University of Zambia Medical Library

Breastfeeding, HIV and AIDS (1997 World AIDS Campaign)

There are three main factors which explain why babies born to poor mothers 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.

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. One South African study, for example, found that mother-to-child transmission of HIV infection was 17% for babies who were fed with infant formula (who are likely to have contracted HIV during pregnancy or at birth) and 38% for breast-fed babies (21% of whom are likely to have contracted the virus from breastmilk). Breastfeeding is promoted heavily by health workers in poor countries because it affords vital protection against deadly childhood diseases, particularly diarrhoea and respiratory infections, 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 in developing countries.

Mounting concern over transmission of HIV during breastfeeding presents HIV-positive mothers, and the health workers who care for them, with a desperate dilemma. Do they risk passing on the virus through breastmilk, or risk feeding babies with infant formula when they may have no access to clean water or may not be able to afford it. Health workers in different countries have tried to tailor their advice to suit the particular circumstances prevailing in their countries. For example, in Thailand there is relatively wide access to safe water and infant death from infectious diseases is less common than it is in Africa. Most pregnant women there are now tested for HIV at delivery. Those found to be positive are given free infant formula and encouraged not to breast feed. In sub-Saharan Africa, and in many other regions, the recommendations are less clear. There, childhood infectious diseases are common and HIV testing is often not available. Most women have been encouraged to breastfeed regardless of their HIV status.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) now encourages as much information as possible on the relative risks of breastfeeding and infant formula feeding to be made available to HIV-positive mothers, requiring that they be tested, to enable them to decide for themselves whether to breastfeed or not. In most poor countries, however, most women still are not provided with sufficient information and support to make an informed choice. UNAIDS encourages countries to make voluntary testing and counselling more widely available so that women can find out if they are HIV-positive and thus make more informed choices on issues such as breastfeeding. As many as 20% of pregnant women are HIV-positive in some of the worst affected countries. Providing infant formula as an alternative to breast-milk for all these women is beyond the health budgets of many of the countries concerned. Nor should the dangers of infant formula feeding be underestimated. Breastfeeding advocates warn that if African mothers stopped breastfeeding, the death rate in under-fives could more than double.

Poor nutrition a factor:
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, in particular, 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 inexpensive tablets containing vitamin A 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 more pernicious problem of malnutrition among women in developing countries.

AZT: An expensive magic bullet......
In 1994, French and American researchers found that the antiviral drug AZT administered to HIV-positive women in pregnancy and to their newborns reduced the rate of HIV transmission from mother to child by 68%. While clearly an important breakthrough, it soon became clear that it would create an enormous ethical dilemma. AZT is a very expensive drug. A full course of treatment for a pregnant woman and her newborn costs about US$1,000. It also must be administered over many weeks during pregnancy and delivery and also to the newborn child who is not breastfed.

If the AZT regimen, known as the ACTG 076 regimen, is administered to women primarily in industrialised countries who do not breastfeed, mother-to-child HIV transmission drops to between 5% and 10%. As most women in developing countries breastfeed, the efficacy of the regimen is unclear. Moreover, women in developing countries only attend prenatal clinics very late in pregnancy and too late to receive the ACTG 076 regimen, there are often no intravenous facilities at delivery sites, women cannot make frequent visits to clinics to receive treatment for their infants in the six weeks following birth, and there are insufficient resources either for the women to buy AZT or governments to provide it.

In many industrialised countries including Britain and the US, AZT therapy is now routinely offered to HIV-positive pregnant women. In developing countries, where the government may have as little as $10 per person per year to spend on all health care, AZT is only available to the very wealthy or to women participating in clinical trials sponsored by agencies from industrialised countries.

...but an ethical dilemma
Clinical research is now underway in developing countries to develop a less expensive, shorter course of antiretroviral 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 short course antiretroviral treatment to no treatment at all, or a 'placebo' to find a feasible way to prevent mother-to-child transmission in developing countries. The aim is not only to find a less expensive treatment, but also to find one that may be given over a shorter period of time, since many women in poor countries do not attend ante-natal clinics until very late in pregnancy, if at all.

Recently, The New England Journal of Medicine and other critics labelled these trials unethical. Citing UN guidelines drawn up after World War II specifying 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, they may then be denied access to these drugs.

UNAIDS recently defended the trials, arguing that African realities, including poverty and deteriorating health systems make the current western 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 the countries where the trials are being conducted, are better than 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.

[Table of Contents] [UNAIDS DOCS Index] [Alphabetical Index] [Zamnet] [UNZA] [UNZA Library]

Last updated November 30, 1997

UNIVERSITY OF ZAMBIA Med Guide      Index    Zamnet    UNIVERSITY OF ZAMBIA    UNIVERSITY OF ZAMBIA Library 

CONTACTING SCHOOL OF MEDICINE     OTHER INSTITUTIONS   BACK TO SOM HOME PAGE     DEPARTMENTS    Central Board of Health 

Send comments and/or suggestions to: Stan chewe 
Copyright © 1996-2001, The University of Zambia Medical Library and Stan Chewe
Guide to Medical Resources WWW site: http://www.medguide.org.zm/