Washington Post Examines Effect of Botswana Infant Formula Program Implemented to Reduce Risk of Mother-to-Child HIV Transmission

Providing infant formula to HIV-positive mothers might "cost at least as many lives as it has saved" because the nutrition and antibodies supplied by breastmilk are "so crucial to young children that they outweigh the small risk of transmitting HIV," the Washington Post reports. According to the Post, CDC researchers have found that a decade-long, global initiative to provide infant formula to HIV-positive mothers has "backfired" in Botswana by causing infants to be more susceptible to other, more immediate deadly diseases. The findings join a "growing body of research" on the potential detriment of providing HIV-positive mothers with infant formula, the Post reports (Timberg, Washington Post, 7/23).

A study published in the March 31 edition of the journal Lancet found that HIV-positive women in developing countries could reduce the risk of transmitting the virus to their infants if they exclusively breast-feed rather than supplement breastmilk with formula, animal milk or solid food. The study, led by Hoosen Coovadia and Nigel Rollins of the Africa Centre for Health and Population Studies at the University of KwaZulu-Natal, found that infants who received milk and solid food were 11 times more likely to become HIV-positive than infants who were exclusively breast-fed. In addition, infants who received both formula and breastmilk were twice as likely to become HIV-positive as exclusively breast-fed infants. About 6.1% of the exclusively breast-fed infants died by age three months, compared with 15.1% of the infants who received other food sources. According to the researchers, breastmilk might reinforce and protect the mucus membrane lining of the intestines, serving as a barrier to HIV.

Rollins said that if women in developing countries exclusively breast-feed, about 50,000 to 100,000 infant deaths would be prevented annually. Some physicians in response to the study called on the United Nations to change its guidelines on breast-feeding for HIV-positive women in developing countries (Kaiser Daily HIV/AIDS Report, 4/2).

Botswana Study
Botswana -- which has an "extensive public water system, good roads and a legacy of competent governance" -- in 1997 joined a UNICEF-led effort to encourage HIV-positive women to use formula whenever supplies could be provided safely and reliably, according to the Post. The country agreed to pay for the formula program as a service for new mothers. However, government clinics "often ran out of cans of formula, forcing parents and grandparents to buy cow's milk and feed their children with diluted porridge or even flour and water," the Post reports.

The CDC researchers, who presented their findings at a conference in Los Angeles in July, were investigating an outbreak of diarrhea during Botswana's rainy season in early 2006. At least 532 children -- 20 times the usual number of deaths from diarrhea -- died during the outbreak. Only a few of the infants' mothers were breast-feeding. According to the researchers, tests conducted among government water pipes in 26 villages in northeastern Botswana found contamination in each one. In addition, tests of the ill infants' feces also found "dangerous" waterborne pathogens and a virulent form of E. coli, the Post reports.

The researchers found that it primarily was the infants who were not breast-fed who were getting sick from the contaminated water. Among a group of infants at one hospital, those admitted for diarrhea were 50 times more likely to be taking formula or cow's milk compared with those admitted for other illnesses. In addition, the researchers found that in one village, 30% of the infants who received formula had died, while none of those being breast-fed had.

The report reflects the "shifting scientific consensus" on breast-feeding, the Post reports. Since Botswana started its formula program, more and more studies have shown that the risk of mother-to-child HIV transmission primarily comes from the combination of breastmilk and other foods, including formula and solids, that can damage the lining of an infant's intestines. In addition, putting an HIV-positive woman on a combination of antiretroviral drugs can reduce the risk of transmission through breast-feeding to less than 2%, according to Coovadia.

UNICEF after providing training and technical assistance to the formula program in Botswana began phasing out its infant-feeding programs in 2002. Health officials in Botswana remain "unconvinced" that the formula program is not effective, the Post reports. Health Minister Sheila Tlou said that the 2006 outbreak was a one-time occurrence that should not dictate a policy. Officials now are focusing on making formula feeding safer by encouraging women to boil water and feed their infants using cups. Tlou also said the ministry will monitor new studies to determine whether a new policy is needed. "We are amenable to research, especially our own research," she said (Washington Post, 7/23).

Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report, search the archives, or sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv. The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of the Kaiser Family Foundation, by The Advisory Board Company. © 2007 by The Advisory Board Company and Kaiser Family Foundation. All rights reserved.