HIV, breastfeeding, and infant mortality: weighing the impact of the non-evidenced-based WHO/UNAIDS recommendations in the low-income, low-resource countries of Sub-Saharan Africa

HIV, breastfeeding, and infant mortality: weighing the impact of the non-evidenced-based WHO/UNAIDS recommendations in the low-income, low-resource countries of Sub-Saharan Africa

Breastfeeding by HIV positive mothers: questioning the recommendations of WHO/UNAIDS

This paper challenges the WHO/UNAIDS recommendations regarding breastfeeding and HIV positive mothers in low-income, low-resource countries.

The paper shows that although almost all paediatric HIV is due to maternal to child transmission (MTCT), in 1992, WHO/UNAIDS recommended that breastfeeding should be advised for pregnant women, including those who are HIV+, in countries with high infant mortality due to infectious diseases and malnutrition. The 1997 UNAIDS Policy Guidelines recommended that, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted, and supported and that HIV+ women should be counselled as to the risks and benefits of breastfeeding and formula feeding relating to MTCT.

Further revisions in 1998 added the recommendation for short-term 3-6 months exclusive breastfeeding and support of informed choice. But in October, 2000 a WHO technical consultation inter-agency task team on MTCT of HIV met in Geneva to review new data on the prevention of MTCT of HIV and their policy implications. Their conclusions and recommendations approved on January 15, 2001 included the following statement: “when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended”.

The paper concludes:

  • Population Reference Bureau’s Breastfeeding Patterns in the Developing World with Selected Maternal and Child Health Indicators unquestioningly uses the 14% MTCT figure. All too often ministries of health feel pressured by such publications and the recommendations of expert organisations such as WHO, World Bank, UNICEF, and UNAIDS when forming their country’s policies
  • further pressure is brought by donors who question a country’s commitment to solving problems if recommendations from experts are not followed
  • global recommendations are simplistic, one-answer-fits-all solutions, which are often inappropriate and destructive to an individual country. The public health community should be mindful that it is unlikely that there is one right answer to any global public health problem
  • the widening gap between industrialised and developing countries is being exacerbated by globalisation, resulting in a transfer of traditional to industrial values and practices
  • making recommendations and decisions based on relevant, community-specific evidence is imperative
  • it is expected that prominent organisations such as WHO and UNAIDS will accept their responsibility to provide a systematic review of all available data and to give evidence-based recommendations that will no longer lead government leaders astray and result in increased infant mortality
  • it is essential that these measures be carried out to responsibly support the needs and realities of any given woman in any specific community in either the industrialised or the least developed, resource poor countries
  • where interventions have been undertaken, these results should be vigorously scrutinised. In these and future intervention trials, overall infant mortality, not HIV transmission, must be the key outcome evaluated
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