Alternative to breastfeeding in El Salvador

In the context of HIV, breast feeding at its safest is exclusive breastfeeding for six months before an abrupt shift to other food sources. Food from other sources may introduce micro-lesions in the baby’s intestinal tract that could allow the HIV virus to enter the baby's blood.

However if artificial substitutes, such as milk, are available, any decision not to breast-feed must balance the risk of HIV transmission with the adverse effects of artificial feeding. If the mother is HIV positive and breast-milk substitutes are available, affordable and safe, then breast-milk substitutes should be used.

In El Salvador most of the population are unable to afford artificial milk and the state unwilling to guarantee the replacement for all who need it. Diarrhoea remains an important cause of infant mortality and morbidity in El Salvador and many have limited capacity to provide safe breast milk substitutes.

One key issue is the cost of milk replacement. Currently six months of replacement milk costs $165. This is the cost to MSF after negotiating a 40% discount. The cost for mothers would be $275 for six months. The minimum wage is $144 a month.

At the moment MSF is the sole provider of free milk for Prevention of Mother to Child Transmission (PMTCT) and is trying to ensure sustained access to milk in the future. There is a strong feeling among doctors in El Salvador, and especially paediatricians - whose prime objective is healthy children - that an HIV mother who knowingly breastfeeds her child should go to jail - a position reflected in the current law.

This is an issue which divides the El Salvador Alliance (named Allianza pro legislation VIH/SIDA) on the current HIV law. MSF is strongly opposed to the application of criminal law.

MSF believes, in line with the position of UNAIDS and many humanitarian organisations, that the application of criminal law in such circumstances is counterproductive and an infringement of human rights.

The Alliance - of which MSF is a part - has succeeded in removing a section of the law allowing employers to demand HIV testing prior to hiring staff. The organisation hopes to repeat that success with regard to breastfeeding.

In the MSF HIV/AIDS programme in El Salvador, the organisation is working to identify and treat HIV mothers in order to prevent HIV being passed on to their children. The organisation is trying to decrease vertical transmission (mother to child) of HIV by offering a multi-staged treatment, including the provision of artificial milk as a complete replacement to breastfeeding.

In order to reduce HIV transmission, the mothers are offered an established protocol of HIV/Aids-treatment with the drug AZT, an elective caesarean section and artificial milk to replace breast feeding.

This programme is supported with both MSF staff and materials. The prime objective of the Prevention of Mother to Child Transmission (PMTCT) project is to work with HIV mothers and pregnant women.

HIV can be transmitted from mother to child by blood during pregnancy and birth, and then after birth via breast milk. With no intervention, 25-40% of all infants born to HIV mothers will be infected.

Of those who become infected, 35-45% are infected during pregnancy, 55-65% during birth and 15-25% during breastfeeding. Of all breastfed infants born to HIV mothers, 2-4% will become infected each month that breastfeeding continues. The PMTCT programmes address all three risk periods.

Pregnant women are given AZT from 14 weeks (at the earliest) until birth. The baby is given AZT until 6 weeks of age and is under follow-up in the Maternity hospital until 4 months of age at which point the baby is then referred to the children’s hospital and the mother referred to adult HIV services.

The baby recieves a milk substitute for the 18 months. Mothers receive extensive counselling and medical advice to explain the possible means of HIV transfer and to develop an informed consent and agreement by the mothers to the exclusive use of artificial milk when feeding the baby.

The risk of transmission is reduced; during pregnancy by giving the mother oral medication (AZT); during birth by giving intravenous medication (AZT) and performing an elective Caesarean Section (this alone cuts the risk of transmission by half); and after birth by not breastfeeding and providing artificial milk as well as giving the newborn oral medication (AZT).

The success of the programme depends on reaching HIV pregnant women, providing voluntary counselling and testing (VCT) for HIV as well as all the elements described above. MSF is promoting voluntary counselling and testing as well as timely access to the programme in order to prevent, as far as possible, the vertical transmission of HIV from mother to child.

In 12 of the 35 health centres in the Department of San Salvador, Health unit staff members refer HIV pregnant women to the Maternity Hospital in San Salvador. However as the hospital has the only facility with a PMTCT programme, HIV mothers come from all over the country. The great challenge facing this programme is reaching as many HIV pregnant women as possible.

Since the start of the project 18 months ago, 111 women have entered the programme. However MSF staff believe there are many more HIV pregnant women as the staff at the health units do not always recommend an HIV test. After the first four months, the mother and child are sent to the Bloom Children's Hospital in San Salvador where they continue to receive artificial milk.

Each mother is given a month’s supply at a time, in part to ensure they return for follow-up consultations. Given the low income of many of the women, MSF offers assistance to cover travel costs (some pay up to $5 each trip) and provides a snack for women coming to the maternity hospital - in effect subsidising their clinic visit.

The MSF doctors are often present in the weekly consultations with staff giving the nutritional advice and training psychologists who are guiding the support groups for HIV/AIDS infected mothers. These groups also serve as a platform for various other education activities.

Testing newborns for HIV

Determining the HIV status of the newborn can take up to 18 months depending on the type of test used. Although newer tests can give an answer quickly, these are not always available. MSF protocol for breastfeeding is determined by the situation faced.

Breastfeeding by HIV mothers should not take place where there is a safe, suitable and sustainable alternative. In countries where this is not possible due to adverse socio-economic factors the risks of not breastfeeding - including death from diarrhoea and respiratory illness - outweigh the benefits. MSF, along with the World Health Organisation (WHO), recommends exclusive breastfeeding with an abrupt weaning at six months.