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• W1994287057 abstract "Future HIV TherapyVol. 1, No. 3 EditorialFree AccessHIV, exclusive breastfeeding and weaning in sub-Saharan Africa: can flash-heating breastmilk help bridge the gap?Barbara AbramsBarbara AbramsUniversity of California, School of Public Health, Berkeley, CA, USA. Search for more papers by this authorEmail the corresponding author at babrams@berkeley.eduPublished Online:28 Aug 2007https://doi.org/10.2217/17469600.1.3.235AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Please click here for a video demonstration of HIV in breastmilk being killed by flash-heating.In wealthy countries, postnatal HIV transmission has been virtually eliminated by replacing breastfeeding with formula. But in sub-Saharan Africa, and in other resource-poor nations, where formula is exorbitantly expensive and sanitation is poor, breastfeeding causes 40% of all infant HIV infections [1]. Mothers in developing countries face a desperate dilemma: prolonged breastfeeding may transmit HIV, yet replacement feeding exposes the baby to malnutrition and infectious diseases that are often fatal.As a recent study in Botswana illustrates, even provision of replacement feeding at no cost can go wrong: after a flood contaminated water supplies used to prepare formula, nonbreastfed infants were 50-times more likely than breastfed babies to die of diarrheal disease [2]. Carefully designed trials of replacement feeding from birth (under best-case research scenarios that provided free formula and healthcare) reported that use of formula did reduce HIV transmission, but, because of the increased risk of infectious diseases in the group fed formula, long-term infant HIV-free survival was no different from infants who had been breastfed for 3–6 months [3,4].The most encouraging news is that short-term exclusive breastfeeding is associated with reduced HIV transmission when compared with the more common practice of mixed feeding (breastfeeding plus animal milk, other liquids or foods) [5–7]. It is hypothesized that exclusive breastfeeding defends the integrity of infant gut mucosa, making it less permeable to the HIV virus, and that women who breastfeed intensively are less likely to develop breast health problems, a known risk factor for HIV transmission [6].However, the longer a mother breastfeeds, the higher the cumulative risk of HIV transmission [1]. A recent study estimated that more than two-thirds of postnatal HIV infections transmitted through breastfeeding occurred after 6 months [5]. Hopes that rapid and early cessation of exclusive breastfeeding could reduce this risk were shattered when the problem of replacement feeding again reared its ugly head: recent studies in several different countries report dramatic increases in diarrhea, gastroenteritis, malnutrition and mortality with early weaning [8–13]. In a randomized Zambian trial, there was no difference in HIV-free survival at 24 months in the early weaning group when compared with long-term breastfeeding. Investigators noted higher viral loads in breastmilk after abrupt weaning, which could translate into higher HIV transmission if a mother decided to reinitiate lactation [14,15]. Thus, the newest recommendation from the WHO endorses the avoidance of breastfeeding only if replacement feeding is deemed acceptable, feasible, affordable, sustainable and safe. If not, they recommend exclusive breastfeeding for 6 months, followed by breastfeeding plus complementary foods to support infant growth until nutritionally adequate alternatives are available [16].One WHO-recommended feeding option that has, unfortunately, received little attention involves expressed and home-pasteurized breastmilk [17,18]. The most widely studied technique to date is flash-heating, in which a mother manually expresses her breastmilk into a glass jar that is then placed, uncovered, into an aluminum pan of water. Both water and milk are then heated together over a high flame. When the water reaches a rolling boil, the jar of breastmilk is immediately removed from the water and covered with a lid. Once cooled, the milk can be fed to the infant. Cup or spoon feeding is recommended to encourage more interaction with the infant, while reducing the substantial risk of bacterial contamination common with bottles, which are difficult to clean.We recently evaluated the impact of flash-heating on HIV-1 in breastmilk samples provided by 84 HIV-positive mothers from Durban, South Africa. Of 98 unheated samples, 31 tested positive for cell-free HIV-1; after flash-heating, no evidence of the virus remained [19]. In 50 breastmilk samples from the same cohort, when compared with unheated breastmilk, flash-heated samples retained 90% or more of five of the six vitamins assayed [20]. Heating did reduce the concentration of eight immunoglobulins studied, but more than 66% of each was retained, suggesting that flash-heated milk may still offer important immunological benefits not available in breastmilk substitutes [21]. Microbiological assays indicated that breastmilk could be safely stored at room temperature for 8 h after flash heating [22]. Although several scientific questions remain to be answered [19], these data suggest that, given the critical need, this method is viable enough to move into field testing.As the period when the infant is weaned from exclusive breastfeeding to other sources of nutrition is extremely perilous, flash-heated human milk could fill an important gap, providing the nutrition of human milk and the majority of its anti-infective properties, while reducing HIV transmission. Ideally, a mother would be encouraged to maintain exclusive breastfeeding from the time of the baby's birth, while at the same time being taught the art of hand-expressing breastmilk and all aspects of the flash-heating technique, including safe methods for cup-feeding, sanitary storage of the milk and other methods of complementary feeding appropriate to the age of the infant. After 6 months of exclusive lactation, when her milk supply is well established, a mother could bridge the transition from complete breastfeeding to table food by offering her infant as much expressed and flash-heated human milk as possible. The process of expressing her milk could make weaning more gradual and would be easier and healthier for the mother by reducing engorgement and mastitis. Extending the production of breastmilk could also increase child-spacing. Exclusively breastfeeding women could also learn to feed flash-heated breastmilk during bouts of mastitis or brief separations from their babies.A 2001 Zimbabwean study of 13 focus groups that included various stakeholders in the infant feeding decision (mothers, fathers, grandmothers and birth attendants) initially rejected the idea of feeding expressed, heat-treated milk to babies of HIV-positive mothers, citing concerns about practicality, acceptability and healthfulness. But after passionate debates about feasibility and sheer survival, every group experienced ‘opinion reversal’, moving from skepticism to a more open and hopeful stance. Participants requested more research to address the safety and nutritional quality of heat-treated breastmilk, concluding that, with education of the mother, father and the community, this method might succeed [23]. Other small studies suggest that interest in the method varies with region, culture, maternal education and social environment, and that barriers to acceptability should be addressed [24–28].Participants in the Zimbabwe focus groups were impressed by the low cost of expressed, flash-heated breastmilk and believed that the method could ultimately be practical. Most women already knew how to express breastmilk, and the utensils needed to heat and feed the milk were usually available at home. However, participants also described long-held cultural taboos about touching human milk and, even more worrisome, explained how their wish to protect infants through safe feeding methods conflicted with the fear that avoiding breastfeeding could make a woman a target for social stigma and rejection by their family and community. Most focus group participants agreed that the decision to provide any safer infant feeding method would require communication between the parents and extended family plus intensive community education, counseling and support. As one mother stated: “We need to raise a lot more awareness; you ought to feed and everyone knows that she's doing everything to take care of the baby, regardless of if she has AIDS or not. It's no longer finger-pointing, but survival of the child”.Many questions still need to be answered if this option is to be transferred into the field. What proportion of women at risk will choose to attempt it? Can mothers produce and express adequate volumes of breastmilk and for how long? Can they safely carry out flash-heating and avoid bacterial contamination? Under field conditions, is flash-heated milk free of HIV, nutritious and immunologically active? How will this method affect the nutrition and health status of the mothers and their infants? What are the characteristics of women who succeed compared with those who do not? What kinds of services are needed to support the process? It is imperative that formative studies using participatory qualitative research methods, such as the focus groups described above, be conducted so that those who might benefit can explore their infant feeding choices and be given the opportunity to contribute to the intervention design, thereby respectfully addressing preferences and obstacles within the cultural context of each community [26].The only way to determine whether expressed, flash-heated breastmilk is a viable feeding option is to test it. One small study is underway in South Africa, and larger field studies in Tanzania and Zimbabwe are currently being planned to test feasibility. Hopefully, other research groups throughout sub-Saharan Africa will also consider investigating whether their populations might benefit from this technique.If feasibility is demonstrated, trials to determine whether this method improves long-term HIV-free survival will be needed. Modifications such as solar pasteurization or alternative methods to inactivate HIV [29] may extend its usefulness into communities where fuel or water supplies are scarce, although flash-heating requires only a small amount of water that can be reused repeatedly.Ideally, in the near future, a vaccine [30] or universal availability of effective antiretroviral medications [31–33] will eliminate the risk of HIV transmission through breastfeeding in poor countries. Alternatively, improvement of living conditions may allow for low-risk replacement feeding. Until then, safe feeding options are urgently needed. Given that each year more than 200,000 infants contract HIV through breastfeeding, even if only 10% of these mothers can use flash-heated breastmilk as a safe and nutritious bridge beyond breastfeeding, 20,000 babies a year could be saved from HIV infection.The words of a traditional birth attendant from a Zimbabwe focus group are as true now as they were 6 years ago:“I think, because of this virus, everyone is trying very hard to save life and now we have this method … to save the baby. I think I can try it. Maybe if people are taught, they can accept.”AcknowledgementsThe author gratefully acknowledges Brenda Eskenazi, Dale Ogar, Kiersten Israel Ballard and Caroline Chantry for their contributions to this manuscript.Financial disclosureThe Thrasher Research Fund and the James B. Pendleton Research Trust support this work.Bibliography1 Coutsoudis A, Dabis F, Fawzi W et al.: Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J. Infect. Dis.189,2154–2166 (2004).Crossref, Medline, Google Scholar2 Creek T, Arvelo W, Kim A et al.: Role of infant feeding and HIV in a severe outbreak of diarrhea and malnutrition among young children, Botswana, 2006. Presented at: XIV Conference on Retroviruses and Opportunistic Infections. Los Angeles, CA, USA (2007).Google Scholar3 Becquet R, Bequet L, Ekouevi DK et al.: Two-year morbidity–mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Côte d’Ivoire. 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Presented at: 4th International AIDS Society Conference on HIV Treatment and Pathogenesis Sydney, Australia, (Abstract TuAX102) (2007).Google ScholarFiguresReferencesRelatedDetails Vol. 1, No. 3 Follow us on social media for the latest updates Metrics Downloaded 7,211 times History Published online 28 August 2007 Published in print September 2007 Information© Future Medicine LtdAcknowledgementsThe author gratefully acknowledges Brenda Eskenazi, Dale Ogar, Kiersten Israel Ballard and Caroline Chantry for their contributions to this manuscript.Financial disclosureThe Thrasher Research Fund and the James B. Pendleton Research Trust support this work.PDF download" @default.
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• W1994287057 title "HIV, exclusive breastfeeding and weaning in sub-Saharan Africa: can flash-heating breastmilk help bridge the gap?" @default.
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