Breastfeeding and the HIV positive mother: the debate continues

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Abstract

Breastfeeding is a route of HIV transmission from an HIV-infected mother to her infant. However, breastfeeding is an important pillar of child survival and the ideal way of feeding an infant as well as providing a unique biological and emotional basis for child development. This article highlights the dilemma created by the risks and benefits of breastfeeding and will discuss factors which increase the risk of HIV transmission during breastfeeding as well as strategies which could be employed to reduce these risks. Many questions still remain unanswered. Until further research results are available, women should be encouraged to follow the UNAIDS guidelines “when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended, otherwise, exclusive breastfeeding (EBF) is recommended during the first months of life”.

Anti-retroviral therapy to the mother and/or infant is likely to offer the possibility of maintaining breastfeeding as a safe option for HIV-infected women.

Section snippets

Background

This manuscript will only consider transmission of HIV-1 (subsequently referred to as HIV), as mother to child transmission (MTCT) of HIV-2 is rare.

The subject of breastfeeding and HIV has become a highly emotive debate because of the polarisation between those whose mandate is preventing the spread of HIV (and would therefore see the importance of replacing breastfeeding) and those whose mandate is child survival and therefore promote breastfeeding as one of the pillars of child survival.

According to duration of breastfeeding

Since the advent of PCR testing, it has been possible to more accurately determine the risk of breastfeeding transmission. To date there has only been one randomised controlled clinical trial (RCT) of breastfeeding vs. formula, however, the study had a serious limitation in terms of lack of compliance with the assigned feeding mode. This Kenyan study found a risk of transmission of 16% transmission by age 24 months [1]. It is unlikely that any groups in the future will attempt an RCT of feeding

Mechanisms of transmission

The exact mechanisms through which infants become infected through breastfeeding are not yet well understood. HIV is found in breastmilk as both cell-associated (DNA) and cell-free (RNA) virus. The origin of HIV in breastmilk remains unclear, although HIV particles and infectivity have been detected both in the liquid phase of breastmilk and in association with breastmilk cells. There is evidence that mammary epithelial cells (MEC) can be infected by the virus [6]. Although in vitro HIV

Risk factors for breastfeeding transmission

Several review papers have recently been published that identify the risk factors for breastfeeding transmission of HIV. The risk factors are summarised in Table 1 into 2 groups viz. those which have stronger supporting evidence and those with limited evidence.

Impact of breastfeeding on the HIV-infected mother

Considerable evidence exists to suggest that breastfeeding may be associated with maternal health benefits [10]. These include: decreased post-partum bleeding and decreased menstrual blood-loss during the months following labor; delayed resumption of ovulation with increased child-spacing; improved post-partum bone remineralization, and decreased post-menopausal hip fractures; and decreased rates of ovarian and breast cancer.

In contrast to these maternal health benefits, Nduati et al. [11]

Morbidity and mortality risks of not breastfeeding

As alluded to earlier, simply encouraging women not to breastfeed in order to prevent postnatal transmission of HIV is not straight forward as this intervention carries its own risks. The objective of any strategy to prevent MTCT must be to optimise overall child survival, including that of children of HIV-uninfected women. Central to this decision is determining the attendant risk of morbidity and death, of breastfeeding vs. not breastfeeding and what impact the recommendation and/or provision

Making informed choices on infant feeding

Because of the paucity of well-designed prospective trials evaluating the long-term relative risks associated with breastfeeding and formula feeding in settings of high HIV prevalences, several groups have designed mathematical models to assess the net mortality. In a recent modelling exercise, Kuhn et al. [18] estimate that when infant mortality rates (IMRs) are greater than about 40 per 1000 live births, providing formula milk to HIV-infected women would result in the excess number of deaths

Strategies to reduce breastfeeding transmission and improve child survival

For women who choose or need to breastfeed, experienced support should be available to ensure good exclusive breastfeeding practices so as to minimize breast pathology, HIV viral load and disruptions to the gut environment and therefore to reduce risk of HIV transmission. Breastfeeding should be discouraged for those women who have progressed to AIDS and have very low CD4 counts.

Strategies which should be employed to minimize risk of transmission during breastfeeding include the following:

Use of antiretrovirals to provide infant prophylaxis during breastfeeding

From recent animal trials and clinical trials, there is a suggestion that antiretrovirals given to the infant during the first few weeks post-delivery may protect the infant from HIV transmission during the breastfeeding period. In order to provide more conclusive evidence on the efficacy of antiretrovirals, several studies are currently underway testing the use of a variety of antiretroviral drug regimens to the mother and/or infant for periods from 1 week to 6 months [19].

Breastfeeding by women on highly active antiretroviral therapy (HAART)

As already mentioned, maternal HIV viral load has been shown to be an important risk factor for breastfeeding transmission. Women on HAART should theoretically have minimal levels of virus in their breastmilk and are therefore likely to be able to safely breastfeed. However, other considerations to bear in mind in this decision would be safety issues in the infant. All antiretrovirals tested thus far are excreted into the breastmilk and the infant will thus be exposed to small quantities. For

Key guidelines

  • Breastfeeding is an important pillar of child survival in disadvantaged communities.

  • Breastfeeding is important even in developed countries to protect against respiratory tract infections, diarrhoea and late onset diabetes, CVD, cancer and obesity.

  • HIV may be transmitted during breastfeeding.

  • The risk of transmission without any interventions is about 4% for every 6 months of breastfeeding.

  • When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all

Research directions

  • 1.

    What is the risk of HIV transmission if HIV-infected women breastfeed exclusively for 6 months and are offered support which is likely to minimize breast pathology?

  • 2.

    Impact of lactation management, nutritional interventions, and antibiotic treatment on clinical and sub-clinical mastitis and therefore on risk of breastfeeding transmission?

  • 3.

    Role of anti-retroviral (ARV) drug prophylaxis to the infant, mother or both during breastfeeding?

  • 4.

    Safety and resistance issues in the infant when mother is on

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    Moreover, it is also promoted by WHO and other organizations for the health benefits that it offers the infant, as it contributes to reducing morbidity and mortality (WHO, 2007). Since the end of the 1980s, international recommendations for HIV and infant feeding in these countries have been progressively developing to find a balance between the risk of HIV transmission and the risks of infant morbidity and mortality linked with replacement feeding (Coutsoudis, 2005). For Sub-Saharan Africa, these recommendations have given rise to two main alternatives to prolonged maternal breastfeeding: substitutes for breastmilk or exclusive breastfeeding with early and rapid weaning.

  • Benefits and Risks of Breastfeeding

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    Whether the risk factors are genetic variations in antiviral agents in human milk or preventable inflammatory processes in the breast or nipples needs to be defined. Also more studies are needed to determine whether antiretroviral agents given during lactation lessen the transmission of HIV-1 to the infant [163,164]. As new drugs are developed, it is important to ascertain whether they may be secreted into human milk and whether their presence poses a threat to the recipient infant.

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