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

organizations.

"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

said.