EDITOR'S NOTE: While the guidelines for breastfeeding among mothers with HIV at the time of the publication of this story suggested using formula where possible to avoid transmission, the WHO in its 2010 guidelines said that exclusive breastfeeding for the first six months, combined with anti-retroviral therapy is now the preferred course of action.
HIV-positive mothers in Cambodia face a choice between two risky options: to breastfeed
and risk transmitting the disease, or use formula and hope that water and bottles
are clean enough to avoid potentially deadly infant illnesses.
But a study into the decision-making processes of women in this situation has found
that the "counselling" offered by clinics was less important to mothers
than what programs for prevention of mother-to-child transmission were available
free through NGOs.
The study, A Choice? By Women? was conducted for the French National Aids Research
Agency by Soizick Crochet and interviewed 43 HIV-positive mothers from the poorest
segments of society in and around Phnom Penh. Almost all were financially supported
by an NGO and all were feeding their baby with milk substitute formula in the hope
they could avoid passing on the disease to their child.
"The preliminary results of the research on infant feeding among HIV-positive
women in Phnom Penh, in 2002-2003, concludes that so far there is little room for
a choice since either method (exclusive breastfeeding or infant formula) is attached
to the institutions' modus operandi," the report said.
The issue of HIV transmission through breastfeeding is a hot topic for health experts
and NGOs. Cambodia's national policy is to advocate for exclusive breastfeeding but
leave the final decision up to the mother. But policies on the issue vary between
"Despite recurring recommendations from several coordinating bodies, each player
tends to follow a different agenda," said the report.
"Furthermore, they can operate independently and depart from the National Strategic
Plan recommendations. As a result distinct, sometimes divergent, policies and programs
are offered to the public."
In middle-income countries, authorities usually recommend the use of infant formula
to avoid the risk of transmission through breastfeeding, but in Cambodia, where access
to safe water to dilute the powdered milk substitute, hygienic preparation of bottles
and the cost of buying products are issues, the choice is more complex.
More than half of the mothers involved in the study believed that breast milk was
preferable to formula in nutritional value, but either did not know the risks of
HIV transmission through breastfeeding or thought it was 100 percent.
The World Health Organization says that breastfeeding can add to the risk of HIV
transmission by 5 to 20 percent, with the overall health of the mother and the timing
of her infection just two of the factors that might account for such a wide range
in the risk of transmission..
Etienne Poirot, from the HIV/AIDS section of UNICEF, offered another breakdown of
the risks: "In addition to the 15 to 20 percent of children who may become infected
during pregnancy or delivery, a further 10 to 20 percent of the children born to
HIV-infected mothers may become infected if they are breastfed," Poirot wrote
in a March 3 email.
There are an average of 20 new cases of HIV every day in Cambodia, said the A Choice?
By Women? report, and five of those would be newborn babies. But figures published
in The Lancet Child Survival Series said that in 2000, diarrhea was responsible for
22 percent of preventable infant deaths in countries like Cambodia with the highest
child mortality rates, compared with AIDS, which caused 3 percent of child deaths.
Most dangerous, said the report's author, Soizick Crochet, was the practice of "mixed
feeding", using both breast milk and formula, which significantly increased
the risk of transmission as well as diarrhea.
Poirot said that evidence suggests this increased risk is caused by damage done to
the intestinal tract of babies by the early introduction of other foods, allowing
infection to take hold more easily.
The issue of whether HIV-positive mothers should breastfeed also touches on social
and cultural issues.
The report notes that the use of formula products carries a social stigma in some
West African countries that is not the same in Cambodia. For Cambodian women, using
expensive breast milk substitute products is "linked to high social status",
not necessarily to HIV status.
"They [mothers surveyed] made it clear that for them biological risk (contamination
of the child) was more important than the social risk (discrimination of the mother)
and they had chosen what they thought would best protect their child," the report