Breastfeeding and the HIV positive mother: the debate continues
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:
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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
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Breastfeeding is an important pillar of child survival in disadvantaged communities.
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Breastfeeding is important even in developed countries to protect against respiratory tract infections, diarrhoea and late onset diabetes, CVD, cancer and obesity.
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HIV may be transmitted during breastfeeding.
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The risk of transmission without any interventions is about 4% for every 6 months of breastfeeding.
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When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all
Research directions
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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?
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Impact of lactation management, nutritional interventions, and antibiotic treatment on clinical and sub-clinical mastitis and therefore on risk of breastfeeding transmission?
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Role of anti-retroviral (ARV) drug prophylaxis to the infant, mother or both during breastfeeding?
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Safety and resistance issues in the infant when mother is on
References (19)
- et al.
Effect of breastfeeding on mortality among HIV-1 infected women: a randomized trial
Lancet
(2001) Does breastfeeding really affect mortality among HIV-1 infected women?
Lancet
(2001)- et al.
Effect of breastfeeding and formula feeding on transmission of HIV-1. A randomised clinical trial
JAMA
(2000) Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis
JID
(2004)- et al.
Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa
AIDS
(2001) - et al.
Early introduction of non-human milk and solid foods increases the risk of postnatal HIV-1 transmission in Zimbabwe
- et al.
Postnatal transmission risk according to feeding modalities in children born to HIV-infected mothers in a PMTCT project in Abidjan, Cote d'Ivoire
- et al.
Productive HIV-1 infection of normal human mammary epithelial cells
AIDS
(1995) Mother-to-child transmission of HIV-1: the ‘all mucosal’ hypothesis as a predominant mechanism of transmission
AIDS
(1999)
Cited by (19)
‘I was told not to do it but…’: Infant feeding practices amongst HIV-positive women in southern Thailand
2017, MidwiferyCitation Excerpt :HIV has a markedly negative impact on motherhood. Often, women living with HIV/AIDS are advised not to breastfeed their infants as HIV can transmit through breast milk (Coutsoudis, 2004, 2005; Kourtis et al., 2006; Coovadia et al., 2007; UNAIDS, 2014). The transmission of HIV through breast milk has created a dilemma for HIV-positive mothers.
Couples, PMTCT programs and infant feeding decision-making in Ivory Coast
2009, Social Science and MedicineCitation Excerpt :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.
Breastfeeding by HIV infected mothers in Spain. Is it worthwhile and advisable?
2009, Anales de PediatriaBenefits and Risks of Breastfeeding
2007, Advances in PediatricsCitation Excerpt :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.
Mother-to-Child Transmission of HIV Through Breastfeeding Improving Awareness and Education: A Short Narrative Review
2022, International Journal of Women's HealthHIV-Infected Mothers Who Decide to Breastfeed Their Infants Under Close Supervision in Belgium: About Two Cases
2020, Frontiers in Pediatrics