Sir: We congratulate BMJ for continuing to follow breastfeeding debates closely, particularly in relation to the issue of HIV transmission through breastfeeding. Jacqui Wise’s article (BMJ 2001; 322: 512e) provides an excellent summary of the Coutsoudis et al article in AIDS and of the responses its predecessor in Lancet received.

Since exclusive breastfeeding is so rare and offers so many other benefits, and since so few HIV+ pregnant women know or are likely to find out about their HIV status, UNAIDS and its partners seem to be missing an opportunity by not focusing more on promoting exclusive breastfeeding for all infants. To the contrary, however, there are worrying signs that breastfeeding in Africa is becoming an endangered practice. Here we explain, mainly via examples from Zimbabwe, how the new UNAIDS/UNICEF/WHO HIV and infant feeding guidelines (1, 2) could contribute to a general decline of breastfeeding in Africa.

These UN Guidelines may be appropriate in industrialized countries where artificial feeding long ago became the norm. In countries where new mothers are expected to choose an infant feeding method, such a plan of care seems reasonable. However, several unforeseen difficulties are emerging in relation to counselling about HIV and infant feeding in the African setting that have no parallel in the industrialised world.

In most of sub-Saharan Africa, the concept of infant feeding choice is virtually unknown because breastfeeding is the cultural norm and is almost universally practised (3). A nurse in a white uniform who counsels a mother about infant feeding options introduces an entirely novel concept, the element of choice, which may be delivered, and certainly perceived as a recommendation rather than an option. The words, “infant feeding counselling and “informed choice” have effectively become euphemisms for artificial feeding and the UN Guidelines a way of promoting it.

In Zimbabwe, a mother’s decisions about replacement feeding involve the baby’s father, her mother-in-law, and often her own mother. This does not allow the mother the autonomy of free choice. In the 1% of births where a mother does not breastfeed (4), questions about her HIV status will be raised and she risks being stigmatised. Many HIV-infected mothers compromise by artificially feeding their babies at home, and breastfeeding in public, thus probably increasing the risk of transmission of HIV through mixed feeding (5, 6).

The possibility that uninfected mothers will consider it desirable to use breast-milk substitutes intended only for their HIV-positive counterparts is known as the “spillover effect.” But the UN Guidelines do not cover the many grey areas that lead health workers to contribute to this effect. When a pregnant woman does not want to be tested but the health worker suspects she is HIV positive, the health worker gives her information about replacement feeding, “just in case.” Counsellors find themselves knowingly violating the provisions of the International Code of Marketing of Breast-milk Substitutes by talking about artificial feeding to groups of mothers because they do not have the time to give individual counselling.

In a country with such a high level of HIV infection, health workers are increasingly asking themselves whether information about replacement feeding ought not to be provided to all mothers. The UN Guidelines stated that “strengthened protection, promotion and support of breastfeeding should be enhanced for HIV-negative mothers and mothers of unknown status.” But something close to the opposite seems to be occurring.

In Zimbabwe breastfeeding promotion began vigorously when the Minister of Health signed the Innocenti Declaration (7). Achievements included the formation of a multi-sectoral breastfeeding committee in 1992, the appointment of a National Breastfeeding Coordinator in 1994, certification of 43 baby-friendly hospitals from 1992 - 1998, and national legislation to give effect to the Code (8).

However, the UN Guidelines stimulated concern that continued promotion of breastfeeding as inappropriate due to the high HIV prevalence (9). Government and municipal policy-makers were accused of failing to acknowledge the problem and of ignoring the risks of HIV-transmission through breast milk. The result was a measurable reduction in efforts to promote breastfeeding.

Since 1998 only three additional hospitals have been certified baby- friendly. Time and energy have instead been diverted to discussing, formulating, and testing HIV and infant feeding guidelines (10).

In April, 1998, local formula and weaning food manufacturers called a meeting with several government ministers at which they stated that enforcement of the new national Code would impact negatively on their business and would contribute to unemployment in Zimbabwe. This suspended formation of a Zimbabwean Infant Nutrition Committee and postponed full enforcement of the provisions of the Code until September 2000.

At least half a dozen separate research studies on HIV and breastfeeding are being conducted in Zimbabwe by outside organizations with large budgets, one of which exceeds the entire annual health budget of the largest municipal health department. Paying salaries that attract some of the best local health care staff and providing free formula (something which used to be forbidden) and health care to study participants, their policies seem eminently worthy of further promotion.

In Africa the risk of not breastfeeding is unknown, but is likely to be extremely high (11), and many of those who “chose” to artificially feed are likely to practice mixed feeding instead, even in a controlled research setting (12). Although infant morbidity and mortality rates are significantly reduced in developing countries when exclusive breastfeeding is practised for the first six months of life (13-15), it is not promoted.

Given the definite possibility that exclusive breastfeeding does not significantly increase the risk of MTCT of HIV beyond that of artificial feeding (5,6), and that the policy changes brought about by the new UN guidelines appear to be leading to the dismantling of previous efforts to promote exclusive breastfeeding, we ask: is it prudent to proceed with the current aggressive, largely externally driven effort to implement the new UN Guidelines in Africa? Surely advice on infant feeding by HIV-infected mothers, if given, should be based on risk assessment. Until proved otherwise, for most HIV-infected mothers from poor families in Africa, the risk of formula feeding will far outweigh the risks of breastfeeding.

Pamela Morrison,
International board certified lactation consultant
Harare, Zimbabwe
pamela@ecoweb.co.zw

Professor Michael Latham, MD
Division of Nutritional Sciences, Cornell University, Ithaca NY 14853 USA
Mcl6@cornell.edu

Ted Greiner PhD
Department of Women’s and Children’s Health, Uppsala University Hospital, Entrance 11, 75185 Uppsala, Sweden
ted.greiner@kbh.uu.se

Competing interests: None declared

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1. UNAIDS, HIV and Infant Feeding: A policy statement developed collaboratively by UNAIDS, WHO and UNICEF, May 1997.

2. UNAIDS/UNICEF/WHO. HIV and infant feeding: A guide for health care managers and supervisors, 1998; WHO/FRH/CHD/98.2.

3. Haggerty PA, Rutsten SO. Demographic and Health Survey. Comparative Studies no. 30. Breastfeeding and Complementary Infant Feeding, and the Postpartum Effects of Breastfeeding. Maryland: Macro International Inc. Calverton, Maryland USA, 1999.

4. Central Statistical Office and Macro International Inc. Zimbabwe Demographic and Health Survey 1994. Calverton, MD: Central Statistical Office and Macro International Inc.

5. Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet 1999;354:471- 76.

6. Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai W-Y, Coovadia HM. 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;15:379-387.

7. Innocenti Declaration on the protection, promotion and support of breastfeeding, produced and adopted by participants at the WHO/UNICEF policymakers’ meeting on Breastfeeding in the 1990s: A global initiative, 1st August 1990.

8. Zimbabwe Public Health (Breast-milk Substitutes and Infant Nutrition) Regulations, Statutory Instrument 46 of 1998.

9. Zimbabwe Ministry of Health and Child Welfare. HIV sentinel surveillance data in antenatal care of women by year, 1991-1997.

10. Zimbabwe Ministry of Health and Child Welfare National Nutrition Unit, Infant Feeding and HIV/AIDS, Guidelines for health workers in Zimbabwe, 12 June 2000.

11. 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 infection diseases in less developed countries: a pooled analysis. Lancet 2000; 355:451-55.

12. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomised clinical trial. JAMA 2000;283:1167-1174.

13. Brown KH, Dewey KG, Allen LH. Complementary feeding of young children in developing countries: a review of current scientific knowledge, Geneva: WHO, 1998. WHO/NUT/98.1.

14. Cesar JA, Victora CG, Barros FC. Impact of breastfeeding on admission for pneumonia during postnatal period in Brazil: nested case- control study. Brit Med J 1999;318:1316-20.

15. Frongillo EA, Habicht JP. Investigating the weanling’s dilemma: lessons from Honduras. Nutr Reviews 1997;55(11): 390-5.

The British Medical Journal has an excellent electronic version online that also rapidly publishes electronic letters to the editor. This one was published on March 2, 2001 in response to a NEWS EXTRA article called Breastfeeding safer than mixed feeding for babies of mothers with HIV by Jacqui Wise BMJ 2001; 322: 512e.