Source: www.aleitamento.com
By: IBFAN
IV, Infant Nutrition and Mother and Child Health
In 1997, the United Nations Political Declaration highlighted that, as a general principle for all populations regardless of HIV infection rate, breastfeeding should be promoted, protected and supported. It also clearly emphasized that HIV-positive mothers are empowered to make a fully informed choice about infant feeding and receive full support to make that decision.
In October 2000, UNICEF, WHO and UNAIDS reviewed the evidence that had accumulated over this 3-year period. Findings were found that required special attention. The results published by Coutsoudis et al. (Lancet, 1999), suggest benefits of exclusive breastfeeding over mixed feeding, with exclusive breastfeeding leading to a similar risk of HIV transmission compared to feeding exclusively with infant formula (published in Atualidades em Amamentação no. 27-28). A follow-up analysis of data published by Coutsoudis et al. in 2001, suggests that newborns who are exclusively breastfed for 3 months or more have no additional risk of HIV infection at 6 months, compared to those who have never been breastfed. Therefore, following these analyses, the United Nations reiterated its policies on HIV and infant feeding, specifically recommending that:
When feeding replacement is acceptable, possible, available, sustainable and safe, it should be recommended that any form of breastfeeding be avoided by HIV-positive mothers.
In the absence of any of the conditions mentioned above, exclusive breastfeeding is recommended during the first months of life.
At that time, experts placed special emphasis on maternal health, recommending the inclusion of family planning and nutritional support services for HIV-positive women.
These recommendations were revised again by the Ministry of Health in 2001, based on the findings of Nduati et al. which suggest that HIV-positive mothers have higher mortality rates if they breastfeed their babies. These results conflicted with studies from South Africa that found no increase in deaths among HIV-positive mothers who breastfed. The Lancet magazine editorial pointed out that these conflicting results should lead to new studies and not recommendations (1) . On June 7, 2001, the WHO published a statement that warned against the impetus to change adopted policies, driven by hasty conclusions (2). The WHO also declared that the limitations in the data from Nduati's study required care in interpreting the results and reiterated the importance of adequate clinical and nutritional support for mothers who were infected with HIV.
The "HIV and Infant Feeding" component of programs to prevent mother-to-child transmission of HIV has been highly contested. This is because studies do not yet have definitive answers to questions such as the effects of exclusive breastfeeding and the impact of antiretroviral therapy during lactation on HIV transmission rates. Many studies dealing with breastfeeding and HIV do not take into account the 1991 WHO definitions of individual infant feeding patterns (exclusive breastfeeding, predominant breastfeeding, partial breastfeeding, etc.). This makes it impossible to separate the data in this regard and provide useful guidance to program managers. In 2001, the WHO, in collaboration with UNICEF and experts, published a study assessment tool to assist scientists in designing their research protocols.
The 2000 recommendation on using food substitutes only when acceptable, practicable, available, sustainable and safe is certainly a step in the right direction. However, all of these conditions are extremely linked to specific situations. It is therefore crucial that an appropriate and detailed analysis of the situation is made such that counselors of HIV-positive mothers have a good understanding of the range of options and conditions, so that they can effectively support mothers in making informed choices. Experience with counseling HIV-positive mothers in various parts of the world suggests that many counselors are not sufficiently equipped with knowledge and skills and often act on the basis of prejudice, personal experiences and sometimes putting pressure on mothers.
1. Newell ML. Does breastfeeding really affect mortality among HIV-1 infected women? Lancet 2001; 357: 1634
2. WHO. Global strategy for infant and young child feeding. Document A54/7, Geneva, 9 April 2001.
IBFAN OCTOBER 2003 No. 30