- Email: [email protected]
Breastfeeding and HIV transmission – Authors' reply
Correspondence
In our Comment on Coovadia and colleagues’ study, we did not discuss the implications for the infant feeding choice of HIV-positive pregnant women, but drew attention to the new WHO Consensus Statement of 2006.1 This statement endorses the recommendation that HIV-positive mothers should avoid all breastfeeding when it is acceptable, feasible, affordable, sustainable, and safe. We agree that some mothers can safely avoid breastfeeding if they can afford or are provided with a sustained supply of formula. It is worth noting that these infants are vulnerable to unpredictable events such as outbreaks of diarrhoea, natural disasters, civil disturbance, or other interruption to the formula supply. But the understandable desire to prevent transmission of HIV has led to promotion of replacement feeding in many situations where it is not acceptable, feasible, affordable, sustainable, or safe (for example in many Indian settings2), and it turns out to be more dangerous than expected. In these situations, exclusive breastfeeding is recommended for the first 6 months of life, the decision depending on the family’s individual circumstances.1 We chose to focus on a different policy implication of the study findings—the general promotion of exclusive breastfeeding—because this is rarely highlighted. General promotion of exclusive breastfeeding could reduce the risk of paediatric HIV where pregnant women are not tested for HIV, or become infected late in pregnancy or during breastfeeding. It would also contribute to child survival.3 Studies show that advice during pregnancy to breastfeed exclusively is insufficient; timely postnatal support and specific information, for example about increased suckling when mothers are worried about their milk supply, are necessary, and these can be provided by trained lay counsellors. Safe formula feeding requires an www.thelancet.com Vol 369 June 23, 2007
equivalent standard of training, counselling, and support. We agree that it would have been appropriate to mention, as the researchers did, that the confounding factor of low maternal CD4 cell count was more frequent in the formula-fed group and would have influenced mortality risk. The size of the formula-fed group was too small to allow adjustment for this factor, but it seems unlikely that the relatively small difference in proportions of low maternal CD4 counts alone could have accounted for the observed difference in early mortality. Higher early mortality has also been seen in other formula-fed cohorts.1,4,5 Perhaps prophylactic cotrimoxazole reduced mortality risk in the Abidjan study mentioned by Haroon Saloojee. We declare that we have no conflict of interest.
*Wendy R Holmes, Felicity Savage [email protected] Centre for International Health, Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria 3001, Australia (WRH); and Centre for International Health and Development, London, UK (FS) 1
2
3
4
5
WHO. WHO HIV and Infant Feeding Technical Consultation Consensus Statement. Geneva: World Health Organization, 2006. http://www.who.int/ child-adolescent-health/New_Publications/ NUTRITION/consensus_statement.pdf (accessed April 30, 2007). Phadke MA, Gadgil B, Bharucha KE, et al. Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization. J Nutr 2003; 133: 3153–57. Bahl R, Frost C, Kirkwood BR, 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; 83: 418–26. Onyango C, Mmiro F, Bagenda D, et al. Early breastfeeding cessation among HIV-exposed negative infants and risk of serious gastroenteritis: findings from a perinatal prevention trial in Kampala, Uganda. 14th Conference on Retroviruses and Opportunistic Infections. Feb 25–28, 2007; Los Angeles, CA, USA. http://www.retroconference.org/2007/ Abstracts/29008.htm (accessed April 30, 2007). Sinkala M, Kuhn L, Kankasa C, et al. No benefit of early cessation of breastfeeding at 4 months on HIV-free survival of infants born to HIV-infected mothers in Zambia: the Zambia Exclusive Breastfeeding Study. 14th Conference on Retroviruses and Opportunistic Infections. Feb 25–28, 2007; Los Angeles, CA, USA. http://www. retroconference.org/2007/Abstracts/30664. htm (accessed April 30, 2007).
Australian politics Among the worst of your recent Editorials is the one condemning the Australian Prime Minister (April 21, p 1320).1 The Editorial is astonishingly superficial, considering the scope of the subject (medical screening of potential immigrants, aboriginal health, academic medicine). It relies on the evidence of a vague remark made by the Prime Minister in a radio interview, a statement by an “Australian columnist” in a newspaper, a recent remark by the Health Minister regarding activists on indigenous health, and the opinion of a “respected scientist”. The gratuitous advice, offered in the last sentence, is a fitting climax to a crescendo of inconsequentialities. Australia should vote against the Prime Minister at the next election, and thereby bring “a new enlightenment to Australian health and medical science”. Really? The writer has now exceeded even the relatively vast scope covered in the previous few hundred words and is reaching for conclusions for which no evidence of any value has been presented.
The printed journal includes an image merely for illustration AP
Authors’ reply
I declare that I have no conflict of interest.
Stephen Due [email protected] Barwon Health Library Service, PO Box 281, Geelong, Victoria 3220, Australia 1
The Lancet. Australia: the politics of fear and neglect. Lancet 2007; 369: 1320.
Your Editorial1 has been dismissed by our great leaders. In this process, The Lancet joins a growing but select swag of intellectual endeavours and criticisms (inconvenient truths) that the Australian masses have been told they best not think about. You write that, to any visitor, Australian culture feels progressive and inclusive. You must be joking! Such a reception might be sensed by those wealthy enough to arrive by air. But if you are unfortunate enough to be fleeing persecution, your fate on seeking Australian protection is likely to be incarceration in an offshore 2075
In our Comment on Coovadia and colleagues’ study, we did not discuss the implications for the infant feeding choice of HIV-positive pregnant women, but drew attention to the new WHO Consensus Statement of 2006.1 This statement endorses the recommendation that HIV-positive mothers should avoid all breastfeeding when it is acceptable, feasible, affordable, sustainable, and safe. We agree that some mothers can safely avoid breastfeeding if they can afford or are provided with a sustained supply of formula. It is worth noting that these infants are vulnerable to unpredictable events such as outbreaks of diarrhoea, natural disasters, civil disturbance, or other interruption to the formula supply. But the understandable desire to prevent transmission of HIV has led to promotion of replacement feeding in many situations where it is not acceptable, feasible, affordable, sustainable, or safe (for example in many Indian settings2), and it turns out to be more dangerous than expected. In these situations, exclusive breastfeeding is recommended for the first 6 months of life, the decision depending on the family’s individual circumstances.1 We chose to focus on a different policy implication of the study findings—the general promotion of exclusive breastfeeding—because this is rarely highlighted. General promotion of exclusive breastfeeding could reduce the risk of paediatric HIV where pregnant women are not tested for HIV, or become infected late in pregnancy or during breastfeeding. It would also contribute to child survival.3 Studies show that advice during pregnancy to breastfeed exclusively is insufficient; timely postnatal support and specific information, for example about increased suckling when mothers are worried about their milk supply, are necessary, and these can be provided by trained lay counsellors. Safe formula feeding requires an www.thelancet.com Vol 369 June 23, 2007
equivalent standard of training, counselling, and support. We agree that it would have been appropriate to mention, as the researchers did, that the confounding factor of low maternal CD4 cell count was more frequent in the formula-fed group and would have influenced mortality risk. The size of the formula-fed group was too small to allow adjustment for this factor, but it seems unlikely that the relatively small difference in proportions of low maternal CD4 counts alone could have accounted for the observed difference in early mortality. Higher early mortality has also been seen in other formula-fed cohorts.1,4,5 Perhaps prophylactic cotrimoxazole reduced mortality risk in the Abidjan study mentioned by Haroon Saloojee. We declare that we have no conflict of interest.
*Wendy R Holmes, Felicity Savage [email protected] Centre for International Health, Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria 3001, Australia (WRH); and Centre for International Health and Development, London, UK (FS) 1
2
3
4
5
WHO. WHO HIV and Infant Feeding Technical Consultation Consensus Statement. Geneva: World Health Organization, 2006. http://www.who.int/ child-adolescent-health/New_Publications/ NUTRITION/consensus_statement.pdf (accessed April 30, 2007). Phadke MA, Gadgil B, Bharucha KE, et al. Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization. J Nutr 2003; 133: 3153–57. Bahl R, Frost C, Kirkwood BR, 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; 83: 418–26. Onyango C, Mmiro F, Bagenda D, et al. Early breastfeeding cessation among HIV-exposed negative infants and risk of serious gastroenteritis: findings from a perinatal prevention trial in Kampala, Uganda. 14th Conference on Retroviruses and Opportunistic Infections. Feb 25–28, 2007; Los Angeles, CA, USA. http://www.retroconference.org/2007/ Abstracts/29008.htm (accessed April 30, 2007). Sinkala M, Kuhn L, Kankasa C, et al. No benefit of early cessation of breastfeeding at 4 months on HIV-free survival of infants born to HIV-infected mothers in Zambia: the Zambia Exclusive Breastfeeding Study. 14th Conference on Retroviruses and Opportunistic Infections. Feb 25–28, 2007; Los Angeles, CA, USA. http://www. retroconference.org/2007/Abstracts/30664. htm (accessed April 30, 2007).
Australian politics Among the worst of your recent Editorials is the one condemning the Australian Prime Minister (April 21, p 1320).1 The Editorial is astonishingly superficial, considering the scope of the subject (medical screening of potential immigrants, aboriginal health, academic medicine). It relies on the evidence of a vague remark made by the Prime Minister in a radio interview, a statement by an “Australian columnist” in a newspaper, a recent remark by the Health Minister regarding activists on indigenous health, and the opinion of a “respected scientist”. The gratuitous advice, offered in the last sentence, is a fitting climax to a crescendo of inconsequentialities. Australia should vote against the Prime Minister at the next election, and thereby bring “a new enlightenment to Australian health and medical science”. Really? The writer has now exceeded even the relatively vast scope covered in the previous few hundred words and is reaching for conclusions for which no evidence of any value has been presented.
The printed journal includes an image merely for illustration AP
Authors’ reply
I declare that I have no conflict of interest.
Stephen Due [email protected] Barwon Health Library Service, PO Box 281, Geelong, Victoria 3220, Australia 1
The Lancet. Australia: the politics of fear and neglect. Lancet 2007; 369: 1320.
Your Editorial1 has been dismissed by our great leaders. In this process, The Lancet joins a growing but select swag of intellectual endeavours and criticisms (inconvenient truths) that the Australian masses have been told they best not think about. You write that, to any visitor, Australian culture feels progressive and inclusive. You must be joking! Such a reception might be sensed by those wealthy enough to arrive by air. But if you are unfortunate enough to be fleeing persecution, your fate on seeking Australian protection is likely to be incarceration in an offshore 2075