A mother and her child in Peru. Photo: Flickr/ Mariano Mantel. CC BY-NC 2.0. Some rights reserved.

At the World Health Assembly in July, an excellent resolution was passed to protect, support and promote breastfeeding – and tighten controls over the unscrupulous marketing of breastmilk substitutes. The controversy it sparked was a stark reminder of the multiple interests that challenge breastfeeding.

The US tried to water down wording to regulate formula milk companies, appearing to support business interests over the health of mothers and children. Among other things, the resolution aims to strengthen the implementation of an international code on the marketing of substitutes.

As a health systems researcher, epidemiologist and paediatrician in South Africa, I am acutely aware of the difficulties that some women face when breastfeeding, including perceived milk insufficiency, cracked or painful nipples, or blocked milk ducts. But the evidence for breastfeeding is robust.

Breastfeeding can prevent common childhood illnesses such as ear infections and pneumonia, and reduce child deaths. It promotes better birth spacing and protects against maternal breast cancer, diabetes and obesity.

Mothers and children in a health centre in Zimbabwe. Photo: DFID/Flickr. CC BY-NC-ND 2.0. Some rights reserved.

When almost one in three pregnant women is HIV positive, as in South Africa where I work, challenges facing breastfeeding are particularly complex. One recent case, of a four-month-old patient of mine and his mother, shows how.

Sammy* was admitted to intensive care for pneumonia. To our surprise, he tested positive on an HIV antibody test but was not HIV-infected.

His mother Barbara* had tested HIV negative during her first antenatal visit and was not re-tested during six follow-up appointments (even though re-testing is national policy in South Africa).

Everyone mistakenly believed that she was still HIV negative. Consequently, she was not on treatment for the virus and the amount of HIV in her blood (her ‘viral load’) was high. Should she stop breastfeeding?

“With the right support, breastfeeding is safe even when the mother is HIV positive.”

There is now much evidence that, with the right support and treatment, breastfeeding is safe when the mother is HIV positive.

Before 2010, the World Health Organisation (WHO) recommended that HIV positive women avoid or reduce breastfeeding to prevent HIV transmission to babies. Several countries, including South Africa, purchased formula milk from companies and provided this free of charge to HIV positive mothers.

Subsequent data from countries including Botswana, Zambia, South Africa and Zimbabwe showed that never breastfeeding increased deaths from common childhood illnesses. Providing HIV positive mothers with formula milk was also misinterpreted as ‘formula milk is good,’ leading to wider use.

In 2010, the WHO and UNICEF advised countries to choose the feeding option for HIV positive mothers that best suits their circumstances and chances of child survival. They also encouraged countries to prioritise HIV positive women for triple antiretroviral therapy (ART), to safely breastfeed.

In 2012, the WHO recommended lifelong ART for all HIV positive pregnant and lactating women. This has now been adopted by almost all of the 22 poorer countries where 90% of the world’s HIV positive women live.

In 2016, the WHO further recommended breastfeeding for at least 12 months for all HIV positive women on lifelong ART who are ‘virally suppressed’ (with no measurable HIV virus in their blood).

Rapid HIV testing. Zimbabwe. Photo: Flickr/DFID. CC BY-NC-ND 2.0. Some rights reserved.

It was a landmark realisation that, with ART, women can breastfeed their babies with minimal risk of HIV transmission. But strong and sufficiently-resourced health systems are needed to implement this.

Formula companies continue to aggressively market breastmilk substitutes, undermining breastfeeding. By 2017, the baby formula market was already worth $47 billion a year, and was predicted to grow by around 50% by 2020.

Breastfeeding rates remain low in South Africa; only 32% of children under the age of 6 months are exclusively breastfed.

In the case of Sammy and Barbara, their local clinic was poorly-staffed and she was not re-tested for HIV despite a policy requiring this. They also struggled with complex personal circumstances. Barbara was single, unemployed, in-between homes and reliant on a meagre, irregular income.

When she learned her HIV status, Barbara had limited options.

It was physically impossible to pasteurise breastmilk before every feed; she could not afford a regular supply of formula milk and cleaning agents; and if she stopped breastfeeding Sammy’s risk of death from diarrhoea or pneumonia may have increased.

“Sammy and Barbara’s story shows the web of complexity around breastfeeding, in the context of HIV.”

Ultimately, Barbara was counselled (on HIV transmission and breastmilk, and ART adherence), and supported to breastfeed. Sammy also received two antiretroviral drugs to prevent HIV infection. He remains HIV negative.

Their story shows how breastfeeding women need ongoing support, particularly where HIV is common.

And this is not the responsibility of one person or sector. Health workers, policymakers and politicians need to understand why and how to support and promote breastfeeding everywhere – and especially for the most vulnerable women and those least likely to access the services they need.

We must also – globally, nationally and locally – strengthen our monitoring of the breastmilk substitutes sold by formula companies, and prevent any misinformation or unscrupulous marketing of breastmilk substitutes.

* Not patients’ real names.