X-g. Infants of HIV-Positive Mothers
The application of nutrition rights in the special case of infants was elaborated in the preceding subsection, X-f. Infants. Here we examine a still more specialized case, the nutrition rights of infants of mothers who have been diagnosed as having the human immunodeficiency virus, HIV. There is a serious debate now underway regarding the feeding of such infants, arising out of the fact that under some circumstances the dangers of breastmilk substitutes may outweigh the risk of being infected with HIV through breastfeeding.
It is widely accepted that there is a possibility of transmission of HIV from mother to child in the uterus, during the birth process, or through breastfeeding. Predictably, the suggestion that the virus can be transmitted through breastmilk has raised concern about whether mothers who are HIV-positive should breastfeed their infants. If there is some chance that HIV can be transmitted through breastfeeding, how should mothers who are HIV-positive feed their infants?
In May 1997 the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF) issued a joint "HIV and Infant Feeding" policy statement (UNAIDS, 1997). It took an "informed choice" approach, meaning that mothers were free to choose the method of feeding, but should be fully informed of the benefits and risks of each in their particular circumstances.
In June 1998 UNAIDS announced New Initiatives to Reduce HIV Transmission from Mother-to-Child in Low-Income Countries (UNAIDS, New Initiatives…). They centered on joint UNAIDS/ UNICEF/WHO pilot projects aiming "to offer voluntary and confidential HIV counseling and testing to pregnant women, and to provide those who learn they are infected with antiretroviral drugs, better birth care and safe infant feed methods". Regarding feeding:
UNICEF will work with governments and suppliers of milk products to identify practical ways of helping pilot countries to provide alternatives—such as home-prepared and commercially-prepared infant formula—to mothers participating in the projects. WHO, UNICEF and the UNAIDS Secretariat will continue to protect, promote and support breastfeeding as the best feeding method for infants whose mothers are HIV-negative or do not know their HIV status. Among other things, this means ensuring that the methods used for producing and distributing alternatives to breast milk comply with the International Code of Marketing of Breast-milk Substitutes and subsequent resolutions of the World Health Assembly.
WHO published three manuals on HIV and Infant Feeding (World Health Organization, HIV and …). They offer a comprehensive overview of the issues, but focus on the objective of preventing HIV transmission through breastfeeding. They do not acknowledge that under some circumstances, it might be better to risk transmission of the virus and try to minimize or ameliorate its consequences. With qualifications, the approach advocated centers on finding ways to provide breast-milk substitutes to infants of HIV positive mothers, possibly with the support of government subsidies. The health risks and the economic plausibility of this approach are not assessed.
Old debates about the merits of formula feeding are now being revisited in the context of HIV/AIDS. A journal in South Africa ran a special issue on the question (Special Report…). On July 26, 1998 the New York Times ran a front-page article on "AIDS Brings Shift in U.N. Message on Breast-Feeding". It began . . .
Countering decades of promoting "breast is best" for infant nutrition, the United Nations is issuing recommendations intended to discourage women infected with the AIDS virus from breast-feeding.
It added:
In its directive, the United Nations said it was deeply concerned that advising infected mothers not to breast-feed might lead many mothers who are not infected to stop breast-feeding. To reduce that possibility, it is advising governments to consider bulk purchases of formula and other milk substitutes, and to dispense them mainly through prescriptions (Altman).
The Steering Committee of the World Alliance for Breastfeeding Action issued a statement, WABA Position on HIV and Breastfeeding. It said, in part, that
WABA is concerned about what appears to be recent changes in the WHO, UNICEF and UNAIDS policy regarding breastfeeding and HIV. We are especially concerned that these changes appear to put major stress on the use of infant formula and less on alternative feeding methods (World Alliance ...).
The statement closed by saying "Extreme caution must be shown in involving the commercial firms that have direct economic interests in the outcome of such policy deliberations."
In a letter to the influential British medical journal, The Lancet, Michael Latham and Ted Greiner, experts on breastfeeding, said they were troubled by "the new proposals to conduct large-scale trials in several developing countries to replace breastfeeding with formula feeding in HIV-1 positive mothers". They said:
We are concerned that WHO and UNICEF will invest major resources in formula feeding and few into alternatives, such as modified breastfeeding, heat treatment of expressed breastmilk to kill the virus, wet nursing, donation (or even sales) of breastmilk, and use of animal milks or homemade formulas. These options are preferable to the use of infant formulas in poor communities. None of them are easy, nor ideal, but they warrant careful study. Much of the successful work over the years to stem the use of commercial breastmilk substitutes in poor countries is now threatened. The involvement of the commercial infant formula industry, both in deliberations leading to the new policy and also in offering to make their products available, is troubling.
We recommend that the UN agencies assess carefully the economic, social, and health consequences of their new policy, and that they provide adequate support to allow investigations of alternative methods. It is a grotesque reality that all HIV-1 infected mothers cannot have full coverage of antiretroviral therapy, that so many mothers and infants do not have access to adequate health care, and that inequities lead to a high prevalence of malnutrition. Given this unfortunate situation, is it wise to be recommending the costly and risky approach of formula feeding for infants born to poor HIV-1 infected mothers (Latham and Greiner)?
On October 5, 1998 the UN's Committee on the Rights of the Child held a Day of General Discussion on "Children Living in a World with HIV/AIDS". Its report said:
Participants discussed at length the need for additional research and to look for strategies that minimize the risk of mother-to-child transmission of HIV without automatically promoting the use of bottle-fed formula. Alternatives such as warming mother’s milk to destroy the virus, or establishing breast-milk banks, [using] wet nurses, etc. need to be better explored, and health care workers must be trained on the availability of such alternatives and on the need to support the mother’s decisions, with primary consideration given to the best interests of the child (Committee on the Rights of the Child).
In my view, to set the task as being "to look for strategies that minimize the risk of mother-to-child transmission of HIV" is to set off in the wrong direction from the outset.
The core question is, in the context of HIV/AIDS, how should parents be advised to feed their infants? In trying to work out appropriate advice, several different kinds of concerns arise:
(a) Likelihood of transmission. One report says that prior to the widespread use of antiretroviral therapy, the rate of transmission of HIV from HIV-positive mothers to their infants ranged from 14% to 33% in the United States and Western Europe, and in the developing world, rates as high as 43% have been reported (Stoto, Section 4, p. 1). According to another report, in the United States, "The maternal to infant transmission rate is approximately 20% to 30%, with the majority of infants who are born to an infected mother being ultimately uninfected (Committee on Pediatric AIDS, 1997)". Another study reported a transmission rate without drug treatment in the U.S. of 15% to 30% (Burr). Estimates of the likelihood of transmission vary widely.
These figures are estimated rates of transmission through all three pathways—during pregnancy, in the birth process, or through breastfeeding. The rate of transmission through breastfeeding itself is a fraction of this figure. Some have estimated that breastfeeding by HIV-positive mothers increases the risk of HIV infection of the infant by about 14 percent (Dunn). Some reports suggest "the incremental risk of transmitting HIV infection to the breastfeeding infant range from 3% to 12% in various African populations (Committee on Pediatric AIDS, 1995)."
One study estimated that only about one percent of infected infants are infected through breastfeeding (Burr). If, as this source estimates, the transmission through all three paths is between 15% and 30%, this means that at most about 0.3% of the infants of HIV-positive mothers are at risk of infection through breastfeeding.
For the U.S., it has been estimated that where there is transmission of the virus to the infant, 70% to 75% of the cases occur during delivery, and 25% to 30% occur in utero (Stoto, Section 4, p. 1). This suggests that at most only about 5% of the cases of infection occur as a result of breastfeeding. If, as they estimate, the overall transmission rate is at most about 33%, then the risk of infection of infants by HIV-positive mothers through breastfeeding is at most about 1.65%.
There are many uncertainties about these figures. While the transmission of the virus through breastfeeding has been widely discussed, there is in fact little firm knowledge about how likely it is to happen.
(b) Influences on likelihood of transmission. The likelihood may differ for different subpopulations in different kinds of circumstances. Also, the transmission likelihood may be influenced by different kinds of treatments. For example, maternal micronutrient deficiencies may increase incidence of infections and viral load in the mother's body fluids, including breastmilk. Furthermore, maternal micronutrient deficiencies may influence the micronutrient status of the infant, thereby affecting the infant’s immune functions and susceptibility. Some studies suggest that maternal vitamin A deficiency in particular could lead to increased exposure of the child for HIV (Friis and Michaelsen).
There may also be differences depending on methods and timing of breastfeeding. A mother in advanced stages of disease may be more likely to transmit the virus through breastfeeding. In addition, because of her illness, she may be less able to sustain breastfeeding, and less able to care for her infant whether the infant is infected or not. Also, there may be differences in the virus content of colostrum and early human milk compared with later milk.
(c) Likely consequences of infants’ HIV infection via breastfeeding. In Thailand it has been found that about half the children born with HIV develop AIDS rapidly and die within two years (UNAIDS, 1996). However, the pattern for children who are not born with HIV but contract the virus through breastfeeding could be different. The immunological properties of breastmilk could outweigh the effects of the virus, or some other mechanism might intervene. A 1995 report by the Committee on Pediatric AIDS on "Human Milk, Breastfeeding, and Transmission …" cites two studies that suggest the potential protective effects of human milk from HIV.
A physician in Uganda claims that "If mothers who are infected with the virus do not breastfeed, their children will have a far better chance of survival." How can he be so sure when he also acknowledges that "In rural areas, 85 percent of babies will die from dirty water used in formula (Specter)"?
If an infant contracts the virus through breastfeeding, what are the likely consequences in terms of morbidity and mortality? How frequently does the virus lead to increased morbidity and mortality associated with AIDS? It may be that the course of HIV/AIDS is different in infants than it is in older people.
It is often recommended that mothers who are designated HIV-positive should not breastfeed because that would prevent the transmission of the virus through breastmilk (Williams; Ramanathan). While it is clear that without breastfeeding there would be no possibility of transmission through that route, it is not clear whether the infant would be better off as a result.
In discussions about feeding choices by HIV-positive mothers, there is a preoccupation with the possible transmission of a virus through breastfeeding. There is practically no discussion of the consequences of that transmission. In the absence of explicit information, people tend to assume the worst.
For the purposes of formulating feeding advice, however, it is not necessary to know the likelihood of virus transmission via breastfeeding. To guide policy as to whether an HIV-positive mother should breastfeed or use some other specific feeding procedure, we need to know and compare the consequences, in terms of the infant's health, that are likely from taking each of these courses of action. The feeding strategy is the key independent variable and health outcome is the key dependent variable. HIV transmission via breastfeeding is an intervening variable that need not be visible in the analysis. For policy purposes, the research needs to focus on likely consequences for the infant, not on the proposed intervening mechanisms. Moreover, it is much easier to assess health outcomes than to try to track a poorly identified virus whose role in causing disease is not entirely clear.
Most critically, we don’t know how the prospects for breastfed infants of HIV positive mothers differ from the prospects of those who are not breastfed. We don’t know what this difference is for infants of infected mothers who are born virus-free and we don’t know what it is for infants of infected mothers who are born with the virus.
Whatever the likely negative consequences of infection of infants with HIV via breastfeeding may be, it is possible that with treatment some of them could be ameliorated. Of course this raises questions about the capacity to deliver treatment. This capacity may be limited by cost or by the development of disease in the mother.
HIV testing is normally done not through detection of the virus itself but through the detection of antibodies that are presumed (but, many say, have not been plainly demonstrated) to be associated with HIV. One of the important advantages of breastfeeding is precisely the fact that it transmits immunological properties from the mother to the infant. Thus, while the prevailing view is that the presence of antibodies in the infant is a cause for alarm, it should perhaps be viewed as just the opposite, a highly desirable finding.
(d) Knowledge of Mother's HIV status. The current consensus among international agencies is that advice regarding feeding alternatives should be provided only when the health worker knows for certain, on the basis of laboratory testing, that the mother is HIV-positive. This position is based largely on the need to respect the privacy of women who may be HIV-positive. In some cases even their spouses may not know, thus creating extremely delicate situations. The task of formulating advice is especially difficult because there may be circumstances in which concern for confidentiality must be balanced against concern for the interests of the child.
(e) Knowledge of Infant's HIV Status. To show that an infant becomes HIV-positive as a result of breastfeeding, it would be necessary to show that the infant is HIV-negative at birth and then HIV-positive after a period of breastfeeding. However, it is not possible to know whether a newborn infant is HIV-infected because it is not possible to distinguish between maternal antibodies and the infants own antibodies in the newborn infant’s bloodstream. Thus there is really no good way to determine whether HIV-infected infants are infected as a result of breastfeeding rather than during pregnancy or in the childbirth process. As indicated above, it may be that only a small proportion of infected infants are infected as a result of breastfeeding. The proportion is not clearly known, and it may not be knowable.
(f) Clarify and assess alternatives. If one is going to recommend against breastfeeding, what are the alternatives? It is sometimes automatically assumed that the alternative to breastfeeding is using commercial infant formula. There are in fact many options.
Breastmilk can be provided in many different ways, and many of these variations can make a difference in the context of HIV/AIDS. Exclusive breastfeeding is different from breastfeeding combined with other liquids or solids. Breastmilk can be delivered directly from the source, or indirectly. Wet nurses, relatives, or friends can provide direct breastfeeding. Or the mother’s breastmilk can be provided indirectly by being expressed, heat treated to inactivate the virus, and then supplied to the infant with a cup. There are also several alternatives to breastmilk, including not only commercial products but also home-made formula based on fresh or processed animal milks, suitably diluted with water and with added sugar and micronutrient supplementation.
The use of commercial formula may itself be managed in a variety of ways. For example, some proposals call upon national governments to pay for the formula and provide it free to HIV-positive mothers. Some hope there will be international subsidies. Some proposals call for using generic labels on formula containers to minimize the promotion of particular brands. It is generally agreed that the use of commercial formula should be in conformity with the International Code of Marketing of Breastmilk Substitutes and subsequent clarifying resolutions of the World Health Assembly.
Considerable effort should be devoted to identifying and creating alternatives, and to designing variations on them. All plausible options should be fairly assessed. For example, while banking of breastmilk may have been deemed impractical in the past, in the context of HIV/AIDS there should be renewed interest in its potential. Even commercial milk banking, with appropriate safeguards, might be feasible (Rao).
The alternatives need to be plainly identified, and their merits and demerits in different circumstances need to be systematically assessed. If breastfeeding does lead to increased risks of morbidity and mortality of the infant due to AIDS, it is important to determine how these might compare with the risks associated with alternative forms of feeding.
(g) Variations across populations. All of these considerations may differ in different populations, so one must be careful about generalizations. For example, it has been estimated that while the average rate of mother-to-child transmission of the virus is around 25%, rates vary from less than 14% in Europe to 45% in sub-Saharan Africa ("Recommendations ...", p. 313). The advice may need to be different according to whether the family being advised lives in a poor area or rich area, or whether the family itself is of low or high socio-economic status. Or there could be other kinds of systematic variations. For example, some of the considerations may vary in important ways among cultural groups. Thus, one of the many contingencies that needs to be taken into account is the type of population, but we do not yet know what variations in types really matter.
(h) Responsibility. The agencies that discuss the question of feeding strategies by HIV-positive mothers are cautious. Instead of providing clear instructions, they say mothers "might want to consider" using formula rather than breastfeeding, and they qualify their positions with numerous cautionary remarks. Despite the agencies' cautions and qualifications, their persistent expression of alarm over the risk of virus transmission tends to lead health workers and mothers to only one conclusion: HIV-positive mothers should not breastfeed. Surely, if the agencies interviewed health workers and mothers, they would find that their careful cautions and qualifications have been lost by the time they reach the ground.
Mothers are urged to make informed choices, but they are not provided with the means required to do that. The agencies avoid responsibility by saying the choice must finally be made by the mother herself, but they fail to meet their responsibility to assure that mothers are provided the information they need.
(i) Quality of Policy Analysis. There is a tendency to jump to conclusions based on the untested assumption that breastfeeding by HIV-positive women is bad for their infants. To illustrate, research trials in Thailand showed that a "short-course" ZDV treatment can substantially reduce the rate of mother-to-child of HIV. (ZDV is zidovudine, the generic name for azidothymidine, or AZT.) The research trials were done with HIV-positive women who were counseled to not breastfeed, and instead exclusively bottle-fed their infants with formula. Subsequently, it has become common practice to recommend that women who are given this treatment use formula. A key report says that together with the treatment, "breast-milk substitutes (commercial infant formula or other products for home preparation) must be organized ("Recommendations ...", p. 316)." However, research results on the use of the short-course treatment with breastfeeding women were not yet reported at the time these recommendations were made. The fact that the women in the research trials did not breastfeed does not establish that it is wiser to not breastfeed. There was no evident basis for recommending that women taking the short-course treatment should not breastfeed. Apparently it was grounded in the unchallengeable assumption that the possibility of transmission of any virus through breastfeeding will be eliminated if there is no breastfeeding.
It was argued that, "Thus for maximum reduction of MTCT [mother-to-child transmission], alternatives to breastfeeding should be considered and their acceptability and safe use examined in developing countries where breastfeeding is the norm ("Recommendations ...", p. 317)." Moreover, "Women must be informed that breastfeeding may reduce the effectiveness of treatment with ZDV ...." This illustrates the preoccupation with the issue of minimizing the likelihood of virus transmission, when the issue of concern should be the well-being of the infant.
The majority of infants of HIV-positive mothers are not infected. Probably most of those who are infected are infected during pregnancy or during the birth process, rather than as a result of breastfeeding. Depriving all of these infants of the benefits of breastfeeding should not be recommended without a sound basis in evidence and argument.
Moreover, it would seem to be especially beneficial to breastfeed infants believed to be at risk of immune deficiency (AIDS). All infants of HIV-positive mothers are exposed to that risk.
If a newborn child is already HIV-positive as a result of transmission during pregnancy or in the birth process, presumably there would be no added risk from breastfeeding.
There are remarkable inconsistencies in the discussions. Why is there so much concern for HIV transmission via breastfeeding in poor countries when, in a recent thorough study of mother-to-child transmission in the United States, the issue was passed over lightly, and the discussion of strategies for preventing transmission of the virus did not even mention feeding options (Stoto)?
(j) Radical Challenges to the AIDS Hypothesis. The doubts created by the concerns listed so far are relatively minor when compared with the level of doubt created by radical challenges to the widely accepted belief that AIDS is caused by HIV. The debate began in 1987 when Peter Duesberg argued, in the journal Cancer Research, that HIV could not possibly be the cause of any immunological disorders (Duesberg, 1987; Duesberg, 1996; Farber, "Does HIV …"; Giraldo; Root-Bernstein; Shenton). The debate continues. Some critics say, for example, that AIDS is neither an infectious disease nor is it sexually transmitted, and that HIV has not been isolated as a real virus (Giraldo). In this discourse HIV is commonly referred to as "the alleged virus suggested to cause AIDS"--and AIDS itself is viewed as very ill-defined. There is now an extensive literature devoted to challenging orthodox thinking on HIV and AIDS. The argument of this subsection is not based on this line of radical questioning, but it certainly tends to reinforce the argument.
The nutrition rights of infants of HIV-positive mothers faced a hard test in Eugene, Oregon, in the United States. On September 17, 1998, Kathleen Tyson of Eugene, then six months pregnant, was told that her blood tests indicated that she was HIV-positive. Her son, Felix, was born on December 7, 1998. He appeared to be healthy in every way. Less than 24 hours after his birth, Kathleen was pressed by a pediatrician to treat Felix with AZT, an antiretroviral drug, and to not breastfeed him.
Having studied the issue along with her husband, David, she declined to accept that advice. Within hours, a petitioner from Juvenile Court came to her room, and issued a summons for her to appear in court two days later. She and her husband were initially charged with "intent to harm" the baby, but the petition, dated December 10, 1998, said that the child "has been subjected to threat of harm." When the Tysons appeared in court, they were ordered to begin administering AZT to Felix every six hours for six weeks, and to stop breastfeeding completely. The court took legal custody of the infant, but allowed the Tysons to retain physical custody so long as they obeyed the court’s orders (Tyson).
A trial was held in Eugene, Oregon from April 16 to April 20, 1999. There were three main lines of argument for the Tysons. First, the Tysons’ advocates questioned the validity of the blood tests used as the basis for diagnosing Kathleen Tyson as HIV-positive. This was supported by expert witness Roberto Giraldo, who has published extensively on the uncertainties surrounding the tests. Second, they raised questions as to whether it has really been clearly demonstrated that HIV causes AIDS. This was the view advanced by expert witness David Rasnick, a leading challenger of conventional thinking about the causes of AIDS. Third, I was to be the expert witness regarding the human rights dimensions of the case.
I wanted to argue that the basic principle underlying health care decision-making normally is that patients themselves are to make the final decisions regarding their care, on the basis of informed consent. The function of health care workers is to provide the information needed, and to give advice, but not to make the final decisions. While there are exceptional cases in which the state may override this principle, and the patient may be treated coercively, the conditions required to justify such an exception were not met in this case. The published scientific evidence was not adequate to justify the state’s presumption that breastfeeding by a woman diagnosed as HIV-positive (but otherwise asymptomatic) would be subjecting that child to excessive risk by breastfeeding. Moreover, I wanted to show that United Nations agencies and the United States government had repeatedly reaffirmed the principle that HIV-positive women should not be coerced. Their official policy is that the treatment of HIV-positive women should be based on their informed consent.
After I was sworn in, and the Tysons’ lawyer explained that he was going to ask me about the human rights dimensions of the case, the judge intervened and said these matters were irrelevant. I then had to step down.
Just hours later, the judge gave his decision: the Tysons lost. Thus, the state retained legal custody of Felix. The Tysons retained physical custody on the condition that, as ordered, Felix would not be breastfed.
The physicians who took the state’s side in the case against the Tysons sincerely believed that the Tysons were endangering Felix. However, the scientific community has failed to meet its obligations to produce the strong and clear scientific knowledge that is needed to guide individuals in situations like the one faced by the Tysons. I believe that if the Tysons had been presented with clear, hard evidence that breastfeeding Felix would be likely to harm him, they would have decided accordingly. We have clear indications of the physicians’ strong beliefs, but we do not have scientifically sound studies of the sort they themselves claim to require. If there is a failure of informed consent, there is an obligation on the part of government and health care workers to provide better information. Resort to coercion is not the appropriate remedy.
Both the Tysons and the cause for realization of the human right to food and nutrition lost in this case. Nevertheless, this setback might be turned to advantage if it helps us to appreciate the importance of clarifying and strengthening those rights. It is as important for health care workers and policy makers to understand the importance of human rights as it is for them to understand the technical and scientific dimensions of health care. (The argument that I would have liked to make in court, similar to that developed here, is available at Kent 1999b.)
The idea that parents should be able to make informed decisions remains valid in the context of HIV/AIDS. However, its application depends on the decision-makers, primarily mothers, being aware of and having real access to a range of feeding alternatives, and it depends on their having good information about these available alternatives. Where commercial interests are represented, the presentation of options and the information about them are likely to be sharply skewed.
The ten principles regarding the nutrition rights of infants that were presented in the preceding subsection should continue to apply in the context of HIV/AIDS; they are not to be suspended. This means, for example, that even HIV-positive mothers have a right to breastfeed. If any country were to prohibit HIV-positive mothers from breastfeeding, that would violate their human rights, and also violate their infants’ human rights.
Particular attention should be given to Principle 7 which focuses on the obligation to assure that the infants’ parents are well informed with regard to their infant feeding choices. This is the major idea underlying the International Code of Marketing of Breastmilk Substitutes. The code does not prohibit marketing or use of formula, but insists that promotion activities for the products must be conducted in ways that are fair rather than being skewed to favor commercial products. Article 24, paragraph 2e of the Convention on the Rights of the Child goes directly to the point. It calls upon States Parties "To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breast-feeding, hygiene and environmental sanitation and the prevention of accidents." This is a legally binding obligation on all States Parties to the convention (all countries except the United States and Somalia), and a strong moral obligation on those that are not. From the debate relating to HIV, it is now increasingly clear that the full array of feeding options should be presented to the parents, and better research is needed about the advantages and disadvantages of each option in particular local circumstances.
In addition, there is a need to enable the mother to learn whether she is HIV-positive through voluntary counseling and testing so that she can make an informed decision regarding the feeding of her infant in relation to her own condition. This counseling should include factual information on the limitations, validity, and meaning of the test.
These points can be formulated as Fundamental Principles on the human rights of infants with regard to nutrition where there is significant risk of HIV infection through breastfeeding. These principles, to be added to the ten listed earlier, might be stated as follows:
(11) Regardless of the mother’s HIV status, infants are entitled to assurance that their parents are informed of the full range of feeding alternatives and their advantages and disadvantages in the local circumstances.
(12) Women in their child-bearing years are entitled to accessible voluntary testing and counseling regarding HIV/AIDS. This counseling must include information about the limitations, validity, and meaning of the test, and about the benefits and risks of various feeding alternatives in the local circumstances.
(13) Infants are entitled to expect that their governments will help to make quality feeding alternatives available, including expressed and heated breastmilk, or breastmilk from others obtained through wet nurses, milk banks, or other comparable arrangements.
(14) Infants are entitled to expect that their governments will seek to obtain and provide the unbiased information needed by their parents regarding HIV/AIDS and feeding alternatives.
In other words, as a consequence of the infant’s human right to nutrition, parents are entitled to good information about a broad range of feeding alternatives.
These are tentative formulations, offered to stimulate discussion. Principles of this sort should be considered in preparing policy at the global level, and also in the drafting of national legislation and national policies relating to HIV/AIDS.
It has been clear that the scientific issues relating to infant feeding in the context of HIV/AIDS need further research and elaboration. Now it should be recognized that infants and parents have a right to this information, and thus have a right to expect that governments and international agencies will develop that information and have it delivered to them. The right of informed choice implies a right to good information.
Subsection X-g last updated on September 27, 1999