Breastfeeding and AIDS in Africa
This article was written in June 2000
and posted during the Internet Discussion
of the South African Presidential AIDS Advisory Panel
For more than a decade publications have been addressing the possibility that AIDS can be transmitted through breastfeeding. The United Nations agencies UNAIDS, UNICEF, and WHO have suggested HIV-positive mother stop breastfeeding to avoid the transmission of HIV/AIDS from mother to child.
In the USA some states have gone further and have regulated the matter, making HIV testing mandatory for all pregnant women and their babies. Mothers and babies who react positively on tests for antibodies to HIV are medicated with anti-retrovirals, and mothers are forced not to breastfeed their babies. Cesarean section and cleansing of the birth canal with antiseptic solutions are also suggested (1,2). Additionally, effective on June 1st 2000, the State of New York passed a new law by which every person who reacts positively on the "tests for HIV" has to be reported to the health authorities (name and address is required) (3).
Regarding the underdeveloped countries, UN agencies have engaged in a great deal of speculation upon these maters (4,5).
However, there is no objective evidence for the hypothesis that HIV/AIDS can be transmitted from mother to child through breast milk. This is an assumption without any scientific validation. Careful analysis of the entire body of research on HIV/AIDS shows a great deal of bias. The trials conducted to test HIV transmission through breastfeeding are no exception; they contain serious bias as well.
Let me analyze briefly some reports of experiments that are often referenced:
1. Bobat R, Moodley D, Coutsoudis A, Coovadia H. Breastfeeding by HIV-1-infected Women and Outcome in Their Infants: A Cohort Study From Durban, South Africa. AIDS 1997; 11: 1627-1633.
In this study the authors were able to follow 133 infants that were born HIV-negative to HIV-positive mothers. 21 infants (16%) were fed exclusively on formula, 36 infants (27%) exclusively breastfed, and 76 (57%) received both breast and formula feeds.
The South African researchers concluded "it was found that infants who were exclusively formula-fed had a lower transmission rate (24%) than those who received either mixed feeding (32%) or were exclusively breastfed (39%); the relative risk for infection in the exclusively breastfed versus those on formula only, was 1.63 (Cl, 0.71-3.76; P = 0.24)." And "there was a stepwise increase in the transmission rate with duration of exclusive breastfeeding of 1, 2, and 3 months (45%, 64%, and 75%, respectively)."
The researchers also concluded "Deaths occurred only in the HIV-infected infants. Of the 17 infected infants who died, seven were exclusively breastfed and 10 had mixed feeding. No deaths occurred in the exclusively formula-fed group during the study period, compared to a mortality of seven out of 36 (19%) in the exclusively breastfed infants, and of 10 out of 76 (13%) in the infants receiving mixed feeding." And "we found mortality to be highest in the exclusively breastfed infants; seven out of 14 (50%), compared to 10 out of 24 (42%) in the infants receiving mixed feeding and 0 out of 5 (0%) in those infants receiving formula only"
"Among the infected infants, seven out of 14 (50%) of those exclusively breastfed, 13 out of 23 (54.1%) on mixed feeding, and none out of four (0%) on formula only, developed AIDS during the study period"
However, following are two of the more evident biases present in this report:
a) This study is strongly influenced by the researchers beliefs. The authors believe that AIDS is an infectious disease caused by HIV, that AIDS is a transmissible disease, that a positive result in tests for antibodies to HIV is indicative of infection with HIV, and that once positive on these tests the individual will develop AIDS, to mention just some of their most evident assumptions that are easily seen on reading the paper.
The authors craft definitions according to their beliefs. In this way they declare "Infants were regarded as infected if they were antibody positive at 15 months or had an HIV-related death". And "They were classified as non-infected if the antibody test was negative from 9 months of age, or if death was non-HIV-related"
The authors tested for antibodies to HIV in both maternal and infant blood by ELISA and immunofluorescent assays. "Samples were considered positive if a second ELISA or the IFA was positive."
The authors defined "transmission of HIV" from HIV-positive mother to infant through breastfeeding as an infant reacting positively on tests for antibodies to HIV after having reacted negatively at birth on the same tests."
However, if one defines as "intoxicated" individuals¾ in this case infants¾ those that react positively on the tests for HIV, and "non-intoxicated" the ones that react negatively; and if one assumes that the only source of intoxication is breast milk, the conclusion would be that what is being "transmitted" from mothers to infants are toxins rather than HIV. But this conclusion would also be wrong since it negates the possibility of becoming intoxicated from exposure to external agents while being breastfed. The source of intoxication could be environmental toxins that have nothing to do with breastfeeding. Breastfeeding would be a practice that happens at the same time that infants are being intoxicated. The longer the time of breastfeeding, the longer the exposure to toxins, and so the greater the possibility of becoming intoxicated and testing positive on the so-called tests for HIV. The intoxication would occur independently of breastfeeding, formula feeding, or mixed feeding.
Also, since it was assumed that breastfeeding could be a source of transmission of the virus that supposedly causes AIDS, the South African researchers did not search for exposure to chemical, physical, biological, or nutritional immunological stressors, as risk factors for reacting positively on the tests for HIV and for developing AIDS. They did not feel the need to search for other risk factors. For them "HIV antibodies" explain everything. It sounds as if these researchers do not know the immunotoxic properties of hundreds of stressor agents that South African families are being exposed to from the very moment of their birth (6,7).
Neither do the South African researchers describe in their article the financial position of the families involved in this study. They do not consider the possibility that mothers who fed their babies only with formula enjoyed better financial conditions (they were able to afford formula) and therefore would have less exposure to immunological stressor agents and therefore the risk that their babies would react positively or would develop AIDS was lower.
The researchers also "found that infants who were exclusively formula fed had a lower transmission rate (24%)" However, researchers did not give any explanation of how these 5 infants got infected with HIV. Since the researchers assumed that infants were infected with HIV through their feedings, this could be interpreted to mean that these infants got infected with HIV from the formula itself or from the bottles in which the formula was placed.
Bobat and coworkers do not consider the possibility that babies who became positive on the tests for HIV months after birth, and who developed AIDS, did so probably due to having been exposed, like their mothers, to more immunological stressor agents than the ones that did not (6,8), and that this has nothing to do with breastfeeding.
b) The researchers did not use controls. They state: "As the benefits of breastfeeding were well established, we did not include a control group of HIV-negative pregnant women and their offspring". And "the women were not randomly allocated to breastfeeding versus non-breastfeeding groups; they self-selected their feeding method. It has been argued, among key research scientists, that randomized studies in poor countries will be unethical."
It is amazing that the South African researchers did not consider it unethical to come to conclusions on breastfeeding based upon a non-controlled study.
In the light of these biases one cannot accept the conclusions from this study as being scientifically valid.
2. Becquart P, Garin B, Sepou A, et al. Early Postnatal Mother-to-Child Transmission of HIV-1 in Bangui, Central African Republic. Abstract 242/Session 33. 5th Retrovir Oppor Inf. 1998 February 1-5; 124 (Abstract No. AIDS/98929169). Viromed <http://126.96.36.199/cgi-bin/version_B/IGT-client?16132+detail+16>
In this study reported at the 5th Conference on Retroviruses and Opportunistic Infections, the authors concluded that "21 of 43 [48%] children were not infected at 6 months, and were therefore at risk for late postnatal HIV transmission. 14 [32%] children were infected perinatally, and 8 [19%] children postnatally". The authors conclude: "These results underline that about 20% of children born from HIV-1-infected mothers are becoming HIV-1-infected by breastfeeding before 6 months. Stopping breastfeeding after 6 months, as previously proposed, could not reduce early postnatal HIV transmission; bottle-feeding or stopping breastfeeding earlier than 6 months should be more convenient."
This study was carried out by African researchers together with researchers from the laboratory on retroviruses at the Pasteur Institute in Paris, including Dr. Barre-Sinoussi, the principal author of the paper that in 1983 reported what was supposedly the first "isolation" of the virus currently known as HIV (9).
This research upon "Early Postnatal Mother-to-child Transmission of HIV-1 in Bangui, Central African Republic" is also replete with bias. It is strongly influenced by the researchers beliefs. They state "Breastfed children born to HIV-positive mothers are known to be at substantial risk of late postnatal HIV transmission." However, the researchers do not provide scientific evidence for stating that infants "are known to be at substantial risk of late postnatal transmission." They ignore the dictum that science is built on facts, not on "known" beliefs.
The African and French researchers employ definitions in accordance with what is "known" or believed about HIV causing AIDS: "HIV-1 infection was assessed by a positive PCR"; "HIV transmission was defined by a positive HIV-1 PCR at birth or 1 month"; "it was further confirmed by genetic relatedness between viral strains from PBMCs child and those from breast milk."
The African and French researchers ignored all scientific publications documenting that PCR is not specific for HIV infection (10,11). They do not know that the reactivity of the PCR test for HIV can also be explained as part of the response of cells to exposure to a variety of stressors or oxidizing agents, rather than due to an infection with a virus named HIV (11). The authors also ignore the immunotoxic properties of malnutrition, infections, parasites, and other consequences of poverty from which many African communities suffer. They prefer to place the blame on HIV. They cannot see the real cause of AIDS in Africa. HIV does not permit them to see it.
3. Lewis P, Nduati r, Kreiss JK, et al. Cell-Free Human Immunodeficiency Virus Type 1 in Breast Milk. J Inf Dis 1998; 177: 34-39.
In this study carried out by researchers at the University of Washington, Seattle and University of Nairobi, Kenya, 75 samples of breast milk from "HIV-1-seropositive women" were analyzed by quantitative competitive reverse transcription¾ polymerase chain reaction¾ and "HIV-1 RNA was detected in 29 (39%)." Also they found that "the prevalence of cell-free HIV-1 was higher in mature milk (47%) than in colostrum (27%)"; and "Because mature milk is consumed in large quantities, these data suggest that cell-free HIV-1 in breast milk may contribute to vertical transmission of HIV-1."
Again, this study is biased: no controls were used. Doctor Lewis and his colleagues did not match their breast milk specimens with breast milk from HIV-1-seronegative women. They do not consider possibilities other than HIV infection to explain the PCR positive reactions to breast milk. It seams that they do not know that the PCR test can react positively in the absence of HIV (12,13).
Dr. Lewis and his group believe that the only reason for reacting positively on HIV-1 PCR is infection with HIV-1. It seams that they do not know that both antibody tests and amplification tests (PCR) for HIV can react positively to more than 70 different common conditions (8,10,11,14,15), all related to oxidative processes (14,16,17). Neither did they consider the possibility that the reactivity for HIV-1-QC-RT-PCR was higher in mature milk than in colostrum simply because mature milk may contain a higher amount of free radicals¾ oxidizing agents¾ than colostrum, as happens in most human processes (18-21).
4. Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of Human Immunodeficiency Virus Type 1 Transmission Through Breastfeeding. Lancet 1992; 340: 585-588.
In this review article from the Unit of Epidemiology and Biostatistics, Institute of Child, London, the authors came to the conclusion that "based on four studies in which mothers acquired HIV-1 postnatally, the estimated risk of transmission is 29%". And this analysis of five studies showed that "when the mother was infected prenatally, the additional risk of transmission through breastfeeding, over and above transmission in uterus or during delivery, is 14%"
It is amazing that these authors who should be familiar with epidemiology did not realize that all of the studies that they analyzed are biased by the belief that reactivity to the tests for HIV is due only and exclusively to an active infection with HIV. None of the articles that Dunn, Newell, Ades, and Peckhman analyzed consider the possibility that mothers and infants can react positively on the tests for HIV due to the exposure to stressor or oxidizing agents not related to HIV (6,8,11). They did not consider "human immunodeficiency virus type 1 transmission through breastfeeding" to be a strong epidemiological confounding factor.
In this review article it is easily seen that the authors were strongly influenced by the mainstream beliefs that HIV is the cause of AIDS, that it is transmitted through body fluids, and that testing positively on the tests for HIV means active infection with HIV. HIV does not permit the authors to consider other possibilities. HIV is by itself a source of bias.
In one of the articles analyzed in the above review study, one which is frequently cited as proof for of the transmission of HIV through breastfeeding, the authors consider the presence of "HIV antibodies" so specific to HIV infection that they define: "in an infant or child with HIV-1 seroconversion after earlier negative PCR result, postnatal HIV-1 infection was considered possible if seroconversion occurred in the first three months of life and proved if seroconversion occurred after that time" (22). With this definition the Rwanda, French, and Belgian researchers were able to come to the conclusion that "HIV-1 infection can be transmitted from mothers to infants during the postnatal period. Colostrum and breast milk may be efficient routes for the transmission of HIV-1 from recently infected mothers to their infants" (22). They do not consider the possibility that exposure to external stressor agents could cause the tests to react positively in both mothers and infants. Again, breastfeeding could perfectly well be an epidemiological confounding factor for "HIV transmission".
The above studies on AIDS and breastfeeding provide excellent examples of the profound crisis in the scientific method that surrounds the entire field of AIDS research.
Possible trial to check if breastfeeding is a real risk factor for AIDS
The only objective way to confirm the hypothesis of the transmission of HIV/AIDS through breast milk is by searching not only for HIV but also for all other potential risk factors for testing positively on the tests for HIV and for immunodeficiency, in at least four different groups of people:
a) One group of HIV-positive mothers and their infants living in a variety of African conditions; b) one group of HIV-positive mothers and their infants living in a variety of developed conditions; c) one group of HIV-negative mothers and their infants living in a variety of African conditions; d) one group of HIV-negative mothers and their infants living in a variety of developed conditions.
In each group there has to be a significant number of mothers that breastfed, formulafed and mixedfed their babies.
Retrospective trial: each mother will respond to a questionnaire with questions looking for past voluntary and involuntary exposure to immunological stressor agents.
Prospective trial: all groups should be followed up for several years to try to find out if seroconvertion to HIV-positive or the development of AIDS is secondary to exposure to immunological stressors. Both mothers and children should be subjected to periodic clinical and laboratory evaluations of their health status.
All conclusions on breastfeeding and AIDS originating from non-controlled surveys are simply subjective speculations and have nothing to do with science.
Until objectively proven to the contrary, even during the AIDS era breastfeeding is still the best choice!
Roberto A. Giraldo