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Telling a new story about risk: gender, breastfeeding, and broadening the questions on child survival.

Stephen Lewis called breastfeeding "the excruciating dimension of HIV transmission," (1) and it was partly these words that inspired a conference at York University on "Gender, Child Survival, and HIV/AIDS: From Evidence to Policy" in May 2006. The issue of HIV transmission through breast milk is difficult politically, conceptually, practically, and scientifically, partly because there is no consensus about how to advise women who are HIV-positive to feed their infants. Although it is technically possible for breast milk to transmit HIV, the exact mechanisms of transmission through breastfeeding remain unclear. While the medical research on the transmission of HIV through breast milk is progressing, (2) interventions requiring exclusive replacement feeding to prevent HIV transmission have undermined child-feeding programs in many parts of the world. (3) And unfortunately, the corresponding research on gender and AIDS is less developed, and less integrated into broader discussions of child survival.

The transmission of HIV through breast milk is only one small part of the problem facing women who are HIV positive. (4) Women are often diagnosed later in the progress of their disease (which results in higher viral loads at diagnosis), and have poor access to care and medications. They are most often the caregivers for HIV-positive family members, and most likely to be exposed to abuse and violence. Because gender inequity underlies the marginalization of women living with HIV, discussions of child survival and feeding must be undertaken within a context of poverty, poor access to treatment, drugs and medical care, and a focus to date on preventing HIV transmission to infants rather than one that aims to improve the health of mothers and their children. (5)

The research agenda has paid attention to women in only cursory ways. When research attention has focused on women, it has often studied sex workers, ignoring the fact that sex workers are also mothers. When research has looked at mothers, treatment was often directed to them only to prevent transmission to their infants. Women, mothers, and children were often ignored when "risk groups" such as gay men or intravenous drug users were studied, and when we shifted paradigms to talk about "risk behaviours," breastfeeding mothers did not fit in well with paradigms that focused on sexuality rather than mothering.

Each shift in framework provided new ways to understand the disease, its transmission, and possible treatment options. When semen and blood were the focus of attention, we learned a great deal from gay men's groups and support groups for people with hemophilia. When we look at breast milk as the carrier fluid, others issues come to the fore and the questions change. For example, why was exclusive breastfeeding overlooked as an intervention, when it has long-term survival advantages for infants? What new processes can be understood when we look at mothers who breastfeed in the context of HIV/AIDS and at breastfeeding support groups? And how can groups working to support breastfeeding mothers further support the research and policy work of AIDS advocacy groups?

By focusing attention on mothers and children, and breast milk rather than semen or blood, it should be possible to move out of the discourse of blame and morality that often accompanies discussions of homosexuality, drug use, and sex work. It should be possible--except that women are still blamed for carrying out their expected gender roles as wives and mothers if fulfilling these roles means that a child becomes infected. How do we draw attention to women without defining mothers as a "risk group," and treating mothering and breastfeeding as "risky behaviour"?

The subject is undertheorized because the storyline of AIDS is about other kinds of risky behaviour, not about mothers breastfeeding their children. We clearly need to develop some new storylines to help bridge the gaps between HIV/AIDS groups, women's groups, child survival groups, and breastfeeding advocacy groups to focus on the intersections between our various concerns, such as care, conflict of interest, gender inequality, and violence.

The conference examined these new stories. Details will be available in a report and CD prepared by conference cosponsor, World Alliance for Breastfeeding Action (WABA). Following the conference, a joint statement was developed and circulated for endorsement and use at the International AIDS Conference in Toronto in August 2006. This statement is also available on the WABA and National Network on Environments and Women's Health (NNEWH) websites. (6)

NOTES

(1.) Greiner T (Ed.). HIV and Infant Feeding: A Report of a WABA/UNICEF Colloquium. Penang, Malaysia: WABA, 2003;17.

(2.) McIntyre J. Mothers infected with HIV. British Medical Bulletin 2003;67:127-135.

(3.) Koniz-Booher P, Burkhalter B, de Wagt A, Iliff P, & Willumsen J (Eds.). HIV and Infant Feeding: A Compilation of Programmatic Evidence. Bethesda, MD: UNICEF and the US Agency for International Development, 2004.

(4.) Cook RJ & BM Dickens. Human rights and HIV-positive women. International Journal of Gynecology and Obstetrics 2002;77:55-63.

(5.) Stillwaggon E. AIDS and the Ecology of Poverty. New York: Oxford University Press, 2006.

(6.) See www.waba.org.my/hiv/conference2006.htm or www.yorku.ca/nnewh

Penny Van Esterik, Department of Anthropology, York University
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Author:Van Esterik, Penny
Publication:Research Bulletin
Geographic Code:1CANA
Date:Sep 22, 2006
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