Breastfeeding & HIV

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06 Jun 2017

Overview

The first evidence that HIV could be transmitted via breast milk was a case report of the child of a previously healthy woman who was delivered by caesarean section. Because of blood loss from the operation, the mother was given a blood transfusion after the delivery. The baby was breastfed for six weeks. Later, it was discovered that a unit of the transfused blood had been contaminated with HIV. The mother and her infant were subsequently found to have both become infected. (1)

Moreover, HIV transmission after childbirth (postpartum) is known to occur because some infants test negative for HIV RNA one month after birth, but test positive later on.(2)

HIV can be detected in breast milk. Three HIV reservoirs coexist in breast milk: RNA (cell-free viral particles), proviral DNA (cell-associated virus integrated in latent T-cells) and intracellular RNA (cell-associated virus in activated producing T-cells). The respective role of each in HIV transmission is poorly understood. (3)

Even if mothers have a suppressed viral load, there is still a risk, albeit a low one, of transmission to their child if they breast-feed.  Latently infected resting cells, HIV-infected macrophages and lymphocytes, and HIV RNA have all been found in breastmilk from women on treatment and play a role in infection. For example, macrophages and lymphocytes (white blood cells which play a role in the immune system) also facilitate the infection of CD4 cells by helping to transport HIV across the epithelial barriers.  Other reasons for increased risk include that breastmilk contains a lot of CD4 cells; infants are exposed to up to 1 million CD4 cells per day. This allows easy access to CD4 cells for infection. Inflammation caused by, for example, mastitis, breast abscesses, and engorgement, also increase the risk and other sources of infection such as cracked, blistered nipples can also provide another source of infection.(4)

In many developed countries, guidelines recommend that HIV-positive women should refrain from breastfeeding and should use formula feed. In many resource-limited settings, the lack of access to clean water means that the risk of HIV transmission through breastmilk must be weighed against the risks of infant malnutrition, infections and mortality posed by formula feeding.  This has led to a differentiation in guidelines depending on geography and resources of the country, and remaining questions about breastfeeding.

Updates in Evidence

Due to the recent evidence coming from African studies that the postnatal transmission of HIV can be as low as 1% when infants are exclusively breastfed, the British HIV Association and the Children’s HIV Association revised infant feeding guidelines for British HIV-infected mothers. They recommended artificial feeding for most mothers diagnosed with HIV, but also recognised that a woman on effective triple antiretroviral therapy, with repeated undetectable viral load at delivery may choose to exclusively breastfeed for the first 6 months of her baby’s life.(5)

Decisions on whether or not HIV-infected mothers should breastfeed their infants is generally based on comparing the risk of infants acquiring HIV through breastfeeding, with the increased risk of death from malnutrition, diarrhoea and pneumonia if the infants are not exclusively breastfed.(6)

Accumulating evidence has shown that giving antiretroviral medicines to the mother or the infant can significantly reduce the risk of HIV transmission through breastfeeding. There are two provisos to this –

-       Mothers must be adherent to their medication, and

-       Breastfeeding should be practiced exclusively during the first six months of life. Mixing breast milk and other foods before this time increases the infant’s risk of HIV.

British HIV Association Guidelines (2014 updates)

The following recommendations come from the British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (British HIV Association, 2014 interim review): (Updated May 2014. All changed text prefixed by **.)

8.4 Infant feeding

8.4.1    All mothers known to be HIV positive, regardless of antiretroviral therapy, and infant PEP,

should be advised to exclusively formula feed from birth.                             Grading: 1A

8.4.2    Where a mother who is on effective cART with a repeatedly undetectable viral load chooses to breastfeed, this should not constitute grounds for automatic referral to child protection teams.

Maternal cART should be carefully monitored and continued until 1 week after all breastfeeding

has ceased. Breastfeeding, except during the weaning period, should be exclusive and all breastfeeding, including the weaning period, should have been completed by the end of 6 months.                                                                                                           Grading: 1B

8.4.3    Prolonged infant prophylaxis during the breastfeeding period, as opposed to maternal cART, is not recommended.                                                                                   Grading: 1D

8.4.4    Intensive support and monitoring of the mother and infant are recommended during any breastfeeding period, including monthly measurement of maternal HIV plasma viral load, and monthly testing of the infant for HIV by PCR for HIV DNA or RNA (viral load).                                                                                                                             Grading: 1D

8.5 Infant testing

8.5.1    **Timing of assessments                      

8.5.1.1 **Exclusively non-breastfed infants                                                      Grading: 1C

Molecular diagnostics for HIV infection should be performed on the following occasions:

• During the first 48 hours and prior to hospital discharge

• 2 weeks post cessation of infant prophylaxis (6 weeks of age)

• 2 months post cessation of infant prophylaxis (12 weeks of age)

• On other occasions if additional risk

• HIV antibody testing for seroreversion should be performed at age 18 months

8.5.1.2 **Breastfed infants                                                                                 Grading: 1D

Additional monthly testing of both mother and infant is recommended (7)  

WHO recommendations (2016)

Mothers known to be HIV-infected should be provided with lifelong antiretroviral therapy or antiretroviral prophylaxis interventions to reduce HIV transmission through breastfeeding.

National or sub-national health authorities should decide whether health services will principally counsel mothers known to be HIV-infected to either breastfeed and take antiretrovirals, or, avoid all breastfeeding.

In settings where national health authorities are recommending breastfeeding for HIV-infected mothers:

Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breast feeding.

Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence (see the WHO Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection for interventions to optimize adherence).

In settings where health services provide and support lifelong ART, including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted.

Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.

National and local health authorities should actively coordinate and implement services in health facilities and activities in workplaces, communities and homes to protect, promote and support breastfeeding among women living with HIV.(6)

Systematic reviews used to develop the guidelines:
Related Cochrane reviews

References

  1. Ziegler JB et al. Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet 1: 896-898, 1985 (as cited in NAM aidsmap Resources – HIV transmission & testing: Breastfeeding) http://www.aidsmap.com/Breastfeeding/page/1321393/
  2. NAM aidsmap Resources – HIV transmission & testing: Breastfeeding http://www.aidsmap.com/Breastfeeding/page/1321393/
  3. Neveu D et al. Cumulative Exposure to Cell-Free HIV in Breast Milk, Rather Than Feeding Pattern per se, Identifies Postnatally Infected Infants. Clin Infect Dis. 2011 Mar 15: 52(6) 819-825. doi:  10.1093/cid/ciq203
  4. DePutter M. Breastfeeding with an Undetectable Viral Load: What do we Know? 07 Mar 2017. Positive Lite.com Canada’s Online HIV Magazine. http://www.positivelite.com/component/zoo/item/breastfeeding-with-an-undetectable-viral-load-what-do-we-know
  5. Tawia S. Mother-to-child transmission of HIV: what do we know in 2015? July 2015 Australian Breastfeeding Association Health Professional Member eNewsletter. https://www.breastfeeding.asn.au/mother-to-child-transmission-of-hiv-what-do-we-know-in-2015
  6. World Health Organisation e-Library of Evidence for Nutrition Actions (eLENA): Infant feeding for the prevention of mother-to-child transmission of HIV. http://www.who.int/elena/titles/hiv_infant_feeding/en/ and 2016 WHO UNICEF  Guideline Updates on HIV and Infant Feeding: The duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV http://apps.who.int/iris/bitstream/10665/246260/1/9789241549707-eng.pdf?ua=1&ua=1
  7. British HIV Association guideliens for the management of HIV infection in pregnant women 2012 [2014 interim review] HIV Medicine (2014), 15 (Suppl. 4), 1-77 doi:10.1111/hiv.12185 http://www.bhiva.org/documents/Guidelines/Pregnancy/2012/BHIVA-Pregnancy-guidelines-update-2014.pdf

 

To date, Timothy Ray Brown (aka the Berlin Patient) is the only person to have been cured of HIV.