the specter of the tragedies of the 1960s, when hundreds of thousands of infants across the equatorial belt died from over-diluted formula made with unsterilized water.  "Potentially [that] could happen again," Cheng admits, "which is why we're treading very carefully. There are just so many variables you have to consider. You especially have to take a look at the surroundings to see whether formula feeding is really feasible; it's not just a question of making it available."
In fact, approximately 52 percent of sub-Saharan Africans have no access to safe water today and 62 percent have no proper sanitation – making formula preparation impossible. Meanwhile, an estimated 50 million preschool children suffer from debilitating protein- energy malnutrition.  WHO has estimated that increasing breastfeeding in these nations could help to prevent as many as 1.5 million children's deaths every year. 
I mention these statistics to Cheng, adding that there seems no doubt that breastfeeding provides an essential defense against malnutrition and disease, especially in much of the Third World. "Definitely," she responds. "Which is why there is such an urgency to come up with AZT, to really try to reduce the risk of HIV transmission to babies."
In other words, a drug (AZT), which can actually impair immunity, will be given to combat a virus (HIV) that has never been proven to destroy immunity, and then finally, the very source of immunity that nature has provided (breastmilk) will be discouraged.
Breastmilk – and this much is not in question – contains a complex mix of nutrients specifically tailored for the developing baby. It contains innumerable vital growth factors, as well as antibodies that can help to fight off infections. In short, breastmilk simply is the perfect food for babies. In December 1997, the American Academy of Pediatrics issued sweeping guidelines stressing breastmilk as the foundation of proper infant nutrition.  "Increasing both the rate of mothers' breastfeeding initiation and the duration should be a national health objective," emphasizes Ruth A. Lawrence, MD, one of the authors of the AAP's position paper. As more information about the countless benefits of breastfeeding is disseminated, the number of mothers who initiate breastfeeding at birth in the US keeps growing, reaching an all-time high this year of 62.4 percent. 
It is highly ironic, therefore, that in AIDS – a condition of severely impaired immunity – women should be advised against breastfeeding. The rationale, of course, is that nothing impairs the human immune system like the HIV virus. Leaving aside the substantial question of whether HIV does, in fact, destroy the immune system, what is the evidence that it transmits via breastmilk?
"There is no proof that HIV exists in breastmilk. It has not, to my knowledge, ever been isolated in breastmilk," says Professor Gordon Stewart, the Emeritus Professor of Public Health at the University of Glasgow and a former consultant to WHO. "I'm quite sure that under present circumstances in Third World countries affected by AIDS, the withdrawal of breastfeeding is a much greater danger to newborns and infants than is the risk of AIDS." 
Stewart adds, "AZT is also more likely to be toxic to a woman when she is pregnant because many women experience elevated blood pressure during pregnancy, which then can interfere with kidney function. Hence, the toxicity [of AZT] rises and, of course, the baby gets whatever the mother gets."
"There are seldom infectious levels of HIV in semen, much less in breastmilk," concurs Dr. David Rasnick, a protease developer and chemist who also doubts many of the claims made about the HIV virus. He's referring to the relatively unknown fact that in some of the studies, infectious HIV appeared in the semen of only about 25 percent of HIV-infected men." 
"It is impossible to be certain if transmission of AIDS is prenatal, in utero, postpartum, or via breastmilk," says Naomi Baumslag, MD, MPH, the author of Money, Milk and Madness. "While there are a very few reported cases of HIV transmission through breastmilk, it has not been absolutely proven. Studies may eventually even show that exclusive breastfeeding is protective against AIDS."
La Leche League (LLL), the 42-year old international breastfeeding-support organization has tried to combat the new zeal to stop all HIV-positive women from breastfeeding their young children. Although LLL's stance is that the transmission of HIV is of concern, a June press release from the group also urges restraint and caution. "Some researchers," LLL's recent statement says, "have isolated HIV in human milk... Yet other studies have not shown there to be a very high risk of transmission through breastfeeding."  The statement points out, too, that many studies have not differentiated between viral fragments of HIV and intact HIV virus within the cells in milk; only the latter type could replicate and therefore be considered infectious. The press release concludes that some recent research has shown breastmilk to actually help slow the progression of the disease in babies who are born positive.
This last action – breastmilk's possible ability to combat HIV – obviously requires more study but it is also extraordinarily intriguing. In some preliminary studies, certain materials in human milk clearly helped to protect against infection.  The most convincing evidence came in a trial during which substances in breastmilk inhibited the binding of an HIV protein to its host cell receptor, an essential first step in HIV infection.  In another study, this one from Zaire, exclusive breastfeeding by HIV-positive mothers played a significant role in decreasing overall infant mortality. 
So, should HIV-positive women be breastfeeding? "I think ultimately it may depend on the individual situation," says Marion Banzhaf, who does health training and consulting for women with HIV. "If a woman had an undetectable viral load, I could see her wanting to breastfeed. What is really needed for women who are HIV-positive, " Banzhaf adds, "is the ability to look at all the information and do her own risk-benefit analysis."
Until AIDS came along, the battlelines were starkly drawn between breastfeeding advocates – including UNICEF and other aid agencies – and formula manufacturers who aggressively marketed their products in the Third World. But now the lines are far more muddled, since the global HIV-prevention community tends to align itself with any measure currently believed to help combat HIV, including restrictions on breastfeeding.
"The idea that giving babies formula can solve the problem of AIDS is like using a Band-Aid against cancer," Baumslag says. "Formula feeding has terrible consequences for most children. Many more infants worldwide die of diarrheal dehydration than of AIDS."
Yet for the foreseeable future, the push to reduce breastfeeding and increase AZT use among all HIV-positive women is likely only to increase. In part this is because limited medical resources mean doctors in the Third World rely on notoriously unreliable – but cheap – forms of HIV testing, which can produce huge numbers of false positives. In one study done at a hospital in Ghana, more than 60 percent of a group who initially tested positive were later found to be in fact negative. 
"There are some very complex, unresolved issues at the center of the HIV and breastfeeding protocol," warns Mary Lofton, Public Relations Manager for LLL.
Dr. Baumslag echoes her concern. "So many essential research questions remain unanswered," she says. "Can HIV be transmitted through breastfeeding? If so, how often and by what mechanism? Does maternal malnutrition play a role? What about micronutrient status, levels of vitamin A, and other nutritional factors? Do infant characteristics such as prematurity matter? Can breastfeeding significantly benefit the HIV-positive infant? And does lactation at all affect the health of the HIV-positive woman?"
Until these and other questions are answered, the rush to judgment that discourages, even prohibits breastfeeding, could be responsible for killing more babies than are saved.
- ↑ HIV and Infant Feeding. An Interim Statement, UNAIDS. July 1996, n. 1-3.
- ↑ Position on the Issue of HIV and Infant Feeding, International Lactation Consultant Association, 1997.
- ↑ UNICEF press release, March 26, 1998.
- ↑ D. B. Jelliffe, and E. F. P. Jelliffe, Human Milk in the Modern World (Oxford, England: Oxford University Press, 1978).
- ↑ C. Geshekter, "A Good Turn for Africa, Please", The Lancet (January 11, 1997): 69.
- ↑ UNICEF, The Progress of Nations, 1997. See Mothering, May-June, 70.
- ↑ "Breastfeeding and the Use of Human Milk", Pediatrics 100, no. 6 (December 1997).
- ↑ "Breastfeeding Trend Is Upward Bound," La Leche League International press release, Ross Mothers' Survey, Ross Products Division, Abbott Laboratories, June 15, 1998.
- ↑ E. Papadopulos-Eleopulos et al., "HIV Antibodies: Further Questions and a Plea for Clarification", Current Medical Research and Opinion 13 627-634.
- ↑ Bradley J. Van Voorhis et al., "Detection of Human Immunodeficiency Type I Virus in Semen from Seropositive Men Using Culture and Polymerase Chain Reaction Deoxyribonucleic Acid Amplification Techniques", Fertility and Sterility 56, no. 3 (March 1991) 588-595.
- ↑ Ruth A. Lawrence, MD, Breastfeeding: A Guide for the Medical Profession (St. Louis, MO: Mosby-Year Book, October 1998).
- ↑ D. S. Newburg and J. M. Street, "Bioactive Materials in Human Milk: Milk Sugars Sweeter the Argument for Breastfeeding", Nutr Today 32, no. 5: 191-201.
- ↑ D. S. Newburg et al., "Human Milk Glycosaminoglycans Inhibit HIV Glycoprotein gp120 Binding to Its Host Cell CD4 Receptor", J Nutr 125 419-424.
- ↑ R. W. Ryder et al., "Evidence from Zaire that Breastfeeding by HIV-1-seropositive Mothers Is Not a Major Route for Perinatal HIV-1 Transmission but Does Decrease Morbidity", AIDS 5, no. 6: 709-714.
- ↑ 0. Hishida et al., "Clinically Diagnosed AIDS Cases Without Evident Association with HIV Type 1 and 2 Infection in Ghana", The Lancet 340 (1992): 971-972.