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AIDS and Breastfeeding

The AIDS War on Breastfeeding
David Crowe
April, 2012


1036283Allopathic medicine was at war with natural birth and childrearing for much of the last century, but the battles were most intense over breastfeeding. Natural infant feeding started a comeback in the 1970s with increasing support from doctors (Wolf, 2003) but then along came AIDS. All of a sudden, millions of women around the world had suspect breasts again, supposedly teeming with deadly viruses, and the life-giving act of nursing their own baby was viewed as deadly. Now we know that there was indeed a slaughter, but it was not the mothers of the world who were responsible.


All the smartest and best educated medical experts quickly agreed that the only way to save the babies of HIV-positive women from AIDS was to replace breastmilk with formula and thus was born the epidemic of “Mother-To-Child-Transmission” (MTCT) prevention programs. There were some critics of this rush to the bottle (such as AnotherLook.org) but they were ignored until, about a decade later, the medical establishment tacitly admitted that they had been wrong and that exclusive breastfeeding was, once again, the best choice for HIV-positive mothers…except in rich countries where breastfeeding by such women is still essentially illegal.


The original claim that breastfeeding could transmit HIV was based on shockingly thin evidence, two anecdotal claims published in 1985. The first was that HIV could be grown in cell culture from the breastmilk of three mothers (one of which was not even HIV-antibody-positive)(Thiry, 1985). This claim is suspect for several reasons-there was no control, no evidence that the biochemical signals found in these cell cultures could not also be stimulated from the breastmilk of HIV-negative women, and no evidence that the children later got sick.


The second anecdotal claim (Ziegler, 1985) was from a baby delivered under difficult circumstances (excessive amniotic fluid, placenta blocking the cervix and a slow heartbeat in the fetus) that led to a C-Section resulting in the transfusion of blood to the mother, one unit of which came from an HIV-negative gay man who developed AIDS just over a year after the donation. The mother received more blood after birth and the baby, not surprisingly, had a number of difficulties such as slow growth, anemia and dermatitis, although there was no evidence that the baby did not recover from what may well have been the consequences of a traumatic arrival. Both mother and baby were found to be HIV-positive and the short article implied that all the health problems of both were due to the virus and that because of the timing the infection must have occurred after birth via breastmilk. There was no consideration that the antibodies in the mother and infant might be due to their exposure to medical interventions (such as blood transfusions) and might not even indicate the presence of a virus, just an activated immune system.


On this basis, breastfeeding by HIV-positive women was essentially banned by the US CDC later in the same year (CDC, 1985). I say ‘essentially banned’ because there is no law that bans breastfeeding, but experience shows that the majority of US doctors will listen to the CDC and recommend that a woman not breastfeed. If she defies them it is likely that the doctors will request a court order to remove the baby from her custody, and it is almost certain that the courts will comply.


International advisers were not so quick to rush to judgment. A 1987 consultation concluded that breastfeeding was still the best option, that there was no certainty that HIV infection through breastfeeding was even possible and, even if it was, the risk was small (compared with the enormous risk of formula feeding) (WHO, 1987).


This international breastfeeding harmony did not last for long. Attitudes against breastfeeding hardened when the Lancet published a paper (Dunn, 1992), based on combining data from a series of small studies, claiming that the risk of a baby developing HIV antibodies, which they called HIV infection, from a breastfeeding mother was 15%. Antibodies are not unambiguous evidence of infection for many reasons, the most important being that validation studies of HIV tests (which would have to involve the injection of purified HIV into animals and consistent observation of the development of HIV antibodies only after this) have never been performed. The main reason for this is that HIV has never been purified so such studies are currently impossible. Despite this, HIV antibodies are still equated with HIV infection by most and it is ‘denialism’ to say otherwise.


There was no evidence that the 15% of children breastfed by HIV-positive mothers who themselves become positive are actually infected with HIV let alone that all, or even most, will develop AIDS. There was also no attempt to factor out how many health risks in these children were due to many of the mothers being IV drug users or malnourished. There should have been concerns about the use of unpublished data and the most extreme data coming from a study of a type that the authors themselves declared should not be used. The extensive problems with this analysis are discussed in detail in an AnotherLook position paper (Crowe, 2006).


But the profitable formula train had left the station and facts and experience were not going to derail it. Drug and formula companies brought women simplified messages, like this from a GlaxoSmithKline-run website in 2004, “If you are HIV positive, do not breast-feed, because it's dangerous for your baby. Your baby can get HIV infection or reinfection from breast milk. Bottle feeding with infant formula will help protect your baby's health.” (TreatHIV.com, 2004) Governments insulted the intelligence of women with capitalized (and unsubstantiated) orders like, “HIV-positive women SHOULD NOT BREASTFEED” (Alberta Health, 1998).


Attention turned to poorer parts of the world when UNAIDS recommended formula feeding by HIV-positive mothers (UNAIDS, 1997). Those who resisted, continuing to promote breastfeeding were characterized in the press as “ideological” rather than driven by experience and evidence.


The fate of breastfeeding was sealed when researchers claimed that they had found that the rate of “HIV-1-free survival at 2 years was significantly lower in the breastfeeding arm than in the formula feeding arm” of their clinical trial (Nduati, 2000). But “HIV-1-free survival” is propaganda, not science, because it lumps babies who die with healthy babies who have merely produced HIV antibodies. An honest statement would have been, “At 2 years, survival was the same in the breastfeeding and formula feeding arm but more breastfed infants were HIV-1-positive.”


Even the finding that breastfeeding survival was the same as formula survival, and not higher, was questionable, because of fundamental problems in this study. Mixed feeding mothers (some breastmilk and some replacement food) were assigned to the breastfeeding group. and those told to formula feed who chose to breastfeed anyway were kept in the formula feeding arm because this was an “intent-to-treat” study. This meant that the study was comparing like with like and concluding they were the same when it was claiming to be comparing like with unlike. Another problem is that women in the study had access to treated water, which is unusual in Africa. Most importantly, formula-fed babies suffered from more dehydration, which means that, if the study had continued, the death rate among formula-fed babies might have soon become greater.


Nduati and colleagues seemed to have it in for breastfeeding because they even published another paper claiming that breastfeeding mothers had higher mortality. They were implying that AIDS weakened mothers so much that breastfeeding was enough of a stress to throw them over the edge, but it was more likely a reflection of serious flaws and biases in their studies.


The claim that HIV antibodies were more frequent in breastfed babies was also suspect because South African researchers had already found that exclusively breastfed babies had a slightly lower risk of HIV antibodies than exclusively formula fed babies (Coutsoudis, 1999). The excess rate of HIV antibodies was found in mixed-fed babies who, in the Nduati study, were carelessly lumped in with exclusive breastfeeders.


This should have lead to the conclusion that every baby should be exclusively breastfed to get its known advantages without the questionable burden of HIV-antibodies. It is known that this practice is best for mothers and babies when HIV is not considered, and now it appeared that health outcomes would be best for HIV+ mothers and their babies too.


Scientists should have already known promoting formula would end up killing babies because a study in Zaire (Ryder, 1991) had previously shown that formula fed babies of HIV-positive mothers had a higher rate of illness and a report from Italy had showed that breastfeeding delayed progression to AIDS by almost a factor of two (Tozzi, 1990). There was enough evidence available for caution, not haste.


Formula feeding programs picked up steam anyway, producing data documenting their destructive potential. A study in Brazil showed formula fed babies were 17 times more likely to be hospitalized for pneumonia (Cesar, 1999). In Los Angeles County, it was found that non-breastfed babies were more likely to have AIDS, were much more likely to die, and were several times more likely to have recurrent diarrhea (Frederick, 1997). Another study showed that formula feeding resulted in a death rate of babies 2-1/2 times higher than exclusive breastfeeding (Taha, 2006). Data from Ghana, India and Peru showed that, “non-breastfed infants had a [10.5 times] higher risk of dying compared with those who had been predominantly breastfed” (Bahl, 2005). The poor Rakai district of Uganda reported a one-year mortality rate of 18% among formula fed infants and only 3% among breastfed infants (Kagaayi, 2008). Despite the evidence, bias often stopped scientists from questioning the current direction. One paper showing that formula feeding was associated with poor growth still focused on how to persuade mothers to not breastfeed (Kiarie, 2004) and the Los Angeles County study still supported formula feeding despite the higher death rate (Frederick, 1997).


Sometimes the death toll was so high that it couldn’t be buried in scientific journals. The Washington Post reported in 2007 on Botswana where formula feeding had been adopted most enthusiastically, and which was now facing an epidemic of fatal diarrhea among infants at rates 20 times higher than normal (Timberg, 2007). The newspaper concluded that replacement feeding “has cost at least as many lives as it has saved”, although the truth is much worse than that. A scientific report on this debacle noted that two year mortality was a shocking 30% in formula fed infants while only 6.7% among breastfed babies of HIV-positive mothers and 1.6% in general (Shapiro, 2007). Given that “AIDS” is associated with malnutrition in Africa and HIV-positive mothers and babies are exposed to toxic antiretroviral, DNA chain-terminating, medications, this may not reflect any risk from HIV at all.


Even where exclusive breastfeeding was still allowed, rapid and early weaning (4-6 months) was recommended. This was also found to bring a higher death rate – 2 to 4 times higher than children weaned after two years (Kuhn, 2010).


Finally, the brilliant minds who tell mothers around the world what to do started to see the light. In 2006 guidelines were softened to encourage formula feeding only where it was AFASS (acceptable, feasible, affordable, sustainable and safe – bureaucrats love their acronyms) but by 2010 they had retreated further, stating “Even when ARVs are not available, mothers should be counselled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding” (WHO, 2010), advice that is once again similar to that given to HIV-negative mothers.


In August, 2011, the South African Minister of Health, Aaron Motsoaledi, announced that his country, the richest in sub-Saharan Africa, was ending its policy of providing free formula at hospitals and would now promote exclusive breastfeeding for all mothers, regardless of HIV status (PlusNews, 2011). The Minister admitted that this policy shift was driven by the “unacceptable” child mortality rates. The HIV-driven free formula policy had put South Africa into an exclusive club of a dozen countries with rising infant mortality rates and one of the lowest exclusive breastfeeding rates in the world.


It is depressing to think how much better off the world would have been, how many babies would be alive and how many mothers would have been spared the agony of watching their baby die in front of them, if only all those PhDs, MDs, RNs and other educated people who have swallowed the HIV=AIDS theory for all these years, had simply done nothing, if the world had paid them to stay at home rather than coming to work and promoting and managing the deadly formula feeding programs of the past decade.


The clock has now turned almost a full circle except in richer countries where it is still stuck at 1985. International agencies like WHO, UNAIDS and UNICEF carefully circumscribe their advice to breastfeed, “unless environmental and social circumstances are safe for, and supportive of, replacement feeding”. If “safe” is defined using the low standard of survival, ‘only’ about 720 children die from formula feeding every year in the United States (Chen, 2004), certainly a much lower number than would die in a similar sized county where clean water and modern medical treatment were not widespread.


The safety of formula feeding is assumed by the CDC which still “recommends that infected women in the United States refrain from breastfeeding to avoid postnatal transmission of HIV-1 to their infants through breast milk. These recommendations also should be followed by women receiving antiretroviral therapy.” (CDC, 2010)


The divide between the rich and poor worlds is summarized by the influential journal Pediatrics, “In the industrialized world, it is not recommended that HIV-positive mothers breastfeed. However, in the developing world, where mortality is increased in non-breastfeeding infants from a combination of malnutrition and infectious diseases, breastfeeding may outweigh the risk of the acquiring HIV infection from human milk.” (Pediatrics, 2012).


In practice these recommendations can have the force of law when doctors decide that HIV-positive women who choose to breastfeed are endangering their child no matter how well read they are on this issue. An example was made of Kathleen Tyson whose right to breastfeed was taken away by an Oregon court in 1999 (Wolf, 2001). Christine Maggiore defied the authorities and, perhaps because she was a public figure with a wide support network, was able to continue to publicly breastfeed her two children. The terror induced in both cases is clearly shown in a recent documentary, “This Child of Mine” (Wolfe, 2010).


Part of the reason so little attention is paid to the violation of the rights of HIV-positive mothers is that there are so few of them. There is no precise count of how many HIV-positive women have babies every year, but roughly estimating from age and gender information provided by the CDC, it would be less than 1000 per year, not even considering that some AIDS-defining illnesses make pregnancy extremely unlikely (e.g. cervical cancer) and a higher than normal number of HIV-positive women may avoid getting pregnant or have an abortion.


HIV-positive women in developed countries have a difficult choice. They can breastfeed and accept that any illness their child develops from formula and other interventions will be blamed on HIV and treated aggressively. Or, they can tell the medical professionals that will surround them that they are going to formula feed while quietly breastfeeding at home. I would not recommend the other alternative of confronting the medical establishment as there is a good likelihood of losing parents losing their child to foster care where what they did not want to have happen, will happen.


Note: Readers who face this challenge are welcome to contact David Crowe at David.Crowe@aras.ab.ca for more information.


References

Alberta Health, 1998: Information on HIV and Pregnancy. Alberta Health. 1998 Aug.


Bahl, 2005: Bahl R et al. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organ. 2005 Jun; 83(6): 418–26. http://davidcrowe.ca/SciHealthEnv/papers/3980-InfantFeedingPatterns.pdf


CDC, 1985: Current Trends Recommendations for Assisting in the Prevention of Perinatal Transmission of Human T-Lymphotropic Virus Type III/Lymphadenopathy-Associated Virus and Acquired Immunodeficiency Syndrome. MMWR. 1985 Dec 6; 34(48): 721–6,731–2. http://www.cdc.gov/mmwr/preview/mmwrhtml/00033122.htm


CDC, 2010: Breastfeeding: Diseases and Conditions: HIV and AIDS. CDC. 2010 Mar 4. http://www.cdc.gov/breastfeeding/disease/hiv.htm


Cesar, 1999: Cesar JA et al. Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study. BMJ. 1999 May 15; 318(7194): 1316–20. http://www.bmj.com/cgi/content/full/318/7194/1316


Chen, 2004: Chen A et al. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004 May; 113(5): e435–9.


Coutsoutdis, 1999: Coutsoudis A et al. Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet. 1999 Aug 7; 354: 442–3,471–6.


Crowe, 2006: Crowe D et al. Commentary: Revisiting the risk of HIV infection from breastfeeding. Another Look. 2006 Dec. http://www.anotherlook.org/papers/g/english.pdf


Dunn, 1992: Dunn DT et al. Risk of Human Immunodeficiency Virus Type 1 transmission through breastfeeding. Lancet. 1992 Sep 5; 340(8819): 585–8.


Frederick, 1997: Frederick T et al. Breastfeeding and Disease Progression Among Perinatally HIV-Infected Children in Los Angeles County (LAC). Conf Retroviruses Opportunistic Infect. 1997 Jan 22-26; 4th: 197 (abstract 720).


Kagaayi, 2008: Kagaayi J et al. Survival of Infants Born to HIV-Positive Mothers, by Feeding Modality, in Rakai, Uganda. PLoS ONE. 2008; 3(12): e3877. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588542/


Kiarie, 2004: Kiarie JN et al. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2004 Jan 1; 35(1): 75–81.


Kuhn, 2010: Kuhn L et al. Elevations in mortality associated with weaning persist into the second year of life among uninfected children born to HIV-infected mothers. Clin Infect Dis. 2010 Feb 1; 50(3): 437–44. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805776/


Nduati, 2000: Nduati R et al. Effect of breastfeeding and formula feeding on transmission of HIV-1; a randomized clinical trial. JAMA. 2000 Mar 1; 283(9): 1167–74. http://jama.ama-assn.org/content/283/9/1167.long


Pediatrics, 2012: Breastfeeding and the use of human milk. Pediatrics. 2012 Mar; 129(3): e827–41. http://pediatrics.aappublications.org/content/129/3/e827.long


PlusNews, 2011: South Africa; Policy turnaround on breastfeeding. PlusNews. 2011 Aug 26. http://www.plusnews.org/report.aspx?ReportID=93600


Ryder, 1991: Ryder RW et al. Evidence from Zaire that Breast-feeding by HIV-1-seropositive Mothers is Not a Major Route for Perinatal HIV-1 Transmission but Does Decrease Morbidity. AIDS. 1991 Jun; 5(6): 709–714. http://davidcrowe.ca/SciHealthEnv/papers/125-BF-Zaire-NotAMajorRoute-MTCT.pdf


Shapiro, 2007: Shapiro RL et al. Infant morbidity, mortality, and breast milk immunologic profiles among breast-feeding HIV-infected and HIV-uninfected women in Botswana. J Infect Dis. 2007 Aug 15; 196(4): 562–9. http://jid.oxfordjournals.org/content/196/4/562.long


Taha, 2006: Taha TE et al. The impact of breastfeeding on the health of HIV-positive mothers. Bull World Health Organ. 2006; 84: 546–54. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2627383/


Thiry, 1985: Thiry L et al. Isolation of AIDS virus from cell-free breast milk of three healthy virus carriers. Lancet. 1985 Oct 19; 2(8460): 891–2. http://davidcrowe.ca/SciHealthEnv/papers/48-HIV-Breastmilk.pdf


Timberg, 2007: Timberg C. Anti-AIDS measure backfires in Africa. Washington Post. 2007 Jul 22.


Tozzi, 1990: Tozzi AE et al. Does breastfeeding delay progression to AIDS in HIV-infected children? AIDS. 1990; 4(12): 1293–1304. http://davidcrowe.ca/SciHealthEnv/papers/1012-BF-Progression-AIDS.pdf


TreatHIV.com: What every pregnant woman should know about HIV. TreatHIV.com. 2004 May 14 (accessed). Website run by GlaxoSmithKline in 2004. Now co-managed with Pfizer. http://davidcrowe.ca/SciHealthEnv/papers/3115-Glaxo-Women-HIV.pdf


UNAIDS, 1997: HIV and infant feeding: A policy statement document. UNAIDS, WHO, UNICEF. 1997. http://davidcrowe.ca/SciHealthEnv/papers/9061-HIVandInfantFeeding.pdf


WHO, 1987: Breastfeeding, breast milk and human immunodeficiency virus (HIV). Statement from the Consultation held in Geneva, 23–25 June, 1987. AIDS Action. 1988; 5: 1–2. http://davidcrowe.ca/SciHealthEnv/papers/9037-WHO%20Breastfeeding%20Recommendation.pdf


WHO, 2010: Guidelines on HIV and infant feeding. WHO, UNAIDS, UNFPA, UNICEF. 2010. http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/


Wolf, 2001: Wolf LE et al. When Parents Reject Interventions to Reduce Postnatal Human Immunodeficiency Virus Transmission. Arch Pediatr Adolesc Med. 2001 Aug; 155(8): 927–33. http://archpedi.ama-assn.org/cgi/content/full/155/8/927


Wolf, 2003: Wolf JH. Low breastfeeding rates and public health in the United States. Am J Public Health. 2003 Dec; 93(12): 2000–10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448139/pdf/0932000.pdf


Wolfe, 2010: Wolfe J. This Child of Mine. 2010. http://familieswithhivmovie.blogspot.com/


Ziegler, 1985: Ziegler J et al. Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet. 1985 Apr 20; 1(8434): 896–897. http://davidcrowe.ca/SciHealthEnv/papers/727-PostnatalTransmission.pdf

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