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Week of 12 March 2004 · Vol. VII, No. 23
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SPH study in Zambia
For HIV-positive mothers, nursing may still be the best choice

By Tim Stoddard

Donald Thea Photo by Vernon Doucette

 

Donald Thea Photo by Vernon Doucette

When it comes to nourishing infants, breast is usually best — except when a mother is HIV-positive. In developed countries, mothers with HIV are urged not to nurse because breast milk is one of the bodily fluids that can transmit HIV. But in developing countries such as Zambia, where about 30 percent of women are HIV-positive, alternatives to breast milk are scarce, unsafe, and culturally unacceptable. In these settings, Donald Thea believes breast is still best, as long as the breast milk is not mixed with other foods and liquids.

For the past four years, Thea, an SPH professor of international health, has been directing the Zambian Exclusive Breastfeeding Study (ZEBS), a randomized trial investigating whether children of HIV-positive mothers are less likely to become infected when they are fed only breast milk for the first four months and then abruptly weaned to solids. “Exclusive breast-feeding seems to protect against the transmission of HIV through breast milk, which is counterintuitive, I know,” Thea says.

Data from an earlier study in South Africa suggest that infants fed only breast milk were less likely to contract HIV from their HIV-positive mothers than were children on a mixed diet. With funding from the National Institutes of Health, Thea set out to explore this idea more carefully among HIV-positive mothers at two urban clinics in Lusaka, the capital of Zambia. “The hypothesis,” he says, “is if we can minimize the amount of time that virus-containing breast milk is in the gut simultaneously with, or around the same time as, other foods are in the gut, then we can minimize the transmission. It's generally believed that the introduction of food in the digestive tract brings with it pathogens and food antigens, which set up inflammation in the lining of the gut, making it leaky and allowing the HIV virus to get in more easily.”

Thea is working with 27 Zambian physicians, nurses, midwives, data managers, and administrators at two urban clinics in Lusaka. The clinics offer free HIV testing and counseling to pregnant women, and those who test positive for the virus are given access to the drug nevirapine, which reduces the chance of the baby being infected with HIV at birth, when most HIV transmission occurs.

About 1,100 women have participated in ZEBS so far, and Thea hopes to enroll another 1,500. Mothers in the study are counseled to breast-feed exclusively for four months. One group of women is instructed to wean their infants abruptly over a 24-hour period, while the other group follows the World Health Organization's nursing guidelines: breast-feeding for six months and gradual weaning to solid food. Thea and his colleagues will monitor the mothers and children for two years, providing them with follow-up medical care and nutritional support.

In ideal circumstances, Thea says, HIV-positive mothers wouldn't nurse at all. “But the trouble is that in really poor areas of Africa, that's not an option,” he says. “If you don't give the child breast milk, the only other things available are either somebody else's breast milk — which isn't very practical — cow's or goat's milk, rarely an option in poor communities, or powdered milk. We know from decades of research that in these settings, it's very difficult to prepare powdered milk hygienically; you end up with a marked increase in the frequency and severity of diarrheal disease and pneumonia events. These poor women are on the horns of a very difficult dilemma.”

Supporting one another

While results from the breast-feeding study will come later, Thea says the ZEBS program is already helping Zambian mothers in unexpected ways. “After a number of women enrolled in 2001, it was interesting to see how they spontaneously coalesced to form mothers' support groups,” he says. As in most African cities, in Lusaka the stigma of HIV is compounded by the lack of psychological and social support services for HIV-positive women. The informal get-togethers turned into regular meetings, where the mothers discussed the challenges of disclosing their HIV status to family and friends and the difficulties of weaning within a 24-hour period. The two support groups, Taonga (which means thank you in Nyanja) and Tilimbizane (which means togetherness), now have about 50 members each. Their meetings usually include lectures from ZEBS staff about health issues, and open question and answer sessions.

ZEBS recently gave the support groups seed money for skill-building workshops, where mothers learned tie-dye and batik methods of fabric decoration. They soon began selling their fabrics at local open-air markets, and the profits became an important part of their income, supporting a community garden, further workshops in tailoring, and special assistance to group members in need. The ZEBS program is now helping the women of Tilimbizane and Taonga apply for microcredit loans to start small businesses.

As the support groups continue to grow in number and expand their enterprises, their products may become increasingly visible in Boston. Thea has already found a small market for their fabrics at SPH. “I shill these products at every class I teach,” he says, “and I was able to go back to Lusaka and give each group a check for $250. That was a really wonderful experience because these women normally live on $1 a day.”

       

12 March 2004
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