Breastfeeding versus formula feeding in HIV infection
Authors: Michael C Latham, Ted Greiner
Journal: The Lancet (1998)

Jane Bradbury and Michael McCarthy's July 4 news item (p 39)1Kirkwood JM Adjuvant IFNa2 therapy of melanoma.Lancet. 1998; 351: 1901-1903Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar discusses the new initiatives of UNAIDs to reduce perinatal HIV-1 transmission with short-term zidovudine treatment. This strategy seems justified, but raises ethical issues for physicians who are expected to discontinue treatment of the mother after the birth of the infant. More troubling are the new proposals to conduct large-scale trials in several developing countries to replace breastfeeding with formula feeding in HIV-1-positive mothers. There is a small risk of transmission of HIV-1 from mothers to infants through breastmilk, and every pregnant woman who knows she is HIV-1 positive has a difficult decision to make. The choice not to breastfeed is especially difficult for poor women in developing countries. Such women have inadequate access to resources, including breastmilk substitutes, plus equipment, fuel, and also education and health care. The decision not to breastfeed increased the risks of early pregnancy and birth of another HIV-1 infected infant. Formula feeding by poor mothers in African countries rarely has involved no breastfeeding at all, from the day of birth. As a result, there is no good research to show how high morbidity and mortality rates will be in infants who are formula fed; these rates may be much higher than those described in newly industrialised countries such as Brazil2Retsas S Quigley M Pectasides D MacRae K Henry K Clinical and histologic involvement of regional lymph nodes in malignant melanoma: adjuvant vindesine improves survival.Cancer. 1994; 73: 2119-2130Crossref PubMed Scopus (53) Google Scholar and Malaysia.3Retsas S Mohith A Macrae K Henry K Adjuvant vindesine in malignant melanoma; 20 years on. Proceedings of the 2nd International Conference on the Adjuvant Therapy of Malignant Melanoma. London Mach 14–15. 1997; 7: 163Google Scholar We are concerned that WHO and UNICEF will invest major resources in formula feeding and few into alternatives, such as modified breastfeeding, heat treatment of expressed breastmilk to kill the virus, wet nursing, donation (or even sales) of breastmilk, and use of animal milks or homemade formulas. These options are preferable to the use of infant formulas in poor communities. None of them are easy, nor ideal, but they warrant careful study. Much of the successful work over the years to stem the use of commercial breastmilk substitutes in poor countries is now threatened. The involvement of the commercial infant formula industry, both in deliberations leading to the new policy and also in offering to make their products available, is troubling. We recommend that the UN agencies assess carefully the economic, social, and health consequences of their new policy, and that they provide adequate support to allow investigations of alternative methods. It is a grotesque reality that all HIV-1 infected mothers cannot have full coverage of antiretroviral therapy, that so many mothers and infants do not have access to adequate health care, and that inequities lead to a high prevalence of malnutrition. Given this unfortunate situation, is it wise to be recommending the costly and risky approach of formula feeding for infants born to poor HIV-1 infected mothers?