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Experience and Outcomes of Breastfed Infants of Women Living With HIV in the United States: Findings From a Single-Center Breastfeeding Support Initiative
Abstract
We assessed breastfeeding outcomes for a cohort of infants born to women living with HIV (WLHIV) at an urban health care center in the United States. Ten infants were exclusively breastfed for a mean duration of 4.4 (1.0-8.6) months. All had negative HIV RNA PCRs at a median age of 16 months.
... In high-income countries, case series have been reported in which ART was started before pregnancy or in the first trimester, with no cases of transmission. [27][28][29][30][31][32][33][34] However, the overall numbers were small. Thirteen women, described in a prospective study conducted in Italy, had no instances of transmission of HIV through breastfeeding. ...
... Twenty-one of these cases had been reported previously in separate publications. 29,30,33 Bodily Autonomy and Reproductive Justice Many activists in the HIV community have framed the issue of choice in infant feeding within the concept of reproductive justice. 35 Reproductive justice is ...
... Several institutions have published information on protocols for managing breastfeeding in people with HIV and their babies. 29,55,56 As more institutions and practitioners develop and refine protocols, materials, and best practices related to HIV and infant feeding, ideally in collaboration with patients and others with expertise that comes from lived experience, we hope these can be shared and disseminated. ...
... 32 Ten infants from WLWH were breastfed in a "permissive" approach in the United States, and no VT was observed after a mean duration of 4.4 months of breastfeeding when mother and infant were under triple cART. 33 None of 3 Canadian infants were infected with 2 WLWH breastfeeding with nondetectable mVL and triple infant prophylaxis after 6 weeks, respectively, 12 weeks of nursing. 34 To the best of our knowledge, no VT has been shown in optimal scenarios in high-income countries. ...
... 17 In the presented cohort, infant prophylaxis was mostly given according to the applicable guidelines for breast milk substitute-fed infants and was seldom extended over 2 or 4 weeks, which is shorter than in other reports. 4,7,33,34 In our cohort, 5 WLWH who did breastfeed even declined infant prophylaxis entirely. Besides the Swiss report from 2021, 22 this is the second report in breastfeeding WLWH cohorts from high-income countries where infant prophylaxis was not applied over the whole breastfeeding period. ...
... Besides the Swiss report from 2021, 22 this is the second report in breastfeeding WLWH cohorts from high-income countries where infant prophylaxis was not applied over the whole breastfeeding period. 7,[32][33][34] The presented analysis shows that women may decide to breastfeed even if an optimal scenario is not present. Although intensive counseling is necessary, patient autonomy must be respected. ...
Background:
Exclusive breastfeeding is recommended for women living with HIV (WLWH) in low-income - but not in high-income - countries, where milk substitutes are preferred. Some guidelines for high-income countries opted for a shared decision making process regarding breastfeeding in optimal scenarios with adherence to antiretroviral therapy (cART), suppressed maternal viral load (mVL) and clinical monitoring. While vertical transmission (VT) risk under cART is estimated below 1% in low-income settings, data from high-income countries is rare.
Methods:
We retrospectively analyzed all 181 live births from WLWH at the LMU Munich university hospital perinatal center in Germany between 01/2016 and 12/2020. We focused on VT, suppressed mVL and optimal scenario rates, breastfeeding frequency, cART regimens and infant prophylaxis. All women were counseled according to current guidelines, foremost recommending avoidance of breastfeeding.
Results:
In the 5-year cohort, no VT was observed. 151 WLWH (83.4%) decided not to breastfeed, even in optimal scenarios. 30 infants (16.6%) were nursed, out of which 25 were within an optimal scenario, while in 5 cases breastfeeding was performed with a detectable VL in pregnancy or the postpartum period. All WLWH were treated with cART at delivery, and 91.7% sustained suppressed mVL. Zidovudine infant prophylaxis was given between 2 and 8 weeks but not necessarily over the whole breastfeeding duration and was declined from 5 breastfeeding WLWH.
Conclusion:
While the cohort is too small to assess VT risk through breastfeeding with cART-suppressed mVL, breastfeeding might be an alternative even in high-income countries, but further studies are needed.
... In this issue of the Journal of the Pediatric Infectious Diseases Society, Yusuf et al describe their intensive monitoring and treatment protocol for management of nine women living with HIV (WLHIV) infection who breastfed their 10 infants without transmitting HIV infection [1]. The women signed a consent waiver acknowledging the risks of possible breastfeeding HIV transmission; mothers and infants alike were administered combination antiretroviral therapy throughout the breastfeeding period; and both mothers and infants were intensively monitored for medication adherence and by serial plasma HIV RNA concentrations. ...
... A similar report of three WLHIV in Toronto who breastfed their infants without transmitting HIV brings the reported number of such instances in North America to 13 [2]. Some authors now postulate that clinicians should move from a position of routinely contraindicating breastfeeding by WLHIV in high-income countries (HIC) to a "risk reduction strategy" in which selected WLHIV breastfeed their infants [1,3]. Is this strategy safe, that is, are the risks of breastfeeding HIV transmission truly manageable, and are they manageable in most circumstances? ...
... at 12 months of age. Yusuf et al [1] cite a lower figure of 1.08% transmission at 6 months of age from the meta-analysis; however, the actual longterm estimate of HIV transmission of 2.93% is more germane, since some infants with apparent breastfeeding HIV transmission will be diagnosed often only after the breastfeeding period is completed [7]. In contrast, in HIC, formula feeding by WLHIV continues to be the standard recommendation [4,5] for very good reasons-formula feeding in these areas is not associated with morbidity and mortality of non-HIV infections, and the risk of HIV transmission by formula feeding is 0.0%. ...
In this issue of the Journal of the Pediatric Infectious Diseases Society, Yusuf et al describe their intensive monitoring and treatment protocol for management of nine women living with HIV (WLHIV) infection who breastfed their 10 infants without transmitting HIV infection [1]. The women signed a consent waiver acknowledging the risks of possible breastfeeding HIV transmission; mothers and infants alike were administered combination antiretroviral therapy throughout the breastfeeding period; and both mothers and infants were intensively monitored for medication adherence and by serial plasma HIV RNA concentrations. A similar report of three WLHIV in Toronto who breastfed their infants without transmitting HIV brings the reported number of such instances in North America to 13 [2]. Some authors now postulate that clinicians should move from a position of routinely contraindicating breastfeeding by WLHIV in high-income countries (HIC) to a “risk reduction strategy” in which selected WLHIV breastfeed their infants [1, 3]. Is this strategy safe, that is, are the risks of breastfeeding HIV transmission truly manageable, and are they manageable in most circumstances? We think not, at least, not with the scientific data at hand.
... Several published cases from high-income countries (Canada, the United States, and Germany) have reported various approaches to clinical management for both mother and infant. [6][7][8][9] What differentiates the current report from those earlier publications is the description of measures taken to facilitate breastfeeding, the complications experienced throughout the breastfeeding period, and the inclusion of cases involving poor adherence to ART and infant prophylaxis. ...
... 10,11 The reasons for wanting to breastfeed include immunologic or nutritional benefits, infant bonding, cultural expectations, and fear of HIV disclosure. 7,8,12 The CPARG guidelines 1 acknowledge the psychological impacts when a person's experience of breastfeeding is limited or constrained and the subsequent feelings of grief or sadness that may arise. The decision to support these women in their choice to breastfeed respected patient desires and promoted harm reduction, given the women's previous experiences of PPD and return to substance use, as well as a history of breastfeeding without disclosure to the health care team. ...
... Implementing a shared decision-making approach to support infant feeding choices can help WLWH to understand the risk of transmission with breastfeeding and why U = U does not, with the current knowledge, apply to breastfeeding, and also accept global differences in guidelines [57,60]. This requires that the risks and benefits of breastfeeding in the context of HIV are discussed, in addition to frequent follow-up visits for both the mother and infant if the mother decides to breastfeed [60]. ...
... Implementing a shared decision-making approach to support infant feeding choices can help WLWH to understand the risk of transmission with breastfeeding and why U = U does not, with the current knowledge, apply to breastfeeding, and also accept global differences in guidelines [57,60]. This requires that the risks and benefits of breastfeeding in the context of HIV are discussed, in addition to frequent follow-up visits for both the mother and infant if the mother decides to breastfeed [60]. ...
Background
Recent changes in the infant feeding guidelines for women living with HIV from high-income countries recommend a more supportive approach focusing on shared decision-making. Limited information is available on the infant feeding knowledge of women living with HIV and how healthcare providers engage with them in this context. This multicenter, longitudinal, mixed methods study aims to get a comprehensive and nuanced understanding of infant feeding knowledge among women living with HIV of Nordic and non-Nordic origin living in Nordic countries, and their interaction with healthcare providers regarding infant feeding planning.
Methods
Pregnant women living with HIV in Denmark, Finland, and Sweden were recruited in 2019–2020. The Positive Attitudes Concerning Infant Feeding (PACIFY) questionnaire was completed in the 3rd trimester (T1), three (T2), and six (T3) months postpartum. Women who completed the quantitative survey were also invited to participate in qualitative semi-structured interviews at T1 and T3. Results from the survey and interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the datasets and to draw meta-inferences.
Results
In total, 44 women living with HIV completed the survey, of whom 31 also participated in the interviews. The merged analyses identified two overarching domains: Knowledge about breastfeeding in the U = U era and Communications with healthcare providers. The women expressed confusion about breastfeeding in the context of undetectable equals untransmittable (U = U). Women of Nordic origin were more unsure about whether breastfeeding was possible in the context of U = U than women of non-Nordic origin. Increased postpartum monitoring with monthly testing of the mother was not seen as a barrier to breastfeeding, but concerns were found regarding infant testing and infant ART exposure. Infant feeding discussions with healthcare providers were welcome but could also question whether breastfeeding was feasible, and many participants highlighted a need for more information.
Conclusions
Healthcare providers caring for women living with HIV must have up-to-date knowledge of HIV transmission risks during breastfeeding and engage in shared decision-making to optimally support infant feeding choices.
... Reassuring reports of infants being breastfed by their virologically suppressed mothers, while on appropriate neonatal antiretroviral (ARV) prophylaxis with zero HIV transmission rates have been emerging in Europe and North America. As detailed recommendations are not yet available, the approaches to managing the care of these WHIV and their infants vary widely; nevertheless, to date none of the breastfed infants have acquired HIV infection [21][22][23][24]. ...
... The majority of WHIV described in these published reports from North America were native to Africa and had breastfed previous children in their respective countries of origin as recommended by the WHO [21][22]. In contrast, the population of WHIV that we serve in Miami is multiethnic and multicultural, with mothers born both in and outside of the U.S., mainly in Latin America and Haiti. ...
Background
Until recently, breastfeeding has been contraindicated for women living with HIV (WHIV) in the U.S. However, given the numerous health benefits of breastfeeding, recommendations have changed to support parental choice to breastfeed through shared decision-making. Although specific guidelines for managing the care of these women and their infants are not yet available, various approaches have been successful without infants acquiring HIV from their virologically suppressed mothers, thus, establishing breastfeeding as a viable option for the rising number of interested WHIV. This descriptive qualitative study aimed to identify factors influencing infant feeding choices decisions among WHIV in a multiethnic and multicultural population.
Methods and findings
A qualitative description design was used. WHIV who had given birth within 6 months were recruited using purposeful sampling. Data were collected using a semistructured interview guide in the participant’s preferred language. Content analysis was used, and barriers and facilitators were separated and used to generate the themes and categories. In total, 20 participants were interviewed, and from these interviews, 11 barriers and 14 facilitators that influenced the decision to breastfeed were identified. Major barriers were related to the interference with daily activities, fear of transmission, lack of a standardized approach to education, and maternal concerns. Key facilitators included the benefits and advantages of breastmilk, access to more scientific research information on breastfeeding in the context of HIV, advice from a lactation consultant, emotional connection and attachment with the child, support from family and partners, empowering and supporting autonomy and decision-making about infant feeding, providing feeding choices, access to the lived experiences of women who have successfully breastfed their infants, and collaborative relationship with the physician and other healthcare providers.
Conclusion
The study identified barriers and facilitators to breastfeeding among WHIV that may influence their infant feeding decision-making process. More research is needed to guide the standardization of institutional policies and develop strategies to support breastfeeding in this population.
... Conversely, in resource-limited settings where infant formula and clean water are scarce, the World Health Organization recommends exclusive breastfeeding for the first 6 months of life among WLWH [5,6]. Despite recommendations to avoid breastfeeding, some WLWH in the US still chose to breastfeed for sociocultural and emotional reasons, in addition to the well-established nutritional benefits of breast milk [7][8][9][10]. Disparate guidelines challenged provider-patient education on infant feeding recommendations for WLWH [8,[11][12][13]. ...
... Multiple studies demonstrated that many women in the US perceive breastfeeding as superior to formula feeding with respect to health benefits, maternal-infant bonding, and desire to breastfeed in the context of stigmatization with formula feeding and HIV [7][8][9]43]. While the national emphasis on exclusive formula feeding aimed to help reduce the risk of mother-child HIV transmission, Tuthill and colleagues found that prohibiting WLWH from breastfeeding may impede mother-infant bonding, leading to psychological distress [8]. ...
Prior to January 2023, women living with HIV (WLWH) in the United States (US) were discouraged from breastfeeding due to the potential risk of mother-to-child HIV transmission through breastfeeding. Lack of breastfeeding decision-making and experience among WLWH may negatively affect maternal mental health. We implemented a quality improvement initiative to screen WLWH for postpartum depression (PPD), evaluate their attitudes toward breastfeeding, and assess their experience with breastfeeding decision-making. We collected quantitative data from WLWH using a voluntary, self-administered 6-item breastfeeding decision-making and experience survey (administered 1 month postpartum) and a 10-item Edinburgh Postnatal Depression Scale (EPDS, negative = 0–9; administered 1 and 4 months postpartum) tool. We conducted descriptive statistics and cross tabulation analysis. We analyzed 106 WLWH (93.4% non-Hispanic Black/African American; mean age 33.1 years; 82.1% HIV RNA < 200 copies/mL). One in five (19.1%) WLWH had a positive baseline EPDS screen, with the mean EPDS scores decreasing from 5.3 ± 5.4 (baseline) to 4.6 ± 4.8 (follow-up). Among 55 WLWH who provided baseline and follow-up EPDS scores, only 3/13 with a positive baseline EPDS screen had resolved depressive symptoms at follow-up. Over one-third (37.7%) of WLWH indicated feeling “sadness” when asked whether lack of breastfeeding negatively affected their feelings or emotions. Over half of WLWH (51.9%) were aware of the US breastfeeding recommendations, but the majority (60.4%) had never discussed breastfeeding options with a medical provider. Improved provider–patient discussions on infant feeding options among WLWH is needed to increase awareness of breastfeeding choices and promote informed, autonomous breastfeeding decision-making among WLWH.
... To the editor-Yusuf et al [1] reported outcomes of 10 infants exclusively breastfed (median 4.4 months) by virally suppressed women living with HIV (WLHIV) in the United States who remained HIV uninfected. The infants received antiretroviral drug (ARV) prophylaxis with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) for 4 to 6 weeks, followed by NVP alone through 6 weeks after breastfeeding cessation. ...
... Many unanswered medical, ethical, and social questions within the U=U (undetectable=untransmittable) paradigm of breastfeeding among WLHIV remain, including the need for prolonged infant ARVs as a trade-off for breastfeeding with effective modern maternal ART, risks of mixed feeding practices with sustained maternal viral suppression in resource-rich settings, optimal mother-infant dyad testing, and optimal ARV regimens for infants and WLHIV including the future use of long-acting maternal ARVs [1][2][3]. Our joint experiences highlight the need for studies to find the best risk-reduction approach to allow WLHIV in the US autonomy when choosing to breastfeed their infants. ...
To the editor—Yusuf et al [1] reported outcomes of 10 infants exclusively breastfed (median 4.4 months) by virally suppressed women living with HIV (WLHIV) in the United States who remained HIV uninfected. The infants received antiretroviral drug (ARV) prophylaxis with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) for 4 to 6 weeks, followed by NVP alone through 6 weeks after breastfeeding cessation. In response, 2 editorial commentaries raised discussions about the prospects of offering WLHIV in the United States the choice of breastfeeding [2, 3].
Despite recommendations to avoid breastfeeding by WLHIV [4], WLHIV in resource-rich settings express a desire to breastfeed or have breastfed their infants [5, 6]. At an urban HIV clinic at Children’s National Hospital (CNH) in Washington, DC, several WLHIV have chosen to breastfeed their infants. Breastfeeding waivers are not required to avoid additional stigma and the risk of generating medical mistrust. Our current approach to risk-reduction includes ensuring maternal viral suppression with antiretroviral therapy (ART), infant ARV prophylaxis (6 weeks ZDV and NVP), counseling on exclusive breastfeeding during the first 6 months of life, HIV nucleic acid tests (NAT) for infants (1, 2, and 4 months of age; every 3 months through breastfeeding; 1, 3, and 6 months after breastfeeding cessation), and bimonthly maternal HIV NATs. In this letter, we provide our perspective and additional data on breastfeeding among WLHIV in the United States.
... 9 It is recommended that the parent receive regular viral load testing during pregnancy and approximately every 1 to 2 months while breastfeeding to ensure that the viral load remains suppressed and that the infant is protected. 10,11 In addition, the infant should be weaned off of breastmilk over a 2-to 4-week period because of the high viral transmission risk that is associated with rapid weaning, especially when the parent is not entirely on an ART regimen. [12][13][14] The clinician and parent should also consider antiretroviral prophylaxis for the child as a preventive measure for contracting HIV. ...
... 3 Our institution and others have seen an increasing number of pregnant people with HIV expressing an interest in breastfeeding. [13][14][15] As of writing, our centre has assisted 11 patients within the last 3 years to breastfeed. This 11 is out of 19 patients (1 patient breastfed twice) who expressed an interest in breastfeeding. ...
Shared decision making for infant feeding in the context of HIV in high-resourced settings is necessary to acknowledge patient autonomy, meet increasing patient requests and address the changing reality of perinatal HIV care. In low-to middle-income countries (LMIC), where the majority of individuals living with HIV reside, persons with HIV are recommended to breastfeed their infants. In the setting of maternal anti-retroviral therapy (ART) use throughout pregnancy, viral suppression and appropriate neonatal post-exposure prophylaxis (PEP) use, updated information indicates that the risk of HIV transmission through breastmilk may be between 0.3 and 1%. While not endorsing or recommending breastfeeding, the United States’ DHHS perinatal guidelines are similarly pivoting, stating that individuals should “receive patient-centred, evidence-based counselling on infant feeding options.” Similar statements appear in the British, Canadian, Swiss, European, and Australasian perinatal guidelines. We assembled a multi-disciplinary group at our institution to develop a structured shared decision-making process and protocol for successful implementation of breastfeeding. We recommend early and frequent counselling about infant feeding options, which should include well known benefits of breastfeeding even in the context of HIV and the individual’s medical and psychosocial circumstances, with respect and support for patient’s autonomy in choosing their infant feeding option.
... Finally, some of these cases have been published as case series since the start of data collection. Data presented here is more extensive, but care should be taken not to consider information from all published reports in an aggregate manner since there are overlapping cases [15][16][17]. ...
Background:
In North American countries national guidelines have strongly recommended formula over breastmilk for people with HIV because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is less than 1% among virally suppressed people. Information regarding breastfeeding experience in high resource settings is lacking.
Methods:
A retrospective multi-site study was performed for individuals with HIV who breastfed from 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis.
Results:
Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy (ART) prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available >= 6 weeks after weaning.
Conclusions:
This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients living with HIV who chose to breastfeed at any one location, and the need for further multi-site studies to identify best care practices.
... Breastfeeding is not recommended in any of the countries, but in recent years more women living with HIV with a strong wish to breastfeed were supported under certain circumstances. Case series were reported from Belgium, Germany and the US [8][9][10][11]. In contrast to our study, all the infants received post- Based on the literature of low resource settings, the risk of HIV transmission to an infant by breastfeeding over 1 year is 1-2 % [2,[12][13][14] However, no case of vertical transmission from mothers with suppressed VL at the end of pregnancy and during breastfeeding could be found in the literature in 2018 when the Swiss recommendations were updated and until today [6]. ...
Introduction:
Swiss national recommendations advise, since end of 2018, supporting women with HIV who wish to breastfeed. Our objective is to describe the motivational factors and the outcome of these women and of their infants.
Methods:
mothers included in MoCHiV with a delivery between January 2019 and February 2021 who fulfilled the criteria of the "optimal scenario" (adherence to cART, regular clinical care, and suppressed HIV plasma viral load (pVL) of <50 RNA copies/ml) and who decided to breastfeed after a shared decision-making process, were approached to participate in this nested study and asked to fill-in a questionnaire exploring the main motivating factors for breastfeeding.
Results:
Between January 9, 2019 and February 7, 2021, 41 women gave birth, and 25 decided to breastfeed of which 20 accepted to participate in the nested study. The three main motivational factors of these women were bonding, neonatal and maternal health benefits. They breastfed for a median duration of 6.3 months (range 0.7-25.7, IQR 2.5-11.1). None of the breastfed neonates received HIV post-exposure prophylaxis. There was no HIV transmission: 24 infants tested negative for HIV at least 3 months after weaning; one mother was still breastfeeding when we analyzed the data.
Conclusions:
As a result of a shared decision-making process, a high proportion of mothers expressed a desire to breastfeed. No breastfed infant acquired HIV. The surveillance of breastfeeding mother-infant pairs in high resource settings should be continued to help update guidelines and recommendations.
... A survey of 15 treatment centers in Germany showed that the number of women with HIV who had opted to breastfeed increased from 1 to 13 between 2009 and 2018 [33]. And we now have published case reports from 3 high-resource sites: 3 patients in Toronto, Canada; 10 in Baltimore, Maryland; and 13 in Italy [3,34,35]. ...
Guidelines in high-income countries generally recommend against breastfeeding for a pregnant person with HIV due to the historical risk of transmission to the infant and generally acceptable, safe, and sustainable access to formula. Maternal antiretroviral therapy and infant prophylaxis have been shown to significantly decrease the risk of transmission during breastfeeding. In addition, formula may not be acceptable to patients for a variety of cultural, social, or personal reasons, and its sustainability is called into question in the setting of the current nationwide formula shortage. Providers caring for pregnant people with HIV have a responsibility to discuss infant feeding with their patients, and help them weigh the risks and benefits within the limits of the current body of evidence. We outline a process, including a written agreement, that can be used to discuss infant feeding with all patients and help them make the best decision for their family.
... However, a secondary analysis of the trial did result in two infants in the maternal ART arm acquiring HIV despite maternal viral loads of less than 40 copies/ml [12]. Although U = U in the setting of breastfeeding is still undetermined, data from women in LMIC and emerging data from HIC show the transmission risk is low in the setting of strict adherence to ART and being virally suppressed [29,30]. Although transmission risk is low, it is still possible. ...
Current management of perinatal HIV infections and exposures involves the administration of antiretroviral therapy to both the pregnant mother and to her child after delivery. Striving to achieve safe and effective medication management is key in preventing new pediatric HIV infections. Maternal HIV testing and subsequent monitoring can help to identify fetal HIV exposures during pregnancy, maternal nonadherence, insufficient treatment regimens, and otherwise undiscovered exposures during the delivery process. There are several well-constructed guidelines that offer expert references for healthcare providers. This chapter will summarize current recommendations from the United States, with a brief insight into select international guidelines. Although available guidelines provide a structured framework for the healthcare team, there has recently been a significant drive to advance current perinatal management and outcomes.
... As a result, a selective, permissive, patient-centered riskreduction approach, with a shared decision-making process regarding infant feeding options has been proposed for HIVpositive mothers living in high-income countries. These proposals are being made despite the continued United States official policy that breastfeeding is not recommended for women with HIV. 7 Given this controversy, there is particular interest in the most recent publication of Yusuf et al. 8 from the Johns Hopkins School of Medicine reporting on their experience with 10 HIV-positive mothers who choose to breastfeed. All the infants were carefully monitored to guarantee that they adhered to a specific ART protocol while they exclusively breastfed (for a mean of 4.4 months), and satisfyingly no HIV viral transmission occurred with this regimen. ...
New US guidelines support shared decision making regarding breastfeeding for mothers living with HIV and their neonates. We surveyed Pediatric Infectious Diseases Society members about implementation of these guidelines. We found heterogeneity in uptake, variability in clinical practice, and concerns about implementation. Future research should address these policy-practice gaps.
Human immunodeficiency virus in pregnant people remains a significant public health issue worldwide. The rate of perinatal transmission is 15% to 40% but can be decreased to less than 1% with appropriate antenatal management. Previous recommendations included a protease inhibitor-based antiretroviral therapy, infant prophylaxis, performance of cesarean section for uncontrolled viremia, and the use of formula for infant feeding. However, recent updates include first line of integrase inhibitor-based regimens and supporting parental choices for safe lactation. In this review, we summarize and provide updated recommendations for the care of people living with human immunodeficiency virus during pregnancy.
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
Introduction
HIV is a major public health issue affecting millions globally. Women and girls account for 46% of new HIV infections in 2022 and approximately 1.3 million females become pregnant every year. Vertical transmission of HIV from persons living with HIV (PLHIV) to infants may occur through different modalities, such as through breast/chest feeding. Notably, 82% of PLHIV who chose to breast/chest feed are on antiretroviral therapy (ART) when feeding their infants. Precise estimates of the risk of postpartum transmission to infants during breast/chest feeding at varying viral load levels remain a significant gap in the literature.
Methods and analysis
A rapid systematic search of electronic databases will be conducted from January 2005 to the present, including Medline, Embase and Global Health. The objective of this rapid review is to explore and assess the available evidence on the effect of varying viral load levels on the risk of HIV transmission to infants during breast/chest feeding when the birthing or gestational parent living with HIV is on ART. Study characteristics will be summarised and reported to support the narrative summary of the findings. The focus will be on the absolute risk of HIV transmission from birthing parent to infant during chest/breast feeding. The findings will also be stratified by month, including the risk of HIV transmission for 6 months and greater than 6 months postpartum. We will ascertain the risk of bias using A Measurement Tool to Assess Systematic Reviews 2, Quality of Prognosis Studies and Downs and Black checklist for the appropriate study type. A summary score will not be calculated, rather the strengths and limitations of the studies will be narratively described.
Ethics and dissemination
No human subjects will be involved in the research. The findings of this rapid review will inform a future systematic review and will be disseminated through peer-reviewed publications, presentations and conferences.
PROSPERO registration number
CRD42024499393.
Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the United States and other resource rich settings was actively discouraged. Formula feeding was mandated as the only feeding option primarily out of concern for breastmilk transmission of HIV, which occurred in 16-24%1-3 of cases pre-antiretroviral therapy (ART) use. In January 2023, the United States’ Department of Health and Human Services (DHHS) Perinatal Guidelines were updated to support shared decision making for infant feeding choices4. Updated data from clinical trials in low- and middle-income settings suggest that the actual rate of HIV transmission through breastmilk in the context of maternal ART or neonatal post-exposure prophylaxis (PEP) is 0.3-1%1-3. High income countries are reporting increasing numbers of people with HIV breastfeeding their infants without cases of HIV transmission to date5-10. Here we will present the reasons for fully embracing breast/chestfeeding as a viable and safe infant feeding option for HIV-exposed infants in high-income settings now, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.
To breast feed or not has long been a difficult question for women with human immunodeficiency virus (HIV) in high-income countries, as undetectable HIV in maternal plasma does not translate to zero risk of transmission while breastfeeding, and clean water and formula are readily available. Recent, and more permissive, changes in US and other high-income-country guidelines regarding breastfeeding underscore this issue and acknowledge the information gaps that are essential for informed maternal choice and provider management. These include lack of guidance as to routine monitoring of mothers during lactation, type and length of prophylaxis for infants, and lack of data on factors associated with increased breast-milk viral load and risk of transmission. Ancillary to data are the education and staffing needs for providers participating in the management of breastfeeding individuals. Future studies of breast-milk transmission will need to evaluate these gaps so that we can move transmission to zero.
Purpose of review
HIV screening in pregnancy, universal suppressive antiretroviral therapy (ART) and breastfeeding avoidance can almost completely prevent vertical transmission of HIV. Breastfeeding is associated with an additional risk of transmission, although this risk is extremely low with suppressive maternal ART. This minimal risk must be balanced with the benefits of breastfeeding for women living with HIV (WLHIV) and their infants. Guidance in high-income countries has evolved, moving towards supported breast feeding for women on suppressive ART.
Recent findings
Breastmilk transmission accounts for an increasing proportion of new infant infections globally. The majority of transmission data comes from studies including women not on suppressive ART. Breastmilk transmissions in the context of undetectable viral load have rarely occurred, although risk factors remain unclear. Outcome data on supported breastfeeding are accumulating, providing evidence for guidelines and informing infant feeding decisions. Long-acting ART for maternal preexposure prophylaxis or treatment, and infant postnatal prophylaxis are promising future options.
Summary
Breastfeeding on suppressive ART has a very low risk of vertical transmission and can have multiple benefits for WLHIV and their infants. However, caution is advised with relaxation of breastfeeding guidance so as not to jeopardise the global goal of elimination of vertical transmission by 2030.
Awareness of updates on the recommendations for the treatment and prevention of HIV in children and adolescents is of vital importance for pediatricians to support HIV elimination efforts in the USA.
Children with HIV infection have access to potent antiretroviral regimens in combined and easier to administer formulations. For youth with HIV, simpler and long-acting treatment regimens are available. For infants born to persons with HIV that have low risk of perinatal transmission, an abbreviated regimen is recommended. Breastfeeding is supported for individuals on HIV treatment who remain virally suppressed. For adolescents and young adults at significant risk of HIV, pre-exposure prophylaxis is recommended.
Early treatment remains paramount for best outcomes in children and adolescents living with HIV, aided by innovative drugs and delivery methods. These advances should strive to equally benefit both the pediatric and adult populations. Despite progress, youth still comprise a significant portion of new HIV cases. Inclusive prevention strategies led by pediatricians are essential for HIV elimination in adolescents and young adults.
Background
The recommendation of breastfeeding avoidance for women living with HIV in high-income settings may be influenced by cultural beliefs and come at an emotional cost. This multi-center, longitudinal, convergent mixed methods study aimed to compare differences in attitudes, concerns and experiences surrounding breastfeeding in women living with HIV of Nordic and non-Nordic origin.
Setting
High-income setting
Methods
Pregnant women living with HIV in the Nordic countries Denmark, Finland, and Sweden were recruited in 2019–2020. Quantitative data on attitudes surrounding infant feeding was assessed using the Positive Attitudes Concerning Infant Feeding (PACIFY) questionnaire completed in the third trimester (T1), and 3 (T2) and 6 (T3) months postpartum. Women who completed the survey were also invited to participate in semi-structured interviews at T1 and T3. Findings from the quantitative survey and qualitative interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the datasets, and to draw meta-inferences.
Results
In total, 44 women completed the survey, of whom 31 also participated in qualitative interviews. The merged analyses identified three overarching domains representing commonalities across the quantitative and qualitative data: emotional impact, justifying not breastfeeding, and coping strategies. Not being able to breastfeed was emotionally challenging. Cultural expectations influenced the women’s experiences and the strategies they used to justify their infant feeding choice.
Conclusion
For women living with HIV in Nordic countries not breastfeeding was a complex, multi-layered process substantially influenced by social and cultural expectations.
Background
With the advancement of antiretroviral therapy scale-up, it is possible for women living with HIV to breastfeed safely. However, this practice has not been adopted in Malaysia. Instead, infants are provided with subsidized human milk substitutes for their first 2 years of life.
Research Aim
This study describes the infant feeding experiences of women living with HIV in Malaysia.
Methods
From August to October 2021, a nationwide, community-based qualitative study was conducted among women living with HIV and who received care from the Malaysian Ministry of Health. Using purposive sampling, participants who met the inclusion criteria were recruited. Interview and focus group transcripts were coded based on a secondary thematic analysis.
Results
Six in-depth interviews and five focus group discussions were conducted among 32 participants. Study participants were mostly Malay secondary school graduates in their 30s and 40s. Due to the fear of vertical transmission, which was explained by healthcare providers to the participants, none of the women breastfed their infants. The three primary themes that emerged from analyzing the women’s infant feeding experiences were (1) a human milk substitute was the only option and was encouraged; (2) feeding infants with a human milk substitute made the women feel incomplete as mothers; and (3) the women encountered difficulties in obtaining the subsidized human milk substitute.
Conclusion
Women living with HIV in Malaysia have been advised to provide human milk substitutes to their infants in fear of HIV transmission.
Around 40% of people living with human immunodeficiency virus (HIV) in Sweden are women. However, little is known about their experiences, particularly those related to sexual and reproductive health and rights (SRHR). This study aims to explore perceptions and experiences of SRHR among women living with HIV (LWH). Twelve interviews were conducted with women LWH from September to October 2019 and analysed using thematic analysis. The central theme describing participants’ experiences of social relationships, intimate encounters and reproductive life, “Discrimination is harder to live with than the disease itself”, is based on three themes that contain subthemes. Theme 1 describes how participants reconsider and reorient their sexual and reproductive life after diagnosis. Theme 2 highlights how (mis)perceptions of HIV affect sexual and
reproductive life and lead to abusive treatment and internalisation. Theme 3 describes a paradoxical shift of responsibilities where participants experience being compelled to take greater responsibility in some situations and stripped of the right to decide in others. This study suggests that despite notable progress in HIV treatment, stigma and discrimination stemming from outdated beliefs and (mis)conceptions, ambiguous policies and guidelines, and unequal access to information affect SRHR experiences of women LWH more than the virus itself. The results emphasise the need to: update knowledge within healthcare settings and among the public; clarify ambiguous legislations and guidelines; ensure equal access to information to enable all women LWH to take informed decisions, make fully informed choices and realise their SRHR; and consider the diversity of women LWH and enable shared decision-making.
Breastfeeding affords numerous health benefits to mothers and children, but for women with HIV in the United States, avoidance of breastfeeding is recommended. Evidence from low-income countries demonstrates low risk of HIV transmission during breastfeeding with antiretroviral therapy, and the World Health Organization recommends exclusive breastfeeding and shared decision making about infant feeding options in low-income and middle-income countries. In the United States, gaps in knowledge exist surrounding the experiences, beliefs, and feelings of women with HIV surrounding infant feeding decisions. Undergirded by a framework of person-centered care, this study describes the experiences, beliefs, and feelings of women with HIV in the United States surrounding recommendations for breastfeeding avoidance. Although no participants reported consideration of breastfeeding, multiple gaps were identified with implications for the clinical care and counseling of the mother-infant dyad.
Background:
Women with HIV in high-income settings have increasingly expressed a desire to breastfeed their infants. While national guidelines now acknowledge this choice, detailed recommendations are not available. We describe the approach to managing care for breastfeeding women with HIV at a single large-volume site in the US.
Methods:
We convened an interdisciplinary group of providers to establish a protocol intended to minimize the risk of vertical transmission during breastfeeding. Programmatic experience and challenges are described. A retrospective chart review was conducted to report the characteristics of women who desired to or who did breastfeed between 2015-2022 and their infants.
Results:
Our approach stresses the importance of early conversations about infant feeding, documentation of feeding decisions and management plans, and communication among the healthcare team. Mothers are encouraged to maintain excellent adherence to antiretroviral treatment, maintain an undetectable viral load, and breastfeed exclusively. Infants receive continuous single drug antiretroviral prophylaxis until four weeks after cessation of breastfeeding. From 2015-2022, we counseled 21 women interested in breastfeeding, of whom 10 women breastfed 13 infants for a median of 62 days (range, 1-309). Challenges included mastitis (N=3), need for supplementation (N=4), maternal plasma viral load elevation of 50 to 70 copies/mL (N=2), and difficulty weaning (N=3). Six infants experienced at least 1 adverse event, most of which were attributed to antiretroviral prophylaxis.
Discussion:
Many knowledge gaps remain in the management of breastfeeding among women with HIV in high-income settings, including approaches to infant prophylaxis. An interdisciplinary approach to minimizing risk is needed.
Background:
WHO guidelines recommend breastfeeding for mothers living with HIV adherent to antiretroviral therapy in countries where formula is not accessible. In Canada and the US, guidelines for mothers living with HIV recommend exclusive formula feeding. Awareness of national infant feeding guidelines and socio-cultural factors influence infant feeding choices that may result in an increased risk of vertical transmission of HIV. The purpose of this paper is to present factors associated with awareness of guidelines among Black mothers living with HIV. Data were derived from a survey conducted as part of a recent international study that examined infant feeding practices among Black women living with HIV in Ottawa, Canada; Port Harcourt, Nigeria; and Miami, Florida.
Methods:
Participants (n = 690) from Port Harcourt (n = 400), Miami (n = 201), and Ottawa (n = 89) were surveyed on their awareness of infant feeding guidelines for mothers living with HIV. Data were collected between November, 2016 and March, 2018.
Results:
Participants' mean ages were 34.3 ± 5.9 years. Across all sites, 15.4% (95% CI 13.2, 7.7) of mothers were NOT aware of their country's infant feeding guidelines. Cultural beliefs (OR = 0.133, p = 0.004, 95% CI 0.03, 0.53) and functional social support influenced infant feeding choices (OR = 1.1, p = 0.034, 95% CI 1.01, 1.20) and were statistically significant predictors of guideline awareness (Χ2 = 38.872, p < .05) after controlling for age, years of formal education, marital status, and country of residence. As agents of functional social support, family members and health workers (e.g., nurses, physicians, social workers, other health care workers) influenced participants' awareness of infant feeding guidelines and guided them in their infant feeding choices.
Conclusions:
Among participants, awareness of national infant feeding guidelines was associated with functional social support and cultural beliefs influenced infant feeding choices. Therefore, culturally adapted messaging via social supports already identified by mothers, including family relationships and health workers, is an appropriate way to enhance awareness of infant feeding guidelines. Ultimately, contributing to the global health goals of maternal health and reduced infant mortality.
Objective:
The aim of the study was to determine whether exclusive breastfeeding or exclusive formula feeding is more cost-effective when a Canadian mother with HIV is adherent to antiretroviral therapy and has full virologic suppression.
Design:
Current Canadian guidelines recommend that mothers with HIV practice exclusive formula feeding. This contradicts the updated World Health Organization (WHO) guidelines which recommend that mothers with HIV should breastfeed for ≥12 months while receiving support for antiretroviral therapy adherence. Due to the economic and health risks and benefits associated with each modality, there remains expert disagreement on whether the WHO recommendations should be adopted in high-income countries.
Methods:
A microsimulation model was developed to estimate lifetime costs and effectiveness (i.e., infant's quality-adjusted life years) of a hypothetical group of 1,000,000 initially healthy, HIV-negative infants, if the mother with HIV was on antiretroviral therapy with full virologic suppression and either exclusive breastfeeding or exclusive formula feeding. The model was developed from the economic perspective of the Ontario Ministry of Health, taking into account direct costs associated with infant feeding modality as well as related indirect costs born out of the child's lifetime health outcomes. Uncertainties related to model parameters were evaluated using one-way and probabilistic sensitivity analyses.
Results:
In comparison to exclusive formula feeding, exclusive breastfeeding was the dominant feeding modality (i.e., less costly and more effective) yielding cost-savings of $13,812 per additional quality-adjusted life year gained. Neither one-way nor probabilistic sensitivity analyses altered the conclusions.
Conclusions:
Despite the risk of HIV transmission, exclusive breastfeeding was more cost-effective than exclusive formula feeding. These findings merit review of current infant feeding guidelines for mothers with HIV living in high-income countries.
J MacGillivray, M H Yudin, D M Campbell, T Barozzino, M Baqi, S E Read, A Bitnun
The reduction in human immunodeficiency virus (HIV) transmission through breastmilk with maternal combination antiretroviral therapy (cART) has led many pregnant women living with HIV and healthcare providers to question exclusive formula feeding in resource-rich settings. Here, we describe cART prophylaxis in 3 breastfed infants whose mothers had sustained virologic suppression; all 3 of these infants remained uninfected.
Combined antiretroviral treatment (cART) has reduced mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV) to virtually zero in industrialised countries, where strictly bottle feeding is recommended for HIV-infected mothers, and to as low as 0.7% after 12 months in low-resource settings, where breastfeeding is strongly encouraged. Given the theoretically very low risk of transmission by breastfeeding with cART, and the advantages and benefits of breastfeeding, also in industrialised countries, the strong recommendation to HIV-infected mothers to refrain from breastfeeding in this setting may no longer be justified. We have evaluated risks of breastfeeding for HIV MTCT in the light of accessible cART, the general benefits of breastfeeding, and the women's autonomy to consent to any intervention. As we found no evidence in the literature of HIV MTCT via breastfeeding whilst on effective cART, we identified a situation of clinical equipoise. We propose how to proceed in Switzerland when HIV-infected women consider breastfeeding. We advocate a shared decision-making process and suggest a list of topics on which to provide unbiased information for the HIV-infected mother to enable her comprehensive understanding of one or the other decision. Although breastfeeding still should not be actively recommended in Switzerland, any HIV-infected mother, regardless of her geographical and cultural background, who decides to breastfeed should be supported by the best strategy to achieve optimal medical care for both herself and her child. This includes continuous support of cART adherence and regular maternal HIV plasma viral load monitoring.
Introduction: To systematically review the literature on mother-to-child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART.
Methods: We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta-analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle-Ottawa Scale (NOS) and GRADE.
Results and discussion: Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk.
Conclusions: There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life-long ART for all.
Background—Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples.
Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples.
In nine countries, we enrolled 1763 couples in which one partner was HIV-1-positive and the other was HIV-1-negative; 54% of the subjects were from Africa, and 50% of infected partners were men. HIV-1-infected subjects with CD4 counts between 350 and 550 cells per cubic millimeter were randomly assigned in a 1:1 ratio to receive antiretroviral therapy either immediately (early therapy) or after a decline in the CD4 count or the onset of HIV-1-related symptoms (delayed therapy). The primary prevention end point was linked HIV-1 transmission in HIV-1-negative partners. The primary clinical end point was the earliest occurrence of pulmonary tuberculosis, severe bacterial infection, a World Health Organization stage 4 event, or death.
As of February 21, 2011, a total of 39 HIV-1 transmissions were observed (incidence rate, 1.2 per 100 person-years; 95% confidence interval [CI], 0.9 to 1.7); of these, 28 were virologically linked to the infected partner (incidence rate, 0.9 per 100 person-years, 95% CI, 0.6 to 1.3). Of the 28 linked transmissions, only 1 occurred in the early-therapy group (hazard ratio, 0.04; 95% CI, 0.01 to 0.27; P<0.001). Subjects receiving early therapy had fewer treatment end points (hazard ratio, 0.59; 95% CI, 0.40 to 0.88; P=0.01).
The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 and clinical events, indicating both personal and public health benefits from such therapy. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 052 ClinicalTrials.gov number, NCT00074581.).
Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission.
To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations.
Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998.
Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states.
Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%.
According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.
Background:
Combination antiretroviral drug regimens are increasingly preferred for neonatal postexposure prophylaxis (PEP) among HIV-exposed infants with high-risk of transmission. We evaluated the adverse events associated with the use of zidovudine (ZDV)/lamivudine (3TC)/nevirapine (NVP) for neonatal PEP during the first 6 weeks of life.
Methods:
A prospective cohort of non-breast-fed HIV-exposed infants was conducted at 5 clinical sites in Thailand. Study population included 100 high-risk HIV-exposed infants (maternal HIV RNA > 50 copies/mL prior to delivery or received antiretroviral therapy less than 12 weeks) and 100 low-risk HIV-exposed neonates. High-risk infants received ZDV/3TC/NVP for 6 weeks whereas low-risk HIV-exposed neonates received a 4-week regimen of ZDV. Complete blood count, aspartate transaminase and alanine transaminase were assessed at birth, 1, 2 and 4 months of life.
Results:
From October 2015 to November 2017, 200 infants were enrolled, of which 18.5% had low birth weight < 2500 g. The proportion of infants with anemia grade 2 or higher at 1 and 2 months of life between ZDV/3TC/NVP and ZDV prophylaxis was 48.5% vs 32.3% (P=0.02); nevertheless, severe anemia (grade 3) was not significantly different; 9.2% vs 10.2% (P=0.81), respectively. At 1 month old, infants on ZDV/3TC/NVP prophylaxis had significantly higher grade 2 anemia versus infants on ZDV alone (33.0% vs 13.4%; P=0.001); however, no difference was observed at 2 months old. No differences in neutropenia or hepatotoxicity between infant prophylactic regimens were observed.
Conclusions:
Triple antiretroviral neonatal PEP with ZDV/3TC/NVP for 6 weeks in high-risk HIV-exposed infants did not significantly increase the risk of short-term toxicity compared with ZDV-monotherapy prophylaxis.
Context Since 1994, the US Public Health Service (PHS) has recommended routine,
voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine
therapy to reduce perinatal HIV transmission.Objective To describe trends in incidence of perinatal AIDS and factors contributing
to these trends, particularly the effect of PHS perinatal HIV recommendations.Design, Setting, and Participants Analysis of nationwide AIDS surveillance data and data from HIV-reporting
states through June 1998.Main Outcome Measures Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger
than 1 year from US natality data for birth cohorts 1988 to 1996; expected
number of infants with AIDS from national serosurvey data; and zidovudine
use data from selected HIV-reporting states.Results Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992
through 1997, including an 80% decline in infants and a 66% decline in children
aged 1 to 5 years. Rates of AIDS among infants (per 100,000 births) declined
69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births
to HIV-infected women from 1992 (n=6990) to 1995 (n=5797). Among infants,
PCP rates per 100,000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar
to the decline in other AIDS conditions. The percentage of perinatally exposed
children born from 1993 through 1997 whose mothers were tested for HIV before
giving birth increased from 70% to 94%; the percentage who received zidovudine
increased from 7% to 91%.Conclusions According to these data, substantial declines in AIDS incidence were
temporally associated with an increase in zidovudine use to reduce perinatal
HIV transmission, demonstrating substantial success in implementing PHS guidelines.
Reductions in the numbers of births and effects of therapy in delaying AIDS
do not explain the decline.
Unlabelled:
Mothers in HIV-endemic countries are advised to exclusively breastfeed their babies until six months because of lack of resources and better chances for child survival, while in developed countries, replacement feeding is advised. What are the experiences of HIV-positive women who migrate from HIV-endemic countries to developed countries, when making infant feeding choices?
Methods:
In-depth interviews and focus group discussions with a total of 25 women living with HIV in Toronto and Hamilton, Ontario.
Results:
Free infant formula alleviates the practical constraints in making infant feeding choices. However, cultural beliefs and social expectations constrain HIV-positive mothers' decision not to breastfeed. This is further complicated by the different policies. Service providers should understand the psychological and emotional experiences of the mothers in order to provide the appropriate support. Peers could be potential sources of support. The differences in policies are issues of global justice that need to be addressed.
Infant feeding policies for HIV-infected women in developing countries differ from policies in developed countries. This article summarizes the epidemiologic data on the risks and benefits of various infant feeding practices for HIV-infected women living in different contexts. Artificial feeding can prevent a large proportion of mother-to-child HIV transmission but also is associated with increases in morbidity and mortality among exposed-uninfected and HIV-infected children. Antiretroviral drugs can be used during lactation and reduce risks of transmission. For most of the developing world, the health and survival benefits of breastfeeding exceed the risks of HIV transmission, especially when antiretroviral interventions are provided.
The promotion of exclusive breastfeeding (EBF) to reduce the postnatal transmission (PNT) of HIV is based on limited data. In the context of a trial of postpartum vitamin A supplementation, we provided education and counseling about infant feeding and HIV, prospectively collected information on infant feeding practices, and measured associated infant infections and deaths.
A total of 14 110 mother-newborn pairs were enrolled, randomly assigned to vitamin A treatment group after delivery, and followed for 2 years. At baseline, 6 weeks and 3 months, mothers were asked whether they were still breastfeeding, and whether any of 22 liquids or foods had been given to the infant. Breastfed infants were classified as exclusive, predominant, or mixed breastfed.
A total of 4495 mothers tested HIV positive at baseline; 2060 of their babies were alive, polymerase chain reaction negative at 6 weeks, and provided complete feeding information. All infants initiated breastfeeding. Overall PNT (defined by a positive HIV test after the 6-week negative test) was 12.1%, 68.2% of which occurred after 6 months. Compared with EBF, early mixed breastfeeding was associated with a 4.03 (95% CI 0.98, 16.61), 3.79 (95% CI 1.40-10.29), and 2.60 (95% CI 1.21-5.55) greater risk of PNT at 6, 12, and 18 months, respectively. Predominant breastfeeding was associated with a 2.63 (95% CI 0.59-11.67), 2.69 (95% CI 0.95-7.63) and 1.61 (95% CI 0.72-3.64) trend towards greater PNT risk at 6, 12, and 18 months, compared with EBF.
EBF may substantially reduce breastfeeding-associated HIV transmission.
The ability of highly active antiretroviral therapy (HAART) to reduce human immunodeficiency virus type 1 (HIV-1) RNA and DNA in breast milk has not been described.
We compared breast-milk HIV-1 RNA and DNA loads of women in Botswana who received HAART (nevirapine, lamivudine, and zidovudine) and women who did not receive HAART.
Women in the HAART group received treatment for a median of 98 days (range, 67-222 days) at the time of breast-milk sampling; 23 (88%) of 26 had whole breast-milk HIV-1 RNA loads <50 copies/mL, compared with 9 (36%) of 25 women who did not receive HAART (P=.0001). This finding remained significant in a multivariate logistic-regression model (P = .0006). The whole-milk HIV-1 DNA load was unaffected by HAART. Of women who received HAART, 13 (50%) of 26 had HIV-1 DNA loads <10 copies/10(6) cells, compared with 15 (65%) of 23 who did not receive HAART (P = .39).
HAART suppressed cell-free HIV-1 RNA in breast milk and may therefore reduce mother-to-child transmission (MTCT) of HIV-1 via breast-feeding. However, HAART initiated during pregnancy or early after delivery had no apparent effect on cell-associated HIV-1 DNA loads in breast milk. Clinical trials to determine MTCT among breast-feeding women receiving HAART are needed.
Counseling and managing women living with HIV in the United States who desire to breastfeed
- Clinical Info
Clinical Info. Counseling and managing women living with HIV in the United
States who desire to breastfeed. Accessed September 28, 2020. https://clinicalinfo.
hiv.gov/en/guidelines/perinatal/counseling-and-managing-women-living-hivunited-states-who-desire-breastfeed
Safety of 6-week triple antiretroviral prophylaxis in high-risk HIV-exposed infants
- S Anugulruengkitt
- P Suntarattiwong
- P Ounchanum
Anugulruengkitt S, Suntarattiwong P, Ounchanum P, et al. Safety of 6-week triple
antiretroviral prophylaxis in high-risk HIV-exposed infants. In: Conference
on Retroviruses and Opportunistic Infections (CROI) Conference (Abstract
Number 759, Session Number P-Q1), Seattle, WA, USA, February 13-16,
2017. Accessed May 27, 2021. https://www.croiconference.org/abstract/
safety-6-week-triple-antiretroviral-prophylaxis-high-risk-hiv-exposed-infants/