Exclusive breastfeeding is best in all cases
Editor We were pleased to see the article by Newell (1) report "the ultimate goal of public health programmes for the prevention of mother-to-child- transmission (MTCT) is to save the lives of large numbers of children born to HIV-infected mothers". Much of the current research uses the reduction of detectable blood viral levels and the prevention of transmission of the virus as the standard by which positive outcomes of programmes should be judged. We question the assumption that reducing transmission is the only effective way to improve health in children of HIV-positive mothers.
In 1985, the United States Centers for Disease Control used two letters published in the Lancet as the basis for a policy to discourage breastfeeding (2). Since then, many agencies have added the avoidance of breastfeeding to programmes to reduce MTCT. Newell reports that avoidance of breastfeeding may be impossible in some settings. In Africa and Asia, breastfeeding avoidance poses serious challenges to the economy, the culture and maternal/infant health. Newell admits that in developing countries, where the emphasis is on antiretroviral monotherapy, "it is unclear whether child deaths are being prevented".
Coutsoudis (3) demonstrated no increase in the risk of HIV transmission by exclusive breastfeeding during the first three months of life; a feeding practice that maximizes infant health, growth and development. The oft-quoted Kenyan randomized controlled trial by Nduati (4) has been criticized because poor study design used definitions so broad that both breastfeeding and formula-feeding groups contained large numbers of mixed feeders (5).
In the developing world breastfeeding remains the cultural norm, but obstacles to instituting widespread exclusive breastfeeding exist. However, Haider and colleagues (6) working in rural Bangladesh, were able to increase the number of mothers exclusively breastfeeding their babies up to 5 months of age tenfold (from 6% to 70%) by providing them with sufficient community assistance and support. In 2000, the WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality found that breastfeeding was protective against diarrhoea and acute respiratory infections (7). In 2001, the WHO expert consultation on the optimal duration of exclusive breastfeeding affirmed the importance of breastfeeding and its protection against diarrhoea and recommended exclusive breastfeeding for 6 months (8). The Fifty-fourth World Health Assembly issued a resolution (WHA54.2) based on these findings "to strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for six months as a global health recommendation" (9). Policy- makers have paid too little attention to the likelihood of a significant increase in infant mortality and morbidity associated with the use of infant formula and to the considerable constraints in achieving exclusive formula feeding among populations where this has never been practised before.
Sufficient political will to support and encourage exclusive breastfeeding would provide the potential to improve the health and survival of all babies, regardless of the HIV status of their mothers. It requires only a modest investment, maximizes resources, and stigmatizes no one. Policy-makers should re-evaluate the risks of breastfeeding abandonment. 
Marian Tompson,1 Judy LeVan Fram,1 Andrea Eastman,1 Valerie W. McClain,1& Pamela Morrison1
Conflicts of interest: none declared
1. Newell M L. Prevention of mother-to-child transmission of HIV: challenges for the current decade. Bulletin of the World Health Organization 2001;79:1138-44.
2. Centers for Disease Control. Current trends recommendations for assisting in the prevention of perinatal transmission of human t-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report 1985; 34:721-6,731-2.
3. Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai W-Y, Coovadia HM for the South African Vitamin A Study Group. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001;15:379-87.
4. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 2000;283: 1167-74.
5. Tompson M, et al. Breastfeeding in HIV-1-positive mothers. Lancet 2001;358:1095. [Corr. 2001; 358:2088].
6. Haider R, Ashworth A, Iqbal Kabir, Huttly SRA. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356:1643-7.
7. World Health Organization Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infection diseases in less developed countries: a pooled analysis. Lancet 2000;355:451-5.
8. Global strategy for infant and young child feeding: the optimal duration of exclusive breastfeeding. Geneva: World Health Organization; 2001. WHO document A54/INF.DOC./4.
9. Infant and young child nutrition. Resolution WHA54.2 of the Fifty-fourth World Health Assembly. Geneva: World Health Organization; 2001. WHA54/2001/REC/3.
1 AnotherLook, PO Box 383, Evanston, Illinois IL 60204, USA (www.AnotherLook.org). Correspondence should be addressed to Andrea Eastman, 59 Highgate Road, Granville, Ohio 43023, USA (email: aeastman@infinet.com).