Ninety percent of the four hundred thousand children in the world who
became infected with HIV in 1996 inherited the virus from their mothers.
Mother to child transmission of HIV may occur during pregnancy or delivery,
or through breastfeeding. Not all children of HIV-positive mothers become
infected with HIV, but the risk is much greater in developing countries.
Zambia, in recognition of this issue, is now developing a policy about
breastfeeding and HIV. There are many issues that are being considered in
the development of this policy.
Researchers estimate, that if no treatment is given, the rates of HIV
transmission from mother to child are between 25% and 45% in developing
countries. In industrialised countries these rates are lower, from 15% to
25%. There are three main factors which explain why babies born to mothers
from poor countries are at greater risk; breastfeeding, the poor nutrition
of many mothers in developing countries, and the lack of access to drug
treatment that can help prevent HIV transmission during pregnancy.
Preventing HIV infection
Primary prevention, however, is the key. Most mothers have been infected
with HIV through unprotected sexual intercourse. The importance of
promoting condom use and other safe sex measures, as well as prompt and
adequate treatment of STDs must not be underestimated. We must also
continue with programmes to reduce women’s vulnerability to being infected
with HIV; programmes to improve their social and economic status.
Breastfeeding and HIV: a desperate dilemma
Recent data from developing countries indicates that up to one half of
mother-to-child HIV transmission is due to breastfeeding. We promote
breastfeeding because it gives vital protection against deadly childhood
diseases, particularly diarrhoea and acute respiratory infections (ARI),
which are far more common than HIV. It is also free, whereas the cost of
dried milk and even the clean water to prepare it, are often beyond the
means of poor families. Providing infant formula is impossible within
Zambia’s health budget. Moreover, the dangers of infant formula feeding
must not be underestimated. Breastfeeding experts warn that if African
mothers stopped breastfeeding, the death rate in under-fives could more than
double. It has been estimated that infants who are not breastfed are 14
times more likely to die from diarrhoea, compared to babies who are
breastfed exclusively. They are also three times more likely to die from ARI.
However, concern over transmission of HIV during breastfeeding presents
HIV-positive mothers, and the health workers who care for them, with a
desperate dilemma. Do we risk passing on the virus through breastmilk, or
risk feeding babies with infant formula when mothers may have no access to
clean water or may well not be able to afford it?
The Joint United Nations Programme on HIV/AIDS (UNAIDS) along UNICEF and
WHO now recommend that we counsel HIV-positive mothers and make available to
them as much information as possible on the relative risks of breastfeeding
and infant formula feeding. We should encourage and, if possible, provide
for voluntary HIV counselling and testing. Then mothers can find out if
they are HIV-positive and use this information, along with information
about the risks of artificial feeding, to decide for themselves whether to
breastfeed or not. Voluntary testing must be offered, though, in a
supportive environment. Clients should never been made to feel guilty about
being HIV positive.
Lack of nutrition is also implicated in the higher rates of
mother-to-child transmission of HIV in developing countries. Thousands of
babies are becoming infected with HIV because their HIV-positive mothers
don't have enough to eat, or are not eating the right kind of foods.
There is some evidence to suggest that women who are vitamin A deficient
are more likely to have HIV-positive babies. Vitamin A is found abundantly
in leafy green vegetables and liver. Trials are now underway in Malawi,
South Africa, Tanzania and Zimbabwe to determine whether vitamin A tablets
might reduce vertical transmission in African women. If vitamin A, or a
combination of other vitamins, really can reduce the risk of transmission of
HIV from mother to child, it could provide a cheap, inexpensive way for
HIV-positive mothers to help protect their unborn children. Such measures
will not, however, solve the larger problem of malnutrition among women.
AZT: An expensive magic bullet......
In 1994, French and American researchers found that if the drug AZT was
administered to pregnant HIV-positive women and to their newborns, the rate
of HIV transmission from mother to child by was reduced by 68%. While
clearly an important research breakthrough, it soon became clear that this
finding would create an enormous ethical dilemma. AZT is very expensive. A
full course of treatment for a pregnant woman and her newborn costs about US
$1,000 (Kw 1,350,000). It must be administered over many weeks during
pregnancy and delivery, as well as to the newborn child. In addition, the
baby must not be breastfed.
As most women in Zambia and other developing countries breastfeed, the
efficacy of the regimen is unclear. Other factors contributing to this
concern are that women in developing countries often attend antenatal
clinics too late in pregnancy to receive the full regimen of treatment, the
lack of capacity to give drugs intravenously in many facilities, and that
women cannot make frequent visits to clinics to receive treatment for
themselves and their infants in the antenatal period as well as the six
weeks following birth. Moreover, the AZT regimen is too expensive for
Zambian women or the Zambian government.
Clinical research is now underway in developing countries to develop a
shorter, less expensive course of treatment for pregnant HIV-positive women
in poor countries. Studies conducted by UNAIDS in South Africa, Tanzania
and Uganda aim to compare the use of a short course AZT treatment to no
treatment at all, or a ‘placebo’ (sugar pill) to find a way to prevent
mother-to-child transmission in developing countries.
Late last year, certain critics labelled these trials unethical. Citing
UN guidelines drawn up after World War II that said that human research
subjects should receive the best available treatment, they argued that
babies born to women receiving a placebo during the trial will be infected
unnecessarily. There are also concerns that once their babies are
considered no longer at risk of contracting HIV, these women may then be
denied access to these drugs.
UNAIDS, supported by other international researchers, recently defended
the trials, arguing that African realities make the developed world regimen
of AZT treatment in pregnancy unfeasible in poor countries.
Placebo-controlled trials were therefore set up to evaluate whether shorter
regimens that can be realistically implemented in developing countries. The
alternative is no treatment at all. UNAIDS has also stressed that the
HIV-positive women who are participating in these trials have signed a form
testifying to their informed consent to participate, are counselled about
HIV infection and prevention measures, and are fully informed about the way
the trial is being conducted.
We in Zambia need to watch for the results of the AZT trials. The
findings will guide our both our policy development and, for those of use
working in health facilities, our advice to HIV positive mothers about
breastfeeding. But first and foremost we must continue to prevent HIV
infection in the first place.
The report was adapted from a paper by UNAIDS. Other references used were HIV and
Breastfeeding: A Policy Statement by UNAIDS, WHO and UNICEF and The 4th
Annual African Regional Meeting Statement on HIV and Breastfeeding, IBFAN.
