What can we do to enhance the health and survival of infants born to HIV-positive mothers?

Published as a Rapid Response on the website
of the British Medical Journal

To the Editor:

McIntyre and Gray1 view programmes to reduce mother-to-child transmission of HIV with rose-coloured glasses. While they believe that 'the challenge remains in their implementation', we believe that scientific justification for these programs has not yet been established.

Two of the most common components of these programs are antiretroviral therapy with AZT or Nevirapine and formula feeding. Although favourably reviewed by McIntyre and Gray, both medications have serious negative health consequences. A number of studies have shown that exposure to ART results in worse health outcomes than in untreated babies2-7.

AZT is associated with a wide variety of serious side effects. Just one of these, anaemia, will have dramatic consequences in third world countries. The Center for Disease Control (CDC) recently issued a warning regarding short-term exposure to nevirapine8. The Guay et al study of nevirapine9 showed that both mothers and babies had a high rate of clinical and lab abnormalities (over 80% of mothers), serious adverse events (about 20% of babies by 18 months) and deaths (6.8% of babies). Boehringer Ingelheim, the manufacturer of nevirapine, supported the Guay study in addition to research trials run by McIntyre and Gray.

Although formula feeding is believed to result in lower rates of HIV transmission, it is known to be associated with serious negative health consequences10. Statistics reported by Nduati11 show that there is no statistically significant difference in the mortality rates at 24 months between breastfed babies of HIV-positive mothers and formula-fed babies of HIV-positive mothers. If there is no child survival advantage when breastfeeding is withheld, then what is the point of abandoning breastfeeding in favor of formula feeding? Coutsoudis12 offers evidence that exclusive breastfeeding may not have a higher rate of transmission than exclusive formula feeding.

There are challenges to instituting widespread exclusive breastfeeding, even in the developing world where breastfeeding remains the cultural norm. However, Haider and colleagues13, working in rural Bangladesh, were able to increase the number of mothers exclusively breastfeeding their babies up to 5 months of age from 6% to 70% by providing them with sufficient support. Too little attention has been paid to the fact that there are much greater constraints in achieving exclusive formula feeding in populations where this has not been practiced before.

The widespread use of HIV transmission rates to measure the success of public health programmes for the prevention of mother-to-child-transmission of HIV is misleading -- true health outcomes must be used. There is an assumption that reducing transmission is the only effective way to improve health in children of HIV+ mothers. Encouragement and support of exclusive breastfeeding would provide the potential to improve the health and survival of all babies, regardless of the HIV status of their mothers. It requires only a modest investment, maximizes resources, and stigmatizes no one.

Those who understand and appreciate the wisdom of a more natural approach to pregnancy, birth and infant feeding are seldom heard in discussions of HIV/AIDS. We must keep the focus on HIV-positive mothers and their babies and how much they stand to lose when offered pharmaceutical, formula and other interventions as a quick fix. Unfortunately, these short-term approaches may create long term problems that are more difficult to solve.

Marian Tompson, Executive Director, AnotherLook
David Crowe, HBSc
Andrea Eastman, MA, IBCLC; Chairman, AnotherLook
Judy LeVan Fram, MEd, PT, IBCLC
Valerie McClain, IBCLC
Pamela Morrison, IBCLC
Francoise Railhet
Magda Sachs, BA, MA

AnotherLook is a nonprofit organization dedicated to gathering information, raising critical questions, and stimulating needed research about breastfeeding in the context of HIV/AIDS.

Competing Interests: None declared.

References

1. McIntyre J, Gray, G. What can we do to reduce mother to child transmission of HIV? BMJ 2002 Jan 26; 324: 218-21.

2. Miller TL, Easley KA, Zhang W, et al. Maternal and infant factors associated with failure to thrive in children with vertically transmitted Human Immunodeficiency Virus-1 infection: the prospective, P2C2 Human Immunodeficiency Virus Multicenter study. Pediatrics 2001 Dec; 108(6): 1287-96.

3. The Italian Register for HIV Infection in Children. Rapid disease progression in HIV-1 perinatally infected children born to mothers receiving zidovudine monotherapy during pregnancy. AIDS 1999 May 28; 13: 927-33.

4. Blanche S. Relation of the course of HIV infection in children to the severity of the disease in their mothers at delivery. NEJM 1994 Feb 3; 330(5): 308-12.

5. Kuhn L, Abrams EJ, Weedon J, et al. Disease Progression and Early Viral Dynamics in Human Immunodeficiency Virus Infected Children Exposed to Zidovudine during Prenatal and Perinatal Periods. J Infect Dis 2000 July; 182: 104-11.

6. de Souza RS, Gomez-Marin O, Scott GB, et al. Effect of prenatal zidovudine on disease progression in perinatally HIV-1-infected infants. JAIDS 2000 Jun 1; 24(2): 154-161.

7. Newschaffer CJ, Cocroft J, Anderson CE, et al. Prenatal Zidovudine Use and Congenital Anomalies in a Medicaid Population. JAIDS 2000 Jul 1; 24(3): 249-256.

8. Center for Disease Control. Serious adverse events attributed to Nevirapine regimens for postexposure prophylaxis after HIV exposures - worldwide 1997-2000. MMWR 2001 Jan 5; 49(51): 1153-6.

9. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354: 795-802.

10. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000 Feb 5; 355(9202): 451-5.

11. Nduati R, John G, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1; a randomized clinical trial. JAMA 2000 Mar 1; 283: 1167-74.

12. Coutsoudis A, Pillay K, Kuhn L, et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001 Feb 16; 15(3): 379-87.

13. Haider R, Ashworth A, Kabir I, Huttly SR. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000; 356: 1643-47.