Healthcare providers need to understand that for HIV-positive African women, following advice not to breastfeed in order to protect their babies from the virus takes a high emotional toll, a U.K. study suggests.

"Firstly, we need to understand that avoiding breastfeeding may carry significant emotional, social and financial cost to women," lead author Dr. Shema Tariq of University College London told Reuters Health. "It is important to build a safe and non-judgmental space where expectant mothers can openly discuss their concerns."

The risks and benefits of breastfeeding while HIV-positive depend on the setting, Tariq and her colleagues write in the journal Sexually Transmitted Infections. In high-income settings like the U.K., there is little risk of malnutrition or diarrheal illness for babies raised without the protective factors in breast milk, so women are advised not to breastfeed, which carries some risk of transmitting the virus.

But in low-income settings, like some areas of Africa, infant death due to malnutrition or diarrhea is much more common, so HIV-positive women are advised to exclusively breastfeed for six months and to be on antiretroviral therapy (ART).

Antiretroviral medications decrease the risk of transmission via breastfeeding to between 0 percent and 6 percent. Without ART, the transmission risk is 16 percent.

"Breastfeeding accounts for almost half of HIV transmissions to children globally," Tariq said by email. "The use of HIV medication (antiretroviral therapy) by mother and/or baby greatly reduces the risk of transmission but does not eliminate the risk completely."

Between 2010 and 2011, researchers interviewed 23 HIV-positive African women at prenatal clinics in London who were pregnant or had recently given birth. Most women had been born in East or West Africa and more than half were employed and had lived in the U.K. for at least five years.

Three women had been diagnosed with HIV during their pregnancy, while 20 were diagnosed earlier in life. Almost all had children prior to their current pregnancy.

Twenty-two women were interviewed during pregnancy and 15 were interviewed again after giving birth. Only one of the 15 women said she had been breastfeeding.

The women understood the risks of breastfeeding and felt that keeping their infants from contracting HIV was the most important factor in decision-making. But those who did not breastfeed also felt guilt, sorrow and fear, the researchers found. Only four women seemed not to be conflicted about formula-feeding their infants.

Mothers felt guilty for not giving their children "the best," and were concerned about not bonding as well with a child who was formula-fed. They were also concerned about the work and expense involved in preparing formula several times during the day and night.

Some felt cultural and social pressure to breastfeed, and were uncomfortable explaining to others that they were not breastfeeding due to their HIV status.

"Some women choose to give a medical reason, such as hepatitis or fever, despite the fact that these are not really valid reasons for not breastfeeding," noted Dr. Laurent Mandelbrot of the University Hospital of Ile-de-France in Paris, who was not part of the new study. "After the baby is born, they can say that they gave up breastfeeding because the baby lost weight or because they have nipple pain or mastitis."

It may not be socially accepted to say that not breastfeeding is a personal choice, but some families and friends will be sympathetic to this type of explanation, Mandelbrot told Reuters Health by email.

Emotional support from loved ones and financial support from formula vouchers both helped the women adhere to not breastfeeding.

"Formula feeding in the context of HIV is a public health intervention and should be funded as such for everyone," but undocumented migrant women do not have access to state benefits, Tariq said.

Some women will choose to breastfeed despite U.K. guidelines and providers should support them with HIV medication and regular monitoring, Tariq said.

"It is really important to support women to exclusively formula feed and if they can't do that to exclusively breastfeed - unfortunately mixed feeding (that is combining formula and breastfeeding) carries a higher risk of HIV transmission than either exclusive breast or formula feeding," though the reason for this is not known, she said. "This can also be challenging as mixed feeding is the norm in many communities."

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