Breast-feeding can increase the risk of HIV transmission.
Prolonged breast-feeding increases the risk of a woman giving HIV to her baby by about 14 percent. Here are what two studies of babies born to HIV-positive women show:
Formula feeding also has risks.
There is no HIV in baby formula, but formula that is not given safely can make a baby very sick. Making formula with dirty water, or serving it in a bottle or cup that isn't totally clean, can expose the baby to dangerous bacteria. According to the World Health Organization (WHO), babies in developing countries who are fed on formula are up to six times more likely to die from diseases like diarrhea and respiratory infections than breast-fed babies are.
Mixed feeding (breast + formula) is most dangerous.
Mixed feeding is the most dangerous method, because formula feeding can irritate the lining of the baby's stomach, making it easier for the HIV in breast milk to get in and cause an infection. In a South African study of HIV-positive women and their babies, 36 percent of babies who received mixed feeding were reported infected compared to about 25 percent of those who were exclusively breast-fed and 19.5 percent of formula-fed babies.
What's an HIV-positive mother to do?
In the United States and other developed nations, HIV-positive women are advised to not breast-feed and to use formula instead. This is because most women in these regions have easy access to formula, clean water for mixing and washing, and refrigeration. Women in developed regions can usually get health care if the baby becomes sick to prevent a case of diarrhea from becoming fatal. While formula feeding may be the most obvious choice for preventing HIV transmission, it's still not easy to use.
During the first years of the epidemic, in developing countries where many people do not have access to clean water, HIV-positive women were often advised to breast feed their babies to protect them from the health problems related to formula feeding. Today, some people still feel that's the best advice, while others feel that women should have more information, more choices and better access to affordable formula. Whichever method a woman chooses, there are some things she can do to make it safer.
Breast-feeding exclusively for 6 months or less is less risky.
Researchers agree exclusive breast-feeding (where no other foods or liquids are given) is safer than mixed feeding. However, they disagree about whether women will realistically be able to do so. A study from South Africa showed that after an educational campaign, 72 percent of participants were able to breast feed exclusively. However, a study in Uganda reported that, of 60 women who used breast-feeding, only six actually breast-fed exclusively. As more people learn about the benefits of exclusive breast-feeding, the number of women who do it will likely rise. But, as several Ugandan women at a recent conference said, it would still be hard for most women to do without exception.
The risk of a baby getting HIV from breast-feeding increases the longer the baby is exposed to HIV in the breast milk. When breast-feeding is stopped at six months, the risk of transmission is reduced -- some say to as little as 5 percent (compared to 14 percent with longer periods of breast-feeding).
What about women who don't know their HIV status?
It is difficult for women to make informed choices when they do not know their HIV status. Some don't know because they are afraid to be tested. In many places, women don't have access to voluntary counseling and testing. Steps are needed to make testing available and to reduce discrimination against those who test positive.
It took years of public health campaigns to teach people that "breast is best." (Of course, if the mother is HIV-negative, breast-feeding is still the best choice.) When these campaigns began no one predicted the AIDS epidemic. Now some believe that every effort should be made to obtain free formula for those who want it -- including changing laws enacted that prohibit formula makers from giving away free product as a marketing strategy. Others think breast-feeding should still be actively promoted for HIV-positive women, fearing that if women with HIV start using formula, there may be a "spill over effect" in which women who are not HIV-positive or don't know their status opt for formula too.
What about the mother's health?
Much of the breast-feeding debate has focused on the baby, however a study in Kenya suggested that women who breast-fed got sicker, faster than those who used formula. This may be because a breast-feeding woman needs the extra calories, nutrient and fluids for her own body's health.
What about HIV drugs?
HIV drugs can reduce the risk of a baby getting infected from breast milk by reducing the viral load in the mother and her milk and by improving the mother's health. However, HIV transmission can still occur through breast-feeding and, in the U.S., HIV-positive women on therapy are encouraged to formula feed. Most women in developing countries do not have access to HIV drugs. Some studies are looking at giving HIV drugs to the mother (or the baby) throughout the breast-feeding period to reduce the chances of HIV transmission to infants. Broader campaigns are working to make HIV drugs available to all HIV-positive people -- adults, children and babies -- worldwide.
Cow's milk has too much protein and salt for a baby's kidneys to process, and not enough calories. However, full fat cow's milk can be modified. For example, for a 1-3 month old infant: mix 2 parts milk + 1 part clean water + sugar to taste, then boil. Whatever baby doesn't drink should be thrown out.
Heat treatment (pasteurization).
Breast milk should not be boiled, but it can be heat treated to inactivate the HIV in it by placing a jar of expressed milk in a pot of boiling water, removing the pot from the heat and leaving the jar in the pot for 60 minutes.
Another strategy is to leave expressed breast milk at room temperature. Unlike formula, which spoils after an hour, breast milk can be left out for several hours before it begins to go bad. Although leaving breast milk to stand won't eliminate the HIV, it may reduce the amount of virus in the milk.
Alternative breast milk sources.
It may be possible to have another woman breast feed the baby or to get breast milk from another woman or from a milk bank. However, this assumes that the woman has tested HIV-negative, is still negative, and that she will not become infected with HIV for as long as she is providing milk. Naturally, this is not an easy thing to guarantee.
Breast-feeding is the norm in most developed countries, and women who bottle-feed may fear questions about why they don't use their breast milk. Birthing classes, WIC, and other programs directed at pregnant women and new mothers actively promote breast-feeding. Many HIV-positive women have had to lie or disclose their status to get counselors, teachers or social workers to stop pressuring them to breast-feed. Often these activities take place in a group, which can cause a woman to become concerned about her confidentiality being violated, or about feeling social isolation when everyone else is having a different experience.
An HIV-positive woman who breast-feeds and discloses that choice could possibly face a legal threat of having her children removed by authorities. Since most people who know of an HIV-positive woman's status believe she has made the safest choice for her child when she formula feeds, they may overlook giving her an opportunity to express her anger or sadness about not being able to breast feed her child.
Exclusive breast-feeding is giving the baby breast milk only.
Breast-feeding increases the risk of a baby getting HIV by up to 14 percent. A baby will be at greater risk of getting HIV through breast feeding if the mother:
Breast-feeding is hard on a woman's body. To maintain her health and milk flow, she needs extra calories and fluids.
Some common problems related to formula feeding include:
Giving foods, formula or drinks to your baby can damage the lining of the stomach and intestines, making it easier for HIV in breast milk to infect the baby.
If it is so risky, why is it so common?
In many places, mixed feeding is the social norm. Women who choose to formula feed sometimes breast feed due to social pressure, fear of relatives discovering their HIV status, or not having enough money for formula.
Women who choose to breast feed sometimes use formula because they get sick, they have to leave the baby with someone to go to work, or they can't produce enough breast milk to adequately nourish the baby.
WORLD: Women Organized to Respond to Life-threatening Disease is a diverse community of women living with HIV/AIDS and their supporters. To subscribe to the newsletter, contact WORLD, 414 13th Street, 2nd Floor. Oakland, CA 94612. Phone: 510/986-0340. Fax: 510/986-0341. Web site: http://www.womenhiv.org.
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Back to the GMHC Treatment Issues February 2002 contents page.