The nurturing act of breastfeeding may also expose an infant to HIV, the virus that causes AIDS. Yet despite the danger, HIV positive mothers are often reluctant to abandon the practice in favor of formula.
Health experts agree that breast milk is more nutritious than milk substitutes because it helps boost an infant’s immune system. That’s especially important in developing countries because it can help a newborn fight off infections and prevent malnutrition. But in this age of HIV/AIDS, the very means of helping a baby survive can also put it at risk.
So, what is a mother to do? Researchers at the Liverpool School of Tropical Medicine have found that the advice many African women are receiving may be impractical or confusing. Dr. James Bunn is a senior clinical lecturer who studied HIV positive mothers in Zambia.
Dr. Bunn, "Knowing what people are advised to do and knowing what they do in practice may be markedly different. And it’s actually very important to look at what mothers are actually doing rather than what we think they’re doing because of the advice we give them. And that’s really what the study has shown, that the expectation would have been mothers’ feeding practice would have been better following advice in a clinic and in fact was worse than mothers who had not got HIV."
It would appear logical that women would abandon breastfeeding in favor of formula if they were infected with HIV. However, the World Health Organization and UNICEF advise women in sub-Saharan Africa to breastfeed. For example, UNICEF says, “If all babies were fed only breast milk for the first six months of life, the lives of an estimated 1.5 million infants would be saved every year and the health and development of millions of others would be greatly improved.”
Dr. Bunn says following that advice carries a risk.
"Mothers with HIV have a risk of up to 40 percent transmission of the virus to their babies. And although much of that risk is around the time of delivery, a third to a half of infections occur through breast milk and feeding practices."
What’s more, not breastfeeding can lead to stigma and discrimination. That’s because it would, in effect, announce to the community that a woman might be infected with HIV. It gets even more complicated. Babies fed strictly formula are often not as healthy at breastfed babies.
But if women in poor countries are unlikely to abandon breastfeeding, what about using animal milk or formula at least part of the time. It’s called mixed feeding. Ironically, that can actually make matters worse. Researchers say, “When a mother mixes feeding methods she is more likely to suffer breast inflammation and cracked nipples.” That, they say, ”greatly increases the risk of HIV transmission to the infant.” But mixed feeding may also cause changes in the baby, itself, making it more vulnerable to HIV. This may be a result of mixing formula with contaminated water or by stirring it with contaminated utensils.
He says, "The introduction of any foods apart from breast milk is associated with changes in the lining of the intestine, which will affect the movement of viruses or particles from the gut into the body. And also one can see proteins coming through the gut from the body as well. So, you get a change in the ability of the gut to resist entry of molecules across it."
Also studying the link between breastfeeding and HIV infection is Dr. Brian Coulter, senior lecturer in tropical child health at the Liverpool School of Tropical Medicine. He gives one reason why safe breastfeeding is difficult to achieve.
Dr. Coulter says, "Most women in sub-Saharan Africa don’t know their HIV status. And many women who are tested for various reasons – perhaps when their children are infected – don’t actually want to know the result because of the enormous problems of family strife, family separation, etc. So, it’s only a minority that actually do know their status."
He says this is often due to a lack of education not only among women, but also among the counselors who are supposed to be advising them.
Dr. Coulter says if women do choose to breastfeed, then they must be adequately advised of the risks in a way that’s sensitive to their culture. And he says they must be told never to use any milk substitute during the breastfeeding months.
Another factor discouraging powdered formula is cost. Dr. Coulter says formula use might become more widespread if the international community committed to a long-range program of buying the formula for poor women.
Nevertheless, Dr. Coulter says, without a doubt, not breastfeeding would go a long way toward preventing many HIV infections in newborns.
"If every mother HIV infected did not breastfeed, you would reduce the number of infected babies by thousands and thousands.
He also says there is hope that in the future it may be possible to breastfeed with little risk of infection.
"There’s a lot of research going on now in giving mothers anti-retrovirals and possibly the baby during the period of breastfeeding. Now we have to wait for the results of those studies. That could well be the way forward," he says.
The drug Nevirapine has been shown to help prevent mother-to-child transmission of HIV during childbirth. But patients may build up a resistance to it over the long term and it’s not known how effective it would be regarding breastfeeding.