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BOTSWANA: HIV-positive Mothers Not Convinced to Exclusively Breastfeed

Alma Balopi

GABORONE, Sep 1 2010 (IPS) - “An HIV-positive woman must never be encouraged to breastfeed because regardless of what the doctors or researchers say – it is too dangerous for the baby,” says Koziba Kelatlhe an HIV-positive mother who was advised by health workers not to breastfeed her child.

It has been over a year since the Harvard-Botswana Mma Bana Study (meaning “Mother baby” in Setswana) found that HIV-positive mothers who take combinations of antiretrovirals (ARVs) can safely breastfeed. The groundbreaking study, conducted in Botswana, was the first randomised study in Africa to compare highly active antiretroviral therapy (HAART) regimens used during pregnancy or breastfeeding. It produced the lowest rate of mother to child transmission in comparison with other studies done in Africa.

Project director, Dr. Joseph Makhema, from the Botswana-Harvard Partnership (BHP) which conducted the study, said it influenced the World Health Organisation (WHO) guidelines on the use of HAART to prevent mother-to-child transmission. At the 2010 HIV Conference in Vienna in July, the WHO passed new recommendations saying mothers may safely breastfeed provided they or their infants receive ARVs during the breastfeeding period of up to one year.

But Kelatlhe and other HIV-positive mothers and even doctors in Botswana are unconvinced that this will be truly effective or implementable.

Seated on a bench in the waiting area at the Infectious Diseases Care Clinic (IDCC), Kelatlhe smiled shyly. She was one of the many women waiting for her prescription of ARVs. She fiddled with her medical cards as she told IPS that her child, who is now two years old, is HIV-negative thanks to the PMTCT medication she took. “Maybe if I breastfed it would be a different story now,” she said implying that if she had been on PMTCT and breastfed she would have passed the virus on to her child.

But according to the study, pregnant HIV-positive mothers were given HAART at 28 weeks of pregnancy. The primary goal of the study, explained Makhema, was to compare the suppression of the viral load at delivery and throughout breastfeeding among women allotted to receive different ARV regimens, and to determine the mother-to-child transmission rate after six months of breast-feeding among all women who received ARV therapy.

Women were instructed to exclusively breastfeed and to wean their infants from breast milk at six months. The study found that mother-to-child transmission was very low at one percent.

“The Botswana government is preparing to roll out a programme to provide HAART to all pregnant women with HIV,” Makhema said.

But the roll out programme may face resistance from pregnant mothers and medical practitioners. Even medical doctors share Kelatlhe’s sentiments about not breastfeeding. Dr. Unabatsho Maposa at the Princess Marina Referral Hospital’s IDCC is one such doctor. Maposa said although the new recommendations by the WHO stated it was safe for HIV-positive mothers to breastfeed, provided they were on ARVs, it was not practical.

“The recommendations have not been instilled in government medical institutions and I doubt it would be because it is not practical,” Maposa said. According to him, mothers can breastfeed in theory but because it has to be exclusive breastfeeding for prevention of transmission to work, it is not practical therefore it would not be possible.

“The baby should not be given any other liquids except the mother’s milk. Therefore there is no woman who can do that because they are bound to give the baby something and that is when it becomes dangerous for the baby,” Maposa explained adding that by the time the baby is given any other liquids the breastfeeding has to be stopped.

His view is that the study was done as a way of finding an option in the resource-limited settings in poor countries and how breastfeeding could benefit HIV-positive mothers and their babies. “There are many deaths for babies born to HIV-positive mothers but recently the rate has gone down as a result of the prevention of mother-to-child transmission and many babies born free of the virus,” Maposa said.

But Makhema explained the problem with the current protocol (Botswana currently discourages HIV-positive mothers to breastfeed) is that babies are exposed to illnesses as a result of bottle-feeding.

“Currently, the protocol has been that women on treatment could not breastfeed their babies while the babies had to take one month treatment while feeding on formula. This exposes children to illnesses as the formula is not always prepared well or the bottles got exposed to infections,” Makhema said. The method was not sustainable because the formula would sometimes run out leaving mothers and babies in a desperate situation.

“It was therefore necessary to find a method that would be affordable and sustainable to control transmission of the virus from mothers to babies,” concluded Makhema.

The ministry of health said the dissemination of the Mma Bana study findings was ongoing. “This has been done through different media portals in the country by the BHP. The government of Botswana provides free ARVs to all HIV infected citizens who are eligible, including nursing mothers,” Koona Keapoletswe, acting director of the department of HIV/AIDS at the ministry said.

He said once the new guidelines were finalised, they would be disseminated to all healthcare workers in the country for implementation to benefit all Batswana.