Breastfeeding and HIV: Recent New Data!

There has been s shift in breastfeeding management for HIV mothers

Hello Mamas. There is new evidence that recommends HIV-positive mothers should breastfeed. Until recently, the World Health Organization (WHO) advised HIV-positive mothers to avoid breastfeeding if they were able to afford, prepare and store formula milk safely. Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first six months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival. (4) (PAID LINK)

In other words, recent research suggests that formula-feeding is more risky than breastfeeding with HIV. As more is known, an increasing number of HIV-positive mothers in industrialized countries are questioning whether the risk of HIV transmission through breastfeeding is as high as they have been led to believe and, if it is not, they are asking if they, too, can breastfeed.

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South African Health Workers Face a Battle to Change Attitudes and Habits. Lungi Langa reports.

Many South African women are struggling with breastfeeding after returning to work

Breastfeeding may be natural, but it is not always simple. Professor Anna Coutsoudis, of the Department of Paediatrics and Child Health at the University of the KwaZulu-Natal, Durban, says the problem begins in the first weeks of breastfeeding. “Health-care providers lack the skills needed to offer support and advice,” she says. “So when problems arise – cracked nipples, babies won’t suck and babies don’t seem satisfied – the mothers get bad advice. Then when they become discouraged, they are told to stop breastfeeding altogether and to give artificial substitutes.”

If the mother is HIV positive, more uncertainty is added. “Some counsellors are themselves confused about what is correct practice regarding HIV and feeding practices,” says Thelma. But research has since emerged, particularly from South Africa, that shows that a combination of exclusive breastfeeding and the use of antiretroviral treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding.

EXCLUSIVE BREASTFEEDING: Reduces HIV Transmission

Exclusive breastfeeding protects the flora of the baby’s stomach

The importance of exclusive breastfeeding in reducing the risk of postnatal HIV transmission was first established in a South African study published in 1999, (11) and subsequently confirmed amongst Zimbabwean infants in 2005. (12) In the latter study, compared with early mixed feeding (breast milk and other foods and liquids), exclusive breastfeeding (feeding only breast milk) reduced transmission by 75% in babies tested at six months. (paid link)

It was hypothesized that too-early feeding with other foods and liquids besides breast milk may disturb the normal infant gastrointestinal flora. (13) When babies are mixed fed, pathogens and dietary antigens in formula can cause small sites of damage and inflammation to the baby’s intestinal mucosa. Once the integrity of the baby’s gut has been compromised, it is easier for HIV in breast milk to cross the mucous membranes and to make contact with the baby’s bloodstream. On the other hand, protective components in mother’s milk, for example epidermal growth factor, can help the intestinal epithelial barrier to mature, thus helping to protect against infection with HIV.

When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding.

Instrumental in guiding the new recommendations were two major African studies that announced their findings in July 2009 at the fifth International AIDS Society conference in Cape Town. The WHO-led Kesho Bora study found that giving HIV-positive mothers a combination of antiretrovirals during pregnancy, delivery and breastfeeding reduced the risk of HIV transmission to infants by 42%. The Breastfeeding Antiretroviral and Nutrition study held in Malawi also showed a risk of HIV transmission reduced to 1.8% for infants given the antiretroviral drug nevirapine daily while breastfeeding for 6 months. This is great news!

WHO recommends that all mothers, regardless of their HIV status, practice exclusive breastfeeding – which means no other liquids or food are given – in the first six months. After six months, the baby should start on complementary foods. Mothers who are not infected with HIV should breastfeed until the infant is two years or older.

WHAT IS THE RISK OF NOT BREASTFEEDING?: Higher Rates of Morbidity and Mortality!
Non breastfed babies are at higher risk

In spite of these excellent results, there remains a common assumption that because mothers living with HIV in industrialized countries such as Europe, North America and Australia have access to clean water and safe infant feeding alternatives, breastfeeding avoidance is free from risk. This may in part stem from misleading reporting of research (21) results but in fact, formula-fed babies experience higher rates of morbidity and mortality than their breastfed counterparts, even in industrialized countries. (22, 23, 24, 25, 26, 27, 28)

PRESENT GUIDANCE IN DEVELOPED COUNTRIES
Many industrialized countries support HIV mothers breastfeeding exclusively for the first 6 months

In the industrialized countries of UK, Europe, Australia and Canada, a high percentage of mothers diagnosed as HIV-positive are immigrants from countries of high HIV-prevalence, particularly those in Eastern and Southern Africa. In recognition that their guidance needed to fit the population it was designed to assist, and following extensive consultation, the British HIV Association (BHIVA) published a revised position paper in 2011 stating that although formula-feeding remains the first recommendation for infant feeding in the context of HIV, when an HIV- positive mother with an undetectable viral load wishes to breastfeed, then she should be supported to do so. (29) BHIVA recommends that mothers who choose this option should practice exclusive breastfeeding for the first six months of life while receiving regular monitoring of maternal viral load and infant HIV status.

A similar relaxation of a formerly absolute prohibition of breastfeeding, and accompanying threats of imposition of child safe-guarding measures against mothers who did not comply, has also occurred in the USA. In early 2013, the American Academy of Pediatrics published revised recommendations to support breastfeeding by HIV-positive mothers when mothers are adherent to ART, achieve an undetectable viral load, and practice exclusive breastfeeding for the first six months, and the health of mother and baby are closely monitored and optimized. (30)(paid link)

Success Comes With Competent, and Well Informed HIV Positive Women

Communication with HIV positive women during pregnancy, goes a long way in filling the gap to exclusively breastfeed and continue taking antiviral meds. Breastfeeding in the context of HIV is best planned meticulously. Antenatally, HIV-positive mothers need to be in touch with their physicians and HIV clinicians.

They should discuss with them what they know of up-to-date research findings, including the risks and benefits of different feeding methods, the importance of ART, the duration of therapy, undetectable viral load, and ongoing adherence to their medications. They might also be advised to inform themselves about local and/or national HIV and infant feeding policy and to seek legal representation if there are likely to be any safe-guarding concerns or any threat of coercion to bottle-feed, as is occasionally reported. (31)

If the decision is made to breastfeed, HIV-positive mothers should receive competent and well-informed breastfeeding assistance from a recognized breastfeeding support organization or an International Board Certified Lactation Consultant (IBCLC) before and after birth. Mothers will need practical assistance with latching their baby comfortably to the breast, and ensuring effective breastfeeding. They may need advice and ongoing follow-up to avoid, minimize and quickly resolve any postpartum breast or nipple problems, such as sore nipples, breast engorgement, or symptoms of mastitis. It is important to prevent or treat these kinds of difficulties promptly should they occur, not only to avoid increasing the risk of transmission of postpartum HIV but also so that exclusive breastfeeding can easily be initiated and maintained for the full first six months of their infant’s life. The baby’s HIV status should be tested at birth, and at monthly intervals until three months after breastfeeding ends. (29, 30)

Finally, it is not possible to overstate the need for breastfeeding counselors or IBCLCs to liaise with and be guided by the mother’s and baby’s primary healthcare providers so that all parties can work together as a team for the best health outcomes for both mother and baby.

Can HIV positive mothers breastfeed? What is HIV breastfeeding? Can I breastfeed if I have a HIV? Should you stop breastfeeding if you have HIV?

What About Women Returning To Work?

Returning to work can be a struggle for many women. As workplace often do not have any proper place for women to breastfeed. This is a challenge because women usually stop breastfeeding and decide to pump instead. Louise Goosen, a breastfeeding consultant at Mowbray Maternity Hospital in Cape Town, says that “going back to work” is one of the most common reasons for stopping breastfeeding.

But even for mothers who don’t have to juggle paid work while caring for their babies, switching to formula is a huge temptation simply because it is thought to be convenient. But even for mothers who don’t have to juggle paid work while caring for their babies, switching to formula is a huge temptation simply because it is thought to be convenient. “However we need to encourage and educate mums on the ease and importance of expressing their breast milk to give to baby while mum is at work so that baby can still get the best nutrition. (paid link)

Bottom Line

When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding. Up-to-date evidence-based research suggests that when HIV-positive women receive adequate ART, they can safely embark upon a pregnancy and deliver their children vaginally. Research also shows that improved health outcomes can be achieved with breastfeeding compared to not breastfeeding. There are only two provisos:

1) mothers must be meticulously adherent to their medication, and

2) breastfeeding should be practiced exclusively during the first six months of life.

3)Health professionals must be trained to provide families with the correct information.

4) The government needs to convince industries to make it easy for mothers to carry on breastfeeding after returning to work

When these two preconditions are met, the risk of mother-to-child transmission of HIV through breastfeeding can be reduced to negligible levels. The World Health Organization describes these findings as “transforming,” and it follows that there should thus be no need to discourage breastfeeding, both within and outside the context of HIV.

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REFERENCES

https://breastfeedsuccessfully.com

2016: World Health Organization Updates on HIV and Infant Feeding

World Health Organization. The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva: WHO (2001).

Horvath, T, Madi, B, Iuppa, I. et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database of Systematic Reviews (1) doi: 10.1002/14651858.CD006734.pub2.

WHO 2010. Guidelines on HIV and infant feeding. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence ISBN 978 92 4 159953 5.

World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach Geneva: WHO 2013.

6 Dunn, DT, Newell, ML, Ades, AE et al. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet Sep 5, 1992;340:585-88.

Samji H et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLOS ONE 8(12): e81355. Doi:10.1371/ journal.pone.0081355. 2014.

8 Rodger A, Bruun T, Cambiano Vet al HIV. Transmission Risk Through Condomless Sex If HIV+ Partner On Suppressive ART: PARTNER Study. Paper presented at 21st Conference on Retroviruses and Opportunistic Infections, Boston. 2014.

BHIVA-NAM. Summary of BHIVA Guidelines, Treatment for pregnant women: mode of delivery, Factsheet 6, updated June 2013.

10 Chibwesha CJ, Giganti MJ, Putta N et al. Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr. 2011;58(2):224-8. doi: 10.1097/QAI.0b013e318229147e.

11 Coutsoudis A, Pillay K, Spooner E et al. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet 1999 Aug 7;354(9177):471-6.

13 Smith MM and Kuhn L. Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1? Nutrition Reviews 2000;58(11):333-340.

UNAIDS. Report on the Global AIDS epidemic 2013.

14 Ekpini ER, Wiktor SZ, Satten GA et al. Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Côte d’Ivoire. Lancet 1997;349: 1054–1059.

15 WHO 2005. HIV and Infant Feeding Counselling Tools, Reference Guide ISBN 92 4 1593016. 

16 Kuhn L, Sinkala M, Kankasa C et al. High Uptake of Exclusive Breastfeeding and Reduced Early Post-Natal HIV Transmission. PLOS ONE Dec 2007; 2(12): e1363. doi:10.1371/journal.pone.0001363.

17 Ngoma M, Raha A, Elong A, et al. Interim Results of HIV Transmission Rates Using a Lopinavir/ritonavir based regimen and the New WHO Breast Feeding Guidelines for PMTCT of HIV. International Congress of Antimicrobial Agents and Chemotherapy (ICAAC) Chicago Il, Sep19,2011. H1-1153.

18 Silverman MS. (Powerpoint Presentation): Interim Results of HIV Transmission Rates Using a Lopinavir/ ritonavir based regimen and the New WHO Breast Feeding Guidelines for PMTCT of HIV [abstr. H1-1153] Presented at: International Congress of Antimicrobial Agents and Chemotherapy (ICAAC) Chicago IL, Sep19, 2011.

19 Gartland MG, Chintu NT, Li MS et al, Field effectiveness of combination antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission in rural Zambia. AIDS 2013 May 15; 27(8): doi:10.1097/ QAD.0b013e32835e3937.

20 Silverman, M. Personal communication, 2 Oct 2011.

21 Smith J, Dunstone M, & Elliott-Rudder M. (2009) Health Professional Knowledge of Breastfeeding: Are the Health Risks of Infant Formula Feeding Accurately Conveyed by the Titles and Abstracts of Journal Articles? Journal of Human Lactation, 2009;25(3): 350-358.

22 Bachrach VR, Schwarz E & Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Archives of Pediatrics & Adolescent Medicine2003;157(3): 237-243.

23 Bartick M, & Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010; 125(5): e1048-1056.

24 Chen A & Rogan W J. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004; 113(5): e435-e439.

25 Duijts L, Jaddoe VW, Hofman A et al. Prolonged and exclusive breastfeeding reduces the Risk of infectious diseases in infancy. Pediatrics 2010;126(1), e18-25.

12 Iliff PJ, Piwoz EG, Tavengwa NV et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005, 19:699–708.

26 Glass RI, Lew JF, Gangarosa RE et al. Estimates of morbidity and mortality-Rates for diarrheal diseases in American children Journal of Pediatrics 1991;118(4),S27-S33.

27 Ip S, Chung M, Raman G et al. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeeding Medicine2009; 4(Suppl 1):S17-30.

28 Quigley MA, Kelly YJ, & Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics 2007;119(4), E837-E842. doi:10.1542/peds.2006- 2256.

29 Taylor GP, Anderson J, Clayden P et al. For the BHIVA/ CHIVA Guidelines Writing Group. British HIV Association and Children’s HIV Association position statement on infant feeding in the UK, 21 March, 2011.

30 American Academy of Pediatrics, Committee on Pediatric AIDS, Infant feeding and transmission of HIV in the United States, COMMITTEE ON PEDIATRIC AIDS. Pediatrics 2013; 131:2 391-396.

Our post for breastfeeding and HIV is completed. I hope you learned something. This evidence brings to light the importance of ongoing research. I am happy to know that women can now breastfeed with the guided precautions. We are finally getting back to the basics of making breastfeeding number one. Let me know your feedback on this topic. Thank you for stopping by. Do visit again.