If it confuses you to find the word ‘breastfeeding' under the heading prevention, you're in the majority. The vast majority. Perhaps that's because, for reasons that defy ethics and logic, it remains a well-kept secret by organizations such as UNICEF, UNAIDS and the World Health Organization that HIV-positive mothers — even the poorest and those without access to a clinic or health professional — can breastfeed without transmitting the virus to their infants.

The only thing more astounding than the scientific evidence is the failure to act on it. In March 2007, The Lancet published a study by South Africa's Dr. Hoosen Coovadia and colleagues confirming that exclusive breastfeeding protects against HIV transmission; that babies given formula or other replacement foods instead of exclusive breastfeeding were twice as likely to die by 3 months of diarrhea and other illnesses; AND that contrary to conventional wisdom, it isn't difficult for mothers to learn what "exclusive breastfeeding" means and how to practice it.¹ But that's the mystery; the very organizations entrusted with protecting child and maternal health, the ones that should be rushing to communicate this life-saving message throughout AIDS-affected countries, are doing no such thing.

And as scientific evidence piles up to show that we already know exactly how to put an end once and for all to "mother-to-child transmission" (it is all but gone from the wealthy world), the negligence of those in a position to save infant lives defies explanation.

A handful of women in developing countries are in-the-know — those lucky enough to have been enrolled in one of the very few programmes, like the ones pioneered by the non-governmental organization Sant'Egidio in Mozambique, that offer HIV-positive African women the same odds that western women are given — a 98% chance — to protect their children from HIV infection.

In July 2007, the journal AIDS reported² on results of the DREAM study in which Sant' Egidio took part.  Funded by the World Bank, the study placed HIV-positive pregnant women on the drug regimen that pre-natal clinics in wealthy countries regularly prescribe for their infected patients. 'Highly active antiretroviral therapy' (HAART) was provided to expectant mothers free of charge from the 25th week of gestation, after which their infants received post-exposure prophylaxis. From 2004-2006, 809 study participants in Mozambique, Tanzania, and Malawi also received water filters and formula for 6 months after giving birth.

In 2005, a second group of 251 women in Mozambique was added to the study. They also received HAART for up to 6 months after delivery, but were given the option to breastfeed. The researchers then compared HIV-1 mother-to-child transmission rates, infant morbidity, and mortality in both groups.

The conclusions?  "The DREAM HIV-1 PMTCT protocol was safe and efficacious in reducing transmission in infants of 1 and 6 months of age. Results were comparable to those from developed countries. Breastfeeding among HIV-1 infected mothers receiving HAART posed no additional risk of late postnatal HIV-1 transmission to the infant by 6 months of age."

Sant' Egidio's 5-year-old AIDS programme has now expanded DREAM to nine other African countries with results that, in their words, "prove that it is possible to virtually eliminate mother-to-child transmission. Furthermore, the drugs given allow the women to breastfeed their babies without the risk of passing on HIV in their milk".³  The success rate so far is 98%, or 2,500 babies born HIV-free.  

You'll be confused once again if you turn to the UNICEF for more information about this extraordinary breakthrough, and are eager to learn about the premiere international children's agency's efforts to take it to scale. Our search of the agnecy's website offered up not a single clue that science has solved the breastfeed-or-not dilemma faced by HIV-positive women. Instead, it led us first to the $1 billion Unite for Children, Unite Against AIDS campaign, and a training module called "Infant feeding in the context of infection" and this questionable information for people involved in public health:  "Antiretroviral (ARV) treatment and prophylaxis has substantially reduced mother-to-child transmission of HIV (MTCT). ARV prophylaxis, however, does not provide long-term protection for the infant who is breastfeeding."

Next, the key words "exclusive breastfeeding" led us to Facts for Life, where we hoped to find that the masses were receiving fuller and more accurate information. The intro was encouraging:

Since it was first published in 1989, Facts for Life has become one of the world's most popular books, with more than 15 million copies in use in 215 languages in 200 countries. The book is co-published by UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank.⁵ This revised edition of Facts for Life has updated information on the major causes of childhood illnesses and death, including HIV/AIDS, Emergencies and Accidents. You can access the complete Facts for Life content on this website, as well as the PDF and text-only versions. We urge everyone to share and use these health messages to help save children's lives."

But in the chapter devoted to Breastfeeding, we found: "Key message #2: There is a risk that a woman infected with HIV can pass the disease on to her infant through breastfeeding. Women who are infected or suspect that they may be infected should consult a trained health worker for testing, counselling and advice on how to reduce the risk of infecting the child.... Pregnant women or new mothers who are infected or suspect that they are infected should consult a qualified health worker to seek testing and counselling."

And in the chapter on HIV/AIDS, the instructions to consult a health worker are repeated, with this addition under "Key message #7: New mothers need to know the different options for feeding their infants and the related risks. Health workers can assist in identifying a feeding method that can maximize the infant's chance of growing up healthy and free of HIV." This from a publication co-produced by WHO, the source of the statistic that sub-Saharan, with 24% of the global disease burden, is short 1.5 million health workers.

Not a mention in either chapter of the protective effect of exclusive breastfeeding - and needless to say, neither chapter defines what ‘exclusive breastfeeding' means.

What exactly is the UN doing to prevent mother-to-child transmission, one of the four "key pillars" of UNICEF's "Unite for Children; Unite Against AIDS" campaign launched in October 2005?  Well, the campaign publication informs us that mother-to-child transmission causes most of the 1800 new HIV infections that occur in children every day; that preventing that transmission is one of the four "urgent imperatives" of the 2-year-old campaign; that the goal is, "By 2010, offer appropriate services to 80 per cent of women in need"; and that so far, only 10 per cent of women have access to those services.

In the UNICEF context (although our search of the agency's various websites yielded no succinct definition), it's safe to say that "appropriate services" means the bare minimum: access to the drug Nevirapine that, when administered to a woman during labour and to her baby upon birth, reduces the chance of HIV transmission to the newborn by 50 per cent. It seems that that's good enough for UNICEF.

Try as we might, we couldn't locate an explanation of what the Unite for Children campaign is doing about the second half of its"urgent imperative" to prevent mother-to-child transmission — breastfeeding. The word appears once in the campaign's flagship publication: "North America and Europe have reduced HIV infections in young children to 1 to 2 per cent by combining antiretroviral treatment with elective Caesarean-section delivery and the avoidance of breastfeeding."

What should UNICEF be doing? For starters, catch up with the science.

Second, take all incomplete, misleading and outdated information about HIV and breastfeeding out of publication.

Third, allocate the dollars, expertise, time, materials, energy and commitment required to initiate a global information campaign about exclusive breastfeeding, so that every woman who needs that "appropriate service" can receive it by the target date of 2010.

Fourth, end the double standard immediately. HIV-positive pregnant women north AND south need and deserve full HAART.  Nothing can explain, justify or excuse the fact that, at a point in time when preventing 98% of transmission to infants is entirely possible, the world seems content to offer protection to 50% of the babies who need it in the developing world and allow the other half die.

1. See comment and a link to the full article at: http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607605054.pdf
2. Read the abstract here.
3. Press release: http://worldaidscenter.blogspot.com/2007/07/mozambique-fifth-annoiversary-of.html
4. Reminder as you read on: the World Bank supported the DREAM research.

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