During the last decade mother-to-child transmission (MTCT) of HIV in high-income countries has been virtually eliminated . This success has been achieved with the provision of antiretroviral treatment (ART) to HIV-infected pregnant women, elective caesarean section if the viral load is not successfully suppressed, and the avoidance of breastfeeding . In low-income countries, where breastfeeding is the most common infant feeding practice, very low MTCT rates are also achieved when ART is provided to pregnant and breastfeeding mothers . A recent study from rural Tanzania, in which the viral load of breastfeeding mothers was monitored, found no HIV transmission from virally suppressed mothers to their infants . In view of this, the discussion about whether breastfeeding is an option for mothers living with HIV in high-income countries is now imperative.
In their timely article “Is breastfeeding an equipoise option in effectively treated HIV infected mothers in a high-income setting?” now published in Swiss Medical Weekly , Kahlert et al. suggest that it is time to rethink the hard-line counselling against breastfeeding for HIV-infected mothers in Switzerland and, implicitly, in all Western countries. The authors define a situation which they call “the optimal scenario”: the pregnant woman is (i) adherent in taking her ART, (ii) under regular care, and (iii) has a suppressed HIV viral load of <50 RNA copies/ml throughout pregnancy and breastfeeding. When these criteria are met, the theoretical risk of MTCT is virtually zero. They argue that this is a situation of clinical equipoise, where the residual risk of MTCT through the breast milk is balanced with the general benefits of breastfeeding, and propose a shared decision-making process to choose the form of infant feeding.
Women living with HIV may desire to breastfeed their infants for several reasons, from promoting bonding with the baby, to cultural, practical or financial reasons. The current categorical advice of abstaining from breastfeeding may preclude women from sharing their feeding preference with providers or cause them to disengage from care because they fear to be judged. Providing a safe space to discuss feeding preferences will certainly contribute to avoid such cases, will promote patient’s autonomy and will allow women to take a well-informed decision.
The article by Kahlert et al. can be very helpful to clinical teams that feel ready to be more flexible with the recommendations they provide to pregnant women living with HIV. In that manuscript they will find a guideline to having a comprehensive discussion with mothers about risks and benefits of breastfeeding and to establish a schedule of clinical and laboratory follow-up of the mother-infant pairs where the mother opts to breastfeed.
An important issue that will need further discussion is whether clinicians should be encouraged to discuss risks and benefits of breastfeeding with all pregnant women meeting the “optimal scenario” or only with those who, besides meeting the “optimal scenario”, verbalise their wish to breastfeed. Discussing breastfeeding with all may lead women who otherwise would not have considered breastfeeding, to do so. On one hand, this may raise a concern of an increase in the transmission risk; on the other hand, keeping the shared decision-making process to only those who express their wish to breastfeed seems paternalistic.
It is time that high-income countries move towards less rigid recommendations about infant feeding. Some families affected with HIV are ready to understand the risks and benefits of breastfeeding their HIV-exposed infants. Therefore, healthcare providers must be able to offer them unbiased information to empower their comprehensive understanding of one or other decision. If, after a shared decision-making process, the mother's choice is supported with a nonjudgmental attitude and close monitoring is arranged, the best care for her and her infant will be guaranteed.
1 Townsend CL, Byrne L, Cortina-Borja M, Thorne C, de Ruiter A, Lyall H, et al.Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, 2000-2011. AIDS. 2014;28(7):1049–57. doi:. http://dx.doi.org/10.1097/QAD.0000000000000212 PubMed
3 Flynn PM, Taha TE, Cababasay M, Fowler MG, Mofenson LM, Owor M, et al.; PROMISE Study Team. Prevention of HIV-1 Transmission Through Breastfeeding: Efficacy and Safety of Maternal Antiretroviral Therapy Versus Infant Nevirapine Prophylaxis for Duration of Breastfeeding in HIV-1-Infected Women With High CD4 Cell Count (IMPAACT PROMISE): A Randomized, Open-Label, Clinical Trial. J Acquir Immune Defic Syndr. 2018;77(4):383–92. doi:. http://dx.doi.org/10.1097/QAI.0000000000001612 PubMed
4 Luoga E, Vanobberghen F, Bircher R, Nyuri A, Ntamatungiro AJ, Mnzava D, et al.No HIV transmission from virally suppressed mothers during breastfeeding in rural Tanzania. J Acquir Immune Defic Syndr. 2018;1; Epub ahead of print. doi:. http://dx.doi.org/10.1097/QAI.0000000000001758 PubMed
5 Kahlert CR, Aebi-Popp K, Bernasconi E, Martinez de Tejada B, Nadal D, Paioni P, et al.Is breastfeeding an equipoise option in effectively treated HIV infected mothers in a high-income setting?Swiss Med Wkly. 2018;148:w14648. doi:10.4414/smw.2018.14648. PubMed
Swiss Tropical and Public Health Institute, University of Basel, Switzerland
Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
No financial support and no other potential conflict of interest relevant to this article was reported.
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Anna Gamell, MD, PhD, Swiss Tropical and Public Health Institute, University of Basel, Socinstrasse 57, CH-4051 Basel, anna.gamell[at]unibas.ch
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