Kaiser Daily HIV/AIDS Report - Wed, 21 Nov 2001
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* HIV-Positive Mothers in Resource-Poor Settings Can Safely Use For-
mula as Alternative to Breastfeeding, Study Says
* AIDS Prevention Work in Mozambique Stunted by Poverty, Taboo,
'Willful' Ignorance
* South African AIDS Activists Insist That Nevirapine Suit Against
Government Will Continue
* Atlanta Journal-Constitution Profiles Not-For-Profit Organization
Art AIDS Africa
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HIV-Positive Mothers in Resource-Poor Settings Can Safely Use Formula
as Alternative to Breastfeeding, Study Says
Mortality and morbidity rates are similar for breastfed and formula-
fed children of HIV-positive mothers, indicating that formula feeding
can be a "safe alternative" to breastfeeding in resource-poor set-
tings as long as women are properly educated and clean water exists,
according to a study in today's Journal of the American Medical Asso-
ciation (Mbori-Ngacha et al., JAMA, 11/21). The study, conducted by
researchers from the University of Nairobi and the University of
Washington between 1992 and 1998 at four Nairobi antenatal clinics,
is a companion to a larger study on the risk of HIV transmission
through breast milk (Reuters/New York Times, 11/21). Dorothy Mbori-
Ngacha and colleagues evaluated 371 live-born singleton or first-born
twin infants. Their mothers were randomly assigned to use formula
(n=186) or to breastfeed (n=185). The researchers compared gesta-
tional age, sex and morbidity at birth among infants in both groups.
Findings
After following the infants for two years, mortality rates were found
to be similar between the groups (20.0% for formula-feeding versus
24.4% for breastfeeding) even after adjusting for HIV status. Among
infants who remained HIV-negative after two years, the mortality rate
was 10.0% in the formula group and 8.1% in the breastfeeding group.
HIV infection, however, was associated with a nine-fold increase in
mortality risk. One hundred thirty-eight infants died during follow-
up (58 in the formula group, 80 in the breastfeeding group). Pneumo-
nia was the leading cause of death (53%), followed by diarrhea (39%)
and sepsis (10%). Among morbidity indicators, diarrhea incidence was
"almost identical" over two years for the formula and breastfeeding
groups (155 versus 149 per 100 person-years) and the incidence of
pneumonia was identical in both groups (62 per 100 person-years).
However, after adjusting for HIV status, children who were breastfed
had significantly better nutritional status over two years than those
who received formula.
Recommendations
Many health advocates have advocated breastfeeding over formula feed-
ing in resource-poor settings, even with the risk of HIV transmis-
sion, because of the "possibility that breast milk avoidance would be
accompanied by an increase in mortality that might offset any gains
achieved by decreasing HIV transmission." However, the authors note
that with "adequate" supplies of formula and nutritional counseling,
the women participating in the trial were able to administer formula
feeding "without seriously compromising the nutritional status of
their infants." They add that the "magnitude of risks" associated
with formula feeding will vary depending on the availability of such
education, access to medical care and clean water. "Because of these
differences, we would advocate context-specific counseling for HIV-
infected expectant mothers so that each woman can select the feeding
method that maximizes benefits and minimizes risks given her individ-
ual situation," the researchers conclude (Mbori-Ngacha et al., JAMA,
11/21). In an accompanying editorial, however, Drs. Laura Guay and
Andrea Ruff of Johns Hopkins University state that there are several
problems with the study's recommendations. Many women in resource-
poor countries do not know their HIV status. Testing is sometimes not
available or "unacceptable" to many women. They also note that the
kind of counseling that would be required to ensure that formula-fed
infants get the nutrition that they need is "difficult in the context
of brief visits in overcrowded antenatal clinics and limited postpar-
tum maternal and infant care." Guay and Ruff state that the type of
health infrastructure required to reduce the risks associated with
formula feeding is not found in most sub-Saharan African countries.
They agree, however, that more should be done to reduce HIV transmis-
sion through breastfeeding and suggest further investigations into
early weaning and avoidance of nursing during periods of breast in-
flammation. Antiretroviral prophylaxis is also one strategy that
should be investigated further, Guay and Ruff add. "The issue of HIV
and breastfeeding cannot be separated from the global reality of in-
creasing malnutrition and mortality rates among children in many sub-
Saharan African countries. That breastfeeding with all its benefits
should also pose a significant risk of HIV transmission is one of the
ultimate public health paradoxes and will likely continue to be a ma-
jor challenge for the prevention of HIV infections in infants living
in resource-poor settings," they conclude (Guay/Ruff, JAMA, 11/21).
--
AIDS Prevention Work in Mozambique Stunted by Poverty, Taboo, 'Will-
ful' Ignorance
HIV prevention efforts in Mozambique have been hindered by poverty,
taboo and sometimes "willfu[l]" ignorance, Reuters reports. An aver-
age of 600 to 700 people a day are infected with HIV in the nation,
which has 17 million citizens. Mozambique is among the world's poor-
est nations, where most people have never seen and do not know how to
use condoms. In addition, it is considered taboo to talk openly about
sex, and many people doubt the existence of HIV/AIDS, making it more
difficult to alter sexual behavior. "There is no proof. I only heard
that it's the most dreaded disease and it is incurable before it
kills. I want to see someone (with AIDS), then I'll believe," trader
Mario Luciano said, adding that he won't use condoms because "How can
I take a shower wearing a raincoat?"
Using Alternative Prevention Methods
Salama, a nongovernmental organization whose name means "good health"
in the local language, is attempting to use nontraditional methods to
spread HIV prevention information. The organization, which has 50
volunteers in northern Mozambique, trains women and midwives on
HIV/AIDS information and uses theatrical productions, charts and bro-
chures to disseminate prevention information in communities. Salama
does not focus exclusively on HIV but addresses other STDs, child
mortality and family planning, which has aided the organization in
spreading the prevention message. "Gonorrhea and syphilis are the
most widespread STD infections here and they lay the foundations for
our activities," Executive Director Micael Sale explained. Others use
social opportunities such as "drinking sprees," where taboos may be
relaxed, to engage in a dialogue about sex and HIV. A Salama worker
in Cunle said, "Taboos and other traditional factors are still major
hiccups but this will iron out as time goes by. They secretly come to
us and ask for condoms and information related to STDs and AIDS."
With the aid of NGOs, the government has developed a National Strate-
gic Plan to battle HIV/AIDS that calls for a coordinated effort from
the departments of health, education, social welfare, agriculture,
transportation, rural development and defense. The government is par-
ticularly worried that HIV rates will increase as economic agreements
made with South Africa, the country with the world's most HIV cases,
facilitate contact between the two nations (Mangwiro, Reuters,
11/19).
--
South African AIDS Activists Insist That Nevirapine Suit Against Gov-
ernment Will Continue
AIDS activists from the Treatment Action Campaign and other groups
will begin a court case Monday against the South African National De-
partment of Health and eight of nine provincial health ministers, al-
leging that government health officials are "violating [AIDS] suffer-
ers' constitutional right to life and health care" by not providing
the antiretroviral drug nevirapine to the nation's pregnant women to
reduce the risk of vertical transmission, Reuters/Contra Costa Times
reports. TAC Chair Zackie Achmat said that the groups had settled
with the Western Cape Province government, as all pregnant women are
offered nevirapine during childbirth there. South Africa has resisted
using nevirapine and AZT in the public health system, saying that the
drugs are "too expensive and toxic." South African President Thabo
Mbeki has denied a causal link between HIV and AIDS and said that the
drugs are as harmful as AIDS itself. The World Health Organization is
backing the activists and will provide written testimony supporting
the efficacy of the drugs. Health Minister Manto Tshabalala-Msimang
insisted in a radio interview that South Africa has a limited budget
for medicines and cannot "spend all that money on antiretrovirals."
She said that the decision not to provide antiretrovirals does not
mean that the government is ignoring those with HIV and AIDS. The
health department is currently conducting pilot projects in hundreds
of hospitals to determine the effectiveness of nevirapine in prevent-
ing mother-to-infant HIV transmission (Reuters/Contra Costa Times,
11/19).
--
Atlanta Journal-Constitution Profiles Not-For-Profit Organization Art
AIDS Africa
The Atlanta Journal-Constitution today profiles Art AIDS Africa, a
not-for-profit organization that purchases traditional art from
"craft cooperatives in the poorest sections of Africa," then sells
the work online and at craft shows throughout the Atlanta area, with
profits going to groups sponsoring HIV/AIDS education and support
programs in Africa. Shirley Harris and Annemarie Eades founded the
organization after traveling to South Africa to visit Harris' sister,
Folami Harris, who was working in West Africa as a director for the
Margaret Sanger Center International. During the vacation, "Folami
started to share ... how some of the things we take for granted, like
soap, just aren't available here. We're not even talking about aspi-
rin, much less being able to treat the opportunistic infections that
go along with HIV/AIDS," Eades said. In the first 18 months of busi-
ness, the organization has raised $20,000 from the sales of pieces
ranging in price between $20 and $100. Fifty percent of that money
has gone to the construction of an AIDS prevention center in Diep-
shoots, South Africa. The remaining funds have helped provide medi-
cine and medical supplies at a Johannesburg orphanage and a hospital
clinic in Zambia. According to Eades, the group "focuses on small
charities that tend to be overlooked by large foundations." She
added, "They're small, they literally slip through the cracks, but
the services they provide are vital to the survival of many of their
communities." In the future, Eades said that the organization would
like to give to groups that work with AIDS orphans (Hill, Atlanta
Journal-Constitution, 11/21).
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The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org,
a free service of The Henry J. Kaiser Family Foundation, by National
Journal Group Inc. c 2001 by National Journal Group Inc. and Kaiser
Family Foundation. All rights reserved.
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