It’s a rare sight but when HIV-positive mothers at Charlotte Maxeke Johannesburg Academic Hospital glimpse another infected mother breast-feeding her baby, they shake their heads in disbelief.
“Most of the HIV-positive moms in our clinics use formula,” explains Dr Louise Gilbert, the programme manager of maternal health at the Wits Reproductive Health and HIV Research Unit. “If they’re sitting in the waiting room, and see another mother breast-feeding, they wonder if she’s crazy.
“It’s going to take a lot to get buy-in from the community (to breastfeed). But it’s really about empowering mothers to make their own decisions and not making decisions for them.”
Gilbert is referring to the government’s adoption of an exclusive breast-feeding strategy, which hopes to save the lives of more babies, especially those whose mothers are infected with HIV and are poverty-stricken.
HIV is transmitted in breast milk but research has shown that exclusive breast-feeding for the first six months of a child’s life, given with antiretroviral medicine such as Nevirapine, slashes the risk of HIV transmission to just below 2 percent.
Breast milk nourishes the immune system of infants, protecting them from two of the biggest baby killers – diarrhoea and pneumonia. Children who are not breast-fed are a staggering six times more likely to die from illnesses such as diarrhoea.
Research has shown how the breast-fed babies of HIV-positive mothers who also feed on formula and other solids in the first six months of their lives, run a greater risk of HIV infection because formula damages the sensitive lining of their intestines, through which HIV can pass.
Health Minister Aaron Motsoaledi has announced that the government will stop providing free formula to HIV-positive mothers in state-run hospitals and clinics, as it has done for several years, and only provide it on prescription for medical conditions.
Bottle-feeding, too, will stop at state health facilities.
Gilbert, 30, a mother of four who fed her babies both formula and breastmilk, sees the value.
“I think it’s good to promote breastmilk but I think it’s really important for mothers to be given the pros and cons of formula and breastmilk to be able to make their own decision about which method is best for their own situation.
“It’s very different when you’re sitting in a nice house in the middle of a suburb to understand the reality of a woman in a squatter camp, an area like Hillbrow or a rural area.
“Very often women don’t have access to clean drinking water or sanitation and are not taught how to sterilise bottles ... We see babies that have less HIV, but all the same they are not well, and are dying from gastro or malnutrition.
“Women dilute formula to stretch it or give their very tiny babies porridge in a bottle. The moms feel like they’re doing their best - they don’t want to harm their babies.”
In South Africa, breast-feeding rates are miserly, with only around 1.4 percent of infants between the ages of four and six months exclusively breast-fed, research shows.
There are many reasons for this, from the lack of support for breast-feeding in the workplace, bias of health care workers towards formula, and perceptions that breast-feeding is a sign of poverty – but the influence of HIV has loomed largest.
The shift towards breast-feeding is a key child survival strategy, Motsoaledi told a 650-strong gathering at a two-day breast-feeding consultation conference late last month.
He was reflecting on South Africa’s high child mortality rates, which rank among the 12th highest in the world, where too many children under five are dying before their time.
To save more lives, Motsoaledi argued, South Africa needs to “reposition, protect and support” breast-feeding.
Globally, the idea is that where the correct facilities are in place for safe infant feeding – clean water, sanitation, electricity and access to healthcare – formula feeding should be the only option for HIV-positive moms.
But where that is lacking – as it is in many parts of South Africa, and much of the developing world, breast-feeding, though it carries its own risk of transmission, is a safer bet for child survival.
For mothers, though, it’s a frightening dilemma. Several experts point out that that the risk of HIV infection via breast-feeding has been overstated, while the risk of illness and death from formula have been understated for all mothers – not just those who are HIV-positive.
“It’s confusing to the public to understand why we’ve changed our minds,” explains Gilbert. “But we really are in a different situation. We’ve opened up antiretrovirals for all pregnant women with a CD4 count of 350. If a mom is on ARVs and decides to breast-feed, she is given Nevirapine for the whole time she is breast-feeding.
“That wasn’t available 18 months ago, but was brought in by the government to increase the safety of breast-feeding for babies to reduce HIV transmission.”
Ellen Kamman, of the La Leche League, which supports breast-feeding mothers, feels the government’s move to provide free formula was based on emotion to eliminate the chance of a baby being infected with HIV through breast milk.
“What was forgotten was that babies die of many different causes, many of which are increased by artificial infant feeding,” she says.
“Unfortunately, in the South African context, the policy that was thought to prevent babies from potentially being infected with HIV turned out to lead to more babies dying of other causes.”
She applauds the shift to breast-feeding, but maintains the government sends mixed messages by providing free artificial milk as it creates perceptions that it is a “good substitute” for breast milk and a “modern way” to feed babies.
“We hear much about the ‘benefits of breast-feeding’, but breast-feeding is the normal way to feed a baby. It is human milk meant for a human baby,” she adds.
In the context of HIV, formula-feeding is a legitimate HIV prevention strategy, argues Professor Haroon Saloojee of the department of community paediatrics at Wits University.
While he supports the Tshwane Declaration in Support of Breastfeeding in SA, which arose from the breast-feeding conference, he is unhappy about the decision to remove free formula – which gulps around 60 percent of the budget of the Prevention-of-Mother-to-Child Transmission-Programme – from state institutions entirely.
“It’s fine to ask middle-class women to pay for the formula themselves, but what about those poor mothers who meet the Afass criteria (accessible, feasible, affordable, sustainable and safe formula-feeding) to safely feed, but cannot afford to pay for it themselves?
“That’s as many as 20 000 mothers countrywide. We should selectively be offering formula feeding to those women – those judged to be capable of safely formula-feeding. Denying these women the option of free formula feeds denies them the prospect of having an HIV uninfected child.”
Originally, the World Health Organisation declared the policy for infant feeding for HIV-positive mothers was that women in developed countries could use formula, while those in developing countries breast-feed.
“This was rightly viewed as discriminatory by women in developing countries and replaced by individualised choice. What the new declaration does is once again remove choice and power away from mothers because all mothers will be told that breast-feeding is public health policy.”
For Saloojee, it’s not just a human rights issue – thousands of babies will be infected by their mother’s breast milk.
“If we went the extended Nevirapine route, evidence suggests that at best we could reduce transmission to about 2 percent. This means we’ll still have 9 000 infants born with HIV each year. This would require 100 percent compliance with treatment. In reality, if we achieve half of that in the next year, I’d be quite pleased.
“Ensuring that 300 000 well (but HIV exposed) infants receive a daily dose of a drug and exclusive breast-feeding is a huge challenge. I’m concerned if mothers stop breast-feeding, or do not give the drugs to their children for a few days, it escalates the risk of HIV.”
Saloojee says the “one size fits all” thrust of the strategy is inappropriate. While in most provinces breast-feeding should be the default position, in those provinces, municipalities and districts that are better resourced – that have adequate rates of water, sanitation, housing and electricity – an economic case could be made for free formula provision.
“One of the key issues is the ability to safely provide formula in different settings in South Africa – this depends heavily on safe water, sanitation and electricity available. Nationally safe water availability is at 64 percent, while in provinces like KZN, pushing for the national change (shift to exclusive breast-feeding), it’s 49 percent. In Gauteng, safe water availability is at 94 percent and sanitation at 92 percent.
“In Gauteng at least half of caregivers could safely formula feed while I would expect a third of caregivers nationally to be able to do this.”
He hopes Gauteng will support both options – formula provision and extended nevirapine – and “not feel compelled to follow a national policy that is restrictive and frankly inappropriate” for the province.
“Over time, as infrastructure improves and safe formula-feeding can be guaranteed, all provinces should be able to do the same. However, as long as breast-feeding continues, even with antiretroviral prophylaxis, children will continue to be infected.”
In Gauteng, there are already signs that formula provision is being halted at some public health facilities, even though the proposal is not yet official policy.
Chantell Witten, a nutrition specialist at Unicef, which has championed exclusive breast-feeding as safe, says it’s exciting the government is putting breast-feeding back on the agenda.
“In the 1980s, breast-feeding was the feeding option of choice, and this only started to tilt in the 1990s (because of HIV). In the past 10 years, we’ve been standing still umming and ahhing about which option is the best for both worlds. We’ve taken the stance both (formula and breast-feeding) would be, but they haven’t… When it comes to nutrition, nothing is equal to the breast.”
Even Motsoaledi, who last year reportedly remarked that he would support a worldwide ban on formula, has noted the misconception that breast-feeding is a sign of poverty, foisting blame on the “aggressive” and “deadly” marketing of formula, which the government hopes to rein in, through better enforcement.
“This propaganda destroys communities like skin lightening creams pushed onto black communities.”
For their part, formula companies have issued a limp response to the breast-feeding strategy, saying only that they support breast-feeding as the first-line of nutrition for infants, and that they will adhere to responsible practices.
It’s not just about perceptions and unethical marketing, but also about how women live in South Africa, and how its societies have been constructed.
Most mothers are discharged from hospital hours after birth, and denied the chance to establish breast-feeding. Health care workers often push formula-feeding, due to their own bias.
For those mothers who work, maternity leave is short, there is little support at work to breast-feed – even though it is legislated – and the lack of crèches means they are separated from their children.
Teenage mothers leave their babies with relatives, while many women who escape rural poverty and find work in the cities send their babies home to their relatives too.
Making breast-feeding work in these contexts is difficult, but not impossible, says Louise Goosen, who heads up Milk Matters, an NGO which provides donated breast milk to nourish premature babies and give them a fighting chance in some of the region’s most impoverished communities.
“Since the Western Cape introduced ARV treatment for babies of mothers who are HIV-positive the number of mothers who are breast-feeding has increased 800 fold at Mowbray. It’s about HIV-positive women being supported physically and psychologically in every aspect.”
Unicef’s Witten says South Africa is taking its lead from countries like Botswana, which have adopted exclusive breast-feeding, following outbreaks of diarrhoea. “Botswana went the formula route. It’s a small country and it could afford it and it didn’t work.”
However, Saloojee says in many southern African countries such as Zambia, Botswana and Malawi, the evidence is that whether you’re exclusively breast-fed or formula-fed, HIV-free survival is the same. “This has not been shown to be true for South Africa.”
“HIV-free survival,” he explains, “means that if you’re formula fed, you’re protected from acquiring HIV, but may die from diarrhoea or malnutrition. If you breast-feed, you’re more likely to acquire HIV and/or die from it.”
He cites Zambian research, which shows the mortality in a group of HIV-exposed children, at 18 months, was 250 per 1 000.
“Children are dying in large numbers in Zambia whether they are formula-fed or breast-fed because their health systems are extremely weak. In South Africa you would be concerned about any district that has an infant mortality greater than 50. So, to claim that formula feeding does not help in Zambia, or Zimbabwe, therefore it’s inappropriate in South Africa, is an argument that cannot hold.”
It’s true that malnutrition rates have climbed since 1993, but he blames HIV-infection, not formula feeding, and says there is no evidence to support whether South Africa is seeing increased cases of malnutrition and diarrhoea because of formula feeding.
But Goosen disagrees. “Formula for HIV-positive mothers has been a mistake. The babies have not done well. In the past decade, the Red Cross Children’s Hospital has had to open 40 extra beds for the so-called rehydration ward. We’re now seeing kwashiorkor in Cape Town, something we only saw before in deepest, darkest Africa.
“One of the problems is when the free formula stops, the mothers feed their babies tea, watered down mealie meal and low nutritional foods. That can be turned around if we return to a culture of breast-feeding.”
She salutes Motsoaledi for the government’s groundbreaking move to reclaim breast-feeding. “It’s long overdue. HIV has done huge damage to breast-feeding in South Africa.”
But it needs to be promoted. “Mothers today think it’s a 50/50 choice between formula or breast milk. It’s not. It’s a 20/80 choice. You either give your baby an inferior product, or the best available – your breast milk.”