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Preventing the spread of HIV through breastfeeding

Statement Attributable to Carol Bellamy, Executive Director of UNICEF

See also: Carol Bellamy's Letter to the Editor, The Wall Street Journal

In A Nutshell: UNICEF Continues To Support Breastfeeding for Most Mothers,
But Continues To Provide Formula to HIV-Positive Women Who Choose It

14 December 2000: Several recent media reports on the subject of preventing mother-to-child transmission of HIV through breast milk have presented an incomplete and in some cases erroneous set of facts. Because this subject is so important to women and children throughout the world, and because UNICEF is playing a leading role in prevention efforts, we believe the public should have all the available information.

At the heart of the matter is a simple fact: Women who are HIV-positive and breastfeed face about a 15 percent chance of transmitting the virus to their infants through breast milk if no intervention takes place. Since the beginning of the HIV/AIDS crisis almost 20 years ago, between 1.1 million and 1.7 million children are believed to have contracted HIV this way. Almost all of these cases have been in the developing world, particularly in sub-Saharan Africa.

In the industrialized world, transmission of HIV through breast milk has been successfully limited through the introduction of HIV tests for pregnant women; quality medical care that includes the use of anti-retroviral drugs; and encouraging the use of breast milk substitutes among women found to be HIV-positive - a strategy that works well in most of the industrialized world because substitutes can be prepared and used safely.

Unfortunately, in the developing world, each of these three keys to prevention is severely lacking.

Access to voluntary and confidential HIV testing is the primary challenge. Only about 5 per cent of adults in sub-Saharan Africa know their HIV status, and testing is not yet widely accessible. Even where testing is available, fear, misinformation, cultural taboos and reluctant leadership all feed a widespread reluctance to embrace it. Yet to effectively prevent mother-to-child transmission of HIV, it is essential that women know whether or not they are HIV-positive. Without that knowledge, women are left with a choice of taking no action at all or to taking blind action that could be very harmful to their infants.

The second challenge is the state of health care in many parts of the developing world, especially in the countries hardest hit by HIV. Governments are stricken with debt, health infrastructures are thin and poorly-equipped, and even basic health care is not available to many women and their children. Meanwhile, the spread of HIV has overwhelmed the capacity of most health systems, and thousands of health care workers themselves are being lost to the disease they are so desperately needed to fight. In this context, providing anti-retroviral treatment for pregnant women is a serious challenge.

The third challenge in preventing the transmission of HIV from mother to child is providing women with the option of safe, feasible, affordable, acceptable and sustainable substitutes for breast milk. This challenge is considerably more complex than it may at first appear, and it is on this point in particular that media reports have been misleading or completely wrong. For this reason further detail is required.

Commercial infant formula can be a valuable substitute for breast milk among HIV-positive women. In the developing world, however, formula has some very significant limitations. Chief among these is that formula poses serious health risks in most developing world settings. Its safe preparation requires clean water, decent sanitation, adequate fuel, and careful instruction. But instead it is often mixed with water from contaminated sources, which, for lack of fuel, cannot be boiled adequately. And the process often takes place in the worst of sanitary conditions, using the wrong concentrations and fed from bottles which are impossible to clean. When any of this happens, formula can quickly introduce deadly infections into infants it is meant to protect.

Scientists and researchers have found, in fact, that in developing countries formula-fed infants are 4 to 6 times more likely to die from infectious diseases than breast-fed infants. And the World Health Organization (WHO) estimates that 1.5 million infants die each year because of a lack of breastfeeding.

These well-documented facts - backed by years of field observation by UNICEF and others - mean that where water, sanitation and poverty are problems formula must be used with the utmost care. In the context of preventing mother-to-child transmission of HIV, free and steady supplies of formula should be made available only to those HIV-positive women who have chosen this option on the basis of full information. Any broader push toward formula - in particular among HIV-free women or women whose HIV status is unknown - would result in deaths among babies not threatened by HIV, and that is an outcome none of us desires.

Taking these facts into account, in 1997 WHO, UNICEF and UNAIDS (the Joint UN Programme on HIV/AIDS) established a basic policy on appropriate approaches to the prevention of mother-to-child transmission of HIV. That policy was reaffirmed and elaborated on this past October at a global consultation of leading physicians, scientists and researchers convened by WHO.

The policy as it has evolved affirms that breastfeeding remains the best and safest choice for women who are HIV-free or who do not know their HIV status.

It also states that in order to effectively stop the spread of HIV from mother to child while at the same time protecting the health of all other infants, the following steps are necessary: First, that voluntary and confidential HIV testing be made available to all people, and that they be publicly encouraged to take advantage of it; second, that HIV-positive women be provided with sound prenatal care and that they be offered anti-retroviral drugs that lessen the risk of HIV transmission to their infants; third, that they be counseled on the benefits and risks of all available feeding options, based on the best available information, and be given specific guidance on what might be best in their local circumstances; fourth, that the choice of feeding option is the woman's by right; fifth, once a woman makes a choice, that she be fully supported in that choice; and sixth, that when an HIV-positive woman chooses to breastfeed, that she be counseled on means of doing it most safely.

In conjunction with the 1997 policy, the three UN agencies also developed guidelines for "pilot projects" to prevent mother-to-child transmission of HIV in developing countries. The pilots were designed to include all the above services, and in 1998 discussions began with governments in 11 countries on the further development and introduction of the projects. UNICEF country offices led these coordinated efforts.

Over the last year, the projects have reached more than 30,000 women with HIV testing and counseling, improved health care, anti-retroviral drugs, counseling on feeding options, and for women who choose formula, a free and steady supply of generic formula and instruction in its safe preparation. In some countries the government procures the formula. In others, UNICEF procures and ships it. It does so using the same expertise it uses each year to procure and deliver millions of dollars worth of vaccines. To date, one-half to two-thirds of the HIV-positive women we have reached through these prevention projects have chosen formula, and we have helped provide it. One-third to one-half of the women have made other choices, including breastfeeding.

The fundamental purpose of these projects is to prevent mother-to-child transmission through the use of anti-retroviral drugs and a proactive approach to feeding options. Yet perhaps no aspect of the work has proven to be more challenging than overcoming the fear and misinformation that keep so many women from learning their HIV status in the first place. Success means not only reaching individual women and helping nurture their inherent courageousness, but helping entire communities overcome the stigma, shame and rejection commonly associated with HIV/AIDS.

There is much work to be done. While we are still learning from the existing projects, we are working as expeditiously as possible with governments to prepare the ground for similar programs in other AIDS-ravaged countries. To support this expansion we are developing partnerships with donor governments and agencies, and with local, national and international non-profit groups. In December 2000, for example, the US Government announced a donation to a prevention program in Botswana that was originally started by the Botswana Government with the support of UNICEF.

One thing that UNICEF is not willing to do is partner with organizations whose business practices do not fit, in our view, with UNICEF's mission and principles. With specific regard to infant formula, UNICEF does not accept donations in cash or in-kind from formula manufacturers that are believed to violate the International Code of Marketing of Breast-Milk Substitutes.

The reasons for this are straightforward. The Code is an internationally-adopted instrument whose only purpose is to protect the health and well-being of women and children. There is no commercial interest behind it, nor commercial benefit to be gained in supporting it. It was born of an urgent need to save the lives of millions of infants world-wide who were dying of diseases related to formula use. The Code, which was developed through a process that included formula manufacturers and which was adopted by the World Health Assembly in 1981, provides common sense rules for protecting women and children from the serious health risks that formula use engenders. For example, among many other provisions it establishes labeling guidelines to ensure that clear instructions for formula preparation are printed in the local language.

UNICEF does not formally monitor the Code. Governments and devoted consumer-protection bodies monitor compliance with the Code and publish periodic reports of their findings. Some of these reports have been confirmed by independent groups seeking to ensure objectivity in the monitoring process. Almost 20 years after the Code was adopted, most large companies that manufacture and market formula are still found to be non-compliant in various ways, to varying degrees, and in varying countries. In the one instance that UNICEF turned down a proposed donation of formula it was for this reason. It was a decision that did not impact in any way our capacity to deliver generic formula to mothers who needed it.

However, it is important to make clear that our door remains open to discussions with formula manufacturers who genuinely are committed to the best interests of children, just as with any other company. Indeed, UNICEF is widely regarded as having excellent relations with the private sector. Over the last two years, we welcomed in-kind donations valued at more than $210 million. And while we are pleased to partner on behalf of children, we are not afraid to stand up for them, either.

UNICEF is very aware of the complex and paradoxical challenges presented by the HIV pandemic. Our devoted staff of doctors, educators, nutritionists, water experts and others in 161 countries around the world witness the struggles daily. But UNICEF has not shied from tackling even the most difficult challenges. We are right in there, pushing forward with intensive efforts to provide widespread and creative AIDS education, as well as to protect and care for the millions of children already orphaned by AIDS. And together with WHO, UNAIDS and UNFPA we have embarked on a serious, sophisticated and promising approach to preventing the spread of HIV from mother to child - one which we will continue to learn from, improve and expand.

We certainly do not have all the answers. The approaches we have developed are a recognition that absolutely nothing is easy about HIV/AIDS, least of all the safe and effective prevention of mother-to-child transmission. But the hard choices we have made have been based on hard-won experience, thorough research and study, a global consensus among scientists, and an abiding and deeply rooted concern for the best interests of women and children.