HIV and breastfeeding: Another swing of the pendulum?
A report at the recent 14th Conference on Retroviruses and Opportunistic Infections (CROI) has generated a lot of attention under headlines like "Formula and death in Botswana" (UPI), "Anti-HIV Strategy Backfires in Botswana (ScienceNow), "Benefits of Breast-Feeding Might Outweigh Risk of Vertical HIV Transmission in Developing Countries, Studies Say" (KaiserNetwork.org), "Researchers urge mothers in Botswana to breast-feed" (San Francisco Chronicle). It seems a little odd me that this single report is being treated as such a surprise and as if it ought to change policies on HIV and breastfeeding.
The core of the story is that during a period of floods in Botswana, there was a large increase in diarrheal disease and mortality among formula-fed children. Formula feeding had been encouraged in HIV positive women. During the floods there were also local shortages of formula as supply lines were cut off.
It has been recognized all along that there is a balance of risks in the question of feeding of infants of HIV-infected mothers. HIV transmission via breast milk, originally thought to be rather uncommon, is now known to be a major risk. The benefits of breastfeeding are well-known. The safety of formula feeding, however, varies widely depending on the circumstances. In the worst case, formula feeding with contaminated water and insufficient quantity of formula (as in the Botswana floods) is obviously very dangerous. At the other extreme, with plentiful formula, clean water, and educated mothers, it is relatively safe. The hot question is, when is formula feeding safer than breastfeeding?
The existing guidelines are that formula feeding should be used only when it meets five criteria: acceptable, feasible, affordable, sustainable and safe. Naturally, each of these exist on a continuum and cannot be thought of as yes-no issues. However, they show that current standards demand contextualization of the decision rather than a one-size-fits-all recommendation for or against formula feeding.
The Botswana story shows, not surprisingly, that a natural disaster can swing the balance, at least temporarily. It shows that formula feeding is dangerous when there is no clean water and not enough formula. Should this prompt any major changes in policy? It is hard to see why it should. At most, the study reminds us that we need to be careful about assessment of the criteria, and consider the possibility that conditions will deteriorate, putting formula-fed infants at risk. The findings also demonstrate the importance of support for families feeding their babies formula.
If families at risk were all in the same environmental conditions, with the same educational and economic backgrounds, simple recommendations might make sense. However, conditions related to the five criteria vary drastically across Africa and within single countries, single cities or towns, and even within a single clinic or treatment program.
There are mothers who are bright, educated university graduates, and others who are uneducated and not-as-bright. There are mothers who are healthy and those who are in the last stages of AIDS. There are those on consistent antiretroviral therapy and those who have no access to it. There are locations with access to clean water, even for the poor, and there are those without. There are programs that can provide free formula and those that cannot. There are programs with counselors and volunteers who can support individual mothers and family units, and there are programs where little can be done individually. It seems ludicrous to ignore all these differences and to make a single recommendation for everyone.
Rather than advocating major changes of the already-nuanced guidelines, or that health officials "should strongly encourage breast-feeding into the second year of life for infants found to be HIV-infected," as one researcher is quoted as saying (New York Times), a practice known to carry a substantial risk of HIV-transmission, it might be more useful to put more effort into
- improving our ability to assess the risks and benefits in specific situations
- strengthening providers’ ability to individualize recommendations
- putting much more energy into making the formula feeding programs safer.
Of course, more fundamental solutions such as methods of blocking transmission in breast milk (HAART for the mother, immunizations for the baby, ART for the baby, etc.) are important in the long run, but are probably not widely applicable in the immediate future.
In summary, we need to remember that this is a complex issue that needs ongoing time, thought, and attention from policy makers and health care providers at all levels, (including community volunteers), not simply another swing of a monolithic pendulum.
Anti-HIV Strategy Backfires in Botswana. ScienceNOW Daily News, 26 Feb 2007.
Formula and death in Botswana. United Press International, 27 Feb 2007.
Scientists Urge New Look at Feeding in AIDS Fight. New York Times, 27 Feb 2007.