Ang, Aila Queen C.

BSN-2 April 2, 2020 Journal Reading

Breast is always best, even for HIV-positive mothers

Despite emerging evidence that HIV-positive mothers should breastfeed to maximize
their babies’ health prospects, South African health workers face a battle to change
attitudes and habits. Lungi Langa reports.
Breastfeeding may be natural, but it is not always simple. Professor Anna Coutsoudis, of the Department of
Paediatrics and Child Health at the University of the KwaZulu-Natal, Durban, says the problem begins in the
first weeks of breastfeeding. “Health-care providers lack the skills needed to offer support and advice,” she says.
“So when problems arise – cracked nipples, babies won’t suck and babies don’t seem satisfied – the mothers get
bad advice. Then when they become discouraged, they are told to stop breastfeeding altogether and to give
artificial substitutes.”
If the mother is HIV positive, more uncertainty is added. “Some counsellors are themselves confused about what
is correct practice regarding HIV and feeding practices,” says Thelma Raqa, an antenatal counsellor based in
Mowbray Maternity Hospital in Cape Town.

AVECC/H Vincent

New evidence recommends HIV-positive mothers should breastfeed.

Until recently, the World Health Organization (WHO) advised HIV-positive mothers to avoid breastfeeding if
they were able to afford, prepare and store formula milk safely. But research has since emerged, particularly
from South Africa, that shows that a combination of exclusive breastfeeding and the use of antiretroviral
treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding.
On 30 November 2009, WHO released new recommendations on infant feeding by HIV-positive mothers, based
on this new evidence. For the first time, WHO is recommending that HIV-positive mothers or their infants take
antiretroviral drugs throughout the period of breastfeeding and until the infant is 12 months old. This means that
the child can benefit from breastfeeding with very little risk of becoming infected with HIV.
Prior research had shown that exclusive breastfeeding in the first six months of an infant's life was associated
with a three- to fourfold decreased risk of HIV transmission compared to infants who were breastfed and also
received other milks or foods.
Instrumental in guiding the new recommendations were two major African studies that announced their findings
in July 2009 at the fifth International AIDS Society conference in Cape Town. The WHO-led Kesho Bora study
found that giving HIV-positive mothers a combination of antiretrovirals during pregnancy, delivery and
breastfeeding reduced the risk of HIV transmission to infants by 42%. The Breastfeeding Antiretroviral and
Nutrition study held in Malawi also showed a risk of HIV transmission reduced to just 1.8% for infants given the
antiretroviral drug nevirapine daily while breastfeeding for 6 months.
In spite of these findings it will be a challenge to change the ingrained culture of formula feeding in South
Africa. Existing attitudes have been influenced by the country’s high HIV-prevalence – 18% of the adult
population is HIV positive, according to 2008 estimates from the Joint United Nations Programme on
HIV/AIDS. The 2003 South African Demographic Health Survey found that fewer than 12% of infants are
exclusively breastfed during their first three months and this drops to 1.5% for infants aged between three and
six months.
Some health workers themselves are yet to be convinced of the benefits of breastfeeding, even for mothers who
aren’t HIV positive. “There exists the general idea that it is not important, that there is no critical reason to
breastfeed, especially when you can formula feed,” says Linda Glynn, breastfeeding consultant at Mowbray
Maternity Hospital in Cape Town. “Some [health workers] think breastfeeding is a waste of time and an
inconvenience.” Yet, the risks of not breastfeeding often go unrecognized. Most children born to HIV-positive
mothers and raised on formula do not die of AIDS but of under-nourishment, diarrhoea, pneumonia and other
causes not related to HIV. Breastfeeding not only provides babies with the nutrients they need for optimal
development but also gives babies the antibodies they need to protect them against some of these common but
deadly illnesses.

AVECC/H Vincent

It takes time to learn the techniques: young mother breastfeeding in Mowbray Maternity Hospital, Cape Town.

WHO recommends that all mothers, regardless of their HIV status, practise exclusive breastfeeding – which
means no other liquids or food are given – in the first six months. After six months, the baby should start on
complementary foods. Mothers who are not infected with HIV should breastfeed until the infant is two years or
older.
Penny Reimers, of the Department of Nursing at Durban University of Technology, says the greatest declines in
breastfeeding have taken place in countries where formula milk has been distributed at no cost, South Africa
being a prime example. Infant formula was distributed by national and local authorities and by local
nongovernmental organizations to prevent the transmission of HIV from mother-to-child, an initiative which
inevitably undermined breastfeeding. An unforeseen consequence of the campaign was that even mothers who
were not HIV positive turned to formula, says Reimers.
One reason for the switch was a belief that formula was in some way superior to breast milk, a perception that
Coutsoudis believes derives, at least in part, from “strong and dishonest” marketing campaigns that make
unfounded claims that the formula milk contains special ingredients that improve baby’s health. “Mothers are
not told the truth, that breast milk is infinitely better [for the infant] and that formula milk can be dangerous; that
it is not always a sterile product and is easily contaminated,” Coutsoudis says.
But even without formula producers’ marketing campaigns, other pressures are at work. One is the changing role
of women in South African society. More women are in paid work than 20 years ago and many struggle to fit
breastfeeding into their routines. When Pato Banzi, an administration officer at the Magistrates’ Court in
Wynberg, Cape Town, had her second son she was granted four months’ maternity leave in accordance with
South African labour law, but then struggled when the time came to return to work. “I was lucky that I lived
close to where I worked so I could drive home to feed him and rush back to work,” she says. Later she switched
to expressing milk, which she conserved in bottles, but had to go into the company boardroom to do this in
private. Deidre Zimri, operations manager for a transport company, did her expressing in the waiting room when
no one was using it. Both Banzi and Zimri felt that four months’ maternity leave was not enough.
Louise Goosen, a breastfeeding consultant at Mowbray Maternity Hospital in Cape Town, says that “going back
to work” is one of the most common reasons for stopping breastfeeding. But even for mothers who don’t have to
juggle paid work while caring for their babies, switching to formula is a huge temptation simply because it is
thought to be convenient. But even for mothers who don’t have to juggle paid work while caring for their babies,
switching to formula is a huge temptation simply because it is thought to be convenient. “However we need to
encourage and educate mums on the ease and importance of expressing their breast milk to give to baby while
mum is at work so that baby can still get the best nutrition,” Goosen explains.
So what can be done to make it easier for women to choose the breastfeeding option? The government needs to
convince industry to make it easy for mothers to carry on breastfeeding after returning to work, says Lulama
Sigasana, a nutritionist working at Ikamva Labantu, a South African non-profit organization based in Cape
Town. She also believes that mothers should be provided with space and time to express milk in private at work.
She says the government could do more to communicate the message that breastfeeding is good. “There are
already some [campaigns]” she says, noting the Baby Friendly Hospital Initiative and World Breastfeeding
Awareness week, held every August, but we need more programmes to boost breastfeeding uptake and
continuation.
Sigasana thinks breastfeeding advocacy should also be directed to the people who may influence a woman’s
decision to breastfeed, i.e. her partner and extended family. “In most households, what grandmother says goes,”
she says. “If she says the mother must breastfeed, she feels she has no choice, but if she says formula, then
formula it is. It’s no use educating mothers only. There need to be nationwide campaigns aimed at everyone.”
Coutsoudis agrees, saying advocacy programmes should be extended to society as a whole so that breastfeeding
can again become the “natural way to feed a baby.” And it doesn’t help when many health workers are so quick
to advise formula feeding, says Coutsoudis: “The representatives from formula companies visit [health workers]
often, build good relationships, and market their products.”
Without their active support, how quickly can attitudes really change? One thing is certain: health professionals
will be more likely to support the underlying message if they have a basic understanding of current research. As
Sigasana puts it: “We need to make sure that people who interact with mothers are giving out the correct
information.” ■
 Ang, Aila Queen C. BSN-2 April 2, 2020 Journal Reading

Breast is always best, even for HIV-positive mothers

Reflection:

If you are a pregnant woman living with HIV there are a number of ways that HIV
might be passed on to your baby. HIV in your blood could pass into your baby’s body. This is
most likely to happen in the last few weeks of pregnancy, during labor, or delivery.
Breastfeeding your baby can also transmit HIV, because HIV is in your breastmilk. There is a
15 to 45% chance of passing HIV on to your baby if neither of you take HIV treatment.
However, taking the correct treatment during your pregnancy and while you breastfeed can
virtually eliminate this risk. If you are pregnant, it is important to attend your antenatal
appointments, as these are the times when you can get an HIV test. Your healthcare
professional will offer you a test at your first appointment. If the result is positive you will be
encouraged to start antiretroviral treatment as soon as possible. You will also be offered a test
in your third trimester (from 28 weeks).

Remember that, whether you are pregnant or not, if you do have HIV you may not show
any symptoms. The only way to know whether you are HIV-positive is to get tested. If at any
point during your pregnancy or breastfeeding stage you think you have been exposed to HIV, you
may be able to take post-exposure prophylaxis (PEP). You need to take PEP within 72 hours of
possible exposure to prevent HIV from establishing in your body and being passed on to your
baby. If you’re breastfeeding, you should discuss whether or not to continue breastfeeding with
your healthcare professional. If you are pregnant, it is important to attend your antenatal
appointments, as this is where you can get an HIV test. If your HIV test result is positive, there
are a number of things you can do to reduce the risk of passing on HIV to your baby. Taking
antiretroviral treatment to protect your baby, taking treatment properly can reduce the risk of
your baby being born with HIV to less than 1%. If you knew that you were HIV-positive before
you got pregnant, you may be taking treatment already.

If you are not, talk to a healthcare professional about starting treatment as soon as
possible. If you found out that you living with HIV during your pregnancy, it is recommended
that you start treatment as soon as possible and continue taking it every day for life. Your baby
will also be given treatment for four to six weeks after they are born to help prevent an HIV
infection developing. Protecting your baby during childbirth, if you take your treatment
correctly, it will lower the amount of HIV in your body. In some people, the amount of HIV in
their body can be reduced to such low levels that it is said to be ‘undetectable’ (undetectable viral
load). This means that you can plan to have a vaginal delivery because the risk of passing on
HIV to your baby during childbirth will be extremely small. If you don’t have an undetectable
viral load, you may be offered a caesarean section, as this carries a smaller risk of passing HIV to
your baby than a vaginal delivery. If your HIV test result comes back positive, there are a
number of things you can do to reduce the risk of passing HIV to your baby.