I recently had an opportunity to present at the Center for Disease Control journal club at its branch here in Pretoria. I had been introduced to some CDC people at a birthday party for Team America. Through them, I met Joel Chehab, the epidemiologist who runs the journal club. He is awesome. By awesome, of course, I mean he attended the Tulane University School of Public Health.
I picked a topic dear to most men’s hearts: their mothers. (Honestly, did you think I was going to write “boobs”? Why would you think that?) And a topic dear to mine: HIV-exposed, uninfected infants. And a topic close to Arianna Huffington’s: why I will never go into plastic surgery.
In the early 2000s, the World Health Organization had been recommending to HIV positive women that they wean early and abruptly. The idea was to maximize the benefit of breast feeding and to limit the risk of mother-to-child (“vertical”) HIV transmission. Sounds great in theory, right?
Unfortunately, as scientists, our collective common sense is either deficient or altogether lacking. It is therefore not to be trusted and even the most basic assertions must be tested, retested, peer-reviewed, misrepresented in the media, meta-analyzed, twisted for political means, discussed at conferences, ignored by many practicing physicians and, finally, rejected in favor of the null hypothesis.
Accordingly, the paper I presented places that specific, common sense WHO recommendation squarely in the latter category: rejected. Louise Kuhn is an expert on HIV-exposed, uninfected infants. (She works at the second best university in New York City.) In 2001 she and her colleagues began a study to test the WHO’s assertion. They gathered about 1000 Zambian, new mothers and separated them into two groups. One group was instructed to stop breast feeding abruptly at four months. The second group was instructed to cease breast feeding whenever they wanted. They found that, not only was there no benefit in terms of the number of infant HIV infections, but that early weaning doubled infant mortality.
In fact, their findings are more compelling than the above paragraph suggests. Almost all of the infants in Dr. Kuhn’s study were enrolled before anti-retroviral drugs were publicly available in Zambia. So, a huge number of those infants became infected with HIV. Today—about seven years after the study ended—the infant infection rate is much lower, because of the drugs that are currently available. So, Dr. Kuhn’s study under-represents the benefit and over-represents the risk of breast feeding.
Their conclusions: boobs are good. Aside from the innate male understanding that this statement is true, it also resonates with quasi-hippie bias that nature’s way is generally the better way.
More importantly, even HIV-infected boobs are good for babies. This news has a huge implications for South Africa, as one-third of all infants born in this country are born to HIV-infected mothers. The South African government has responded to this research by phasing-out its formula subsidies for nursing, HIV positive women.
As an aside, from my discussions with CDC staff and from my own observations, the barriers to breast-feeding appear to be more social than biological. South Africa functions like the US or Europe in that many mothers work. Moreover, unlike surrounding countries, there is safe tap water with which to mix formula. It is therefore quite difficult to convince a working, HIV-positive woman that breast feeding is worth the substantial effort required, notwithstanding the perceived risk to her child.
The experience of presenting to the 10 or so medical officers was a real pleasure. Though my critique of the paper was quite boring—it was a well conducted, compelling study, with few weaknesses to criticize—the ensuing discussion was fascinating. It ranged from PEPFAR programs to personal anecdotes about the dysfunctional South African medical system. (Quite honestly, from my experiences working in the district emergency department, South Africa puts the “fun” in dysfunctional. Har, har.) Perhaps those types of discussions are tiring for CDC officers up to their ears in programmatic politics, but I rarely get to be involved in high level considerations of health systems and programming.
I have been attending the journal club for almost two months and I have found the discussions a refreshing break from my day-to-day research. Other recently presented articles include the effect of point-of-care CD4 testing and an analysis of the effectiveness of PEPFAR. I plan to continue for the rest of my time here and I hope to get involved with a CDC study on cryptococcal meningitis early next year. And, if Joel will let me, I will definitely present again.