Review article: Biomedical intelligence
Vol. 148 No. 2930 (2018)
Is breastfeeding an equipoise option in effectively treated HIV-infected mothers in a high-income setting?
Summary
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.
References
- Luzuriaga K, Mofenson LM. Challenges in the Elimination of Pediatric HIV-1 Infection. N Engl J Med. 2016;374(8):761–70. doi:.https://doi.org/10.1056/NEJMra1505256
- Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, et al., Breastfeeding and HIV International Transmission Study Group. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis. 2004;189(12):2154–66. doi:.https://doi.org/10.1086/420834
- WHO. Updates on HIV and infant feeding [Internet]. WHO. [cited 2017 May 15]. Available from: http://www.who.int/nutrition/publications/hivaids/guideline_hiv_infantfeeding_2016/en/
- Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al.; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. doi:.https://doi.org/10.1016/S0140-6736(15)01024-7
- 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:.https://doi.org/10.1097/QAI.0000000000001612
- Evaluating Strategies to Reduce Mother-to-Child Transmission of HIV Infection in Populations Using Formula Feeding (PROMISE) - Full Text View - ClinicalTrials.gov [Internet]. [cited 2017 May 17]. Available from: https://clinicaltrials.gov/show/NCT01253538
- Hurst S. Ein paar Gedanken zum Thema Autonomie … 2016 [cited 2017 Jun 11]; Available from: http://dxdoiorg/1.044.14/sae.z20160483.2
- Kennedy CE, Yeh PT, Pandey S, Betran AP, Narasimhan M. Elective cesarean section for women living with HIV: a systematic review of risks and benefits. AIDS. 2017;31(11):1579–91. doi:.https://doi.org/10.1097/QAD.0000000000001535
- De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA. 2000;283(9):1175–82. doi:.https://doi.org/10.1001/jama.283.9.1175
- Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA. 2000;283(9):1167–74. doi:.https://doi.org/10.1001/jama.283.9.1167
- Günthard HF, Frost SD, Leigh-Brown AJ, Ignacio CC, Kee K, Perelson AS, et al. Evolution of envelope sequences of human immunodeficiency virus type 1 in cellular reservoirs in the setting of potent antiviral therapy. J Virol. 1999;73(11):9404–12.
- Bispo S, Chikhungu L, Rollins N, Siegfried N, Newell M-L. Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. J Int AIDS Soc. 2017;20(1):21251. doi:.https://doi.org/10.7448/IAS.20.1.21251
- Kohler P, Schmidt AJ, Cavassini M, Furrer H, Calmy A, Battegay M, et al.; Swiss HIV Cohort Study. The HIV care cascade in Switzerland: reaching the UNAIDS/WHO targets for patients diagnosed with HIV. AIDS. 2015;29(18):2509–15. doi:.https://doi.org/10.1097/QAD.0000000000000878
- Rudin C, Spaenhauer A, Keiser O, Rickenbach M, Kind C, Aebi-Popp K, et al.; Swiss HIV Cohort Study (SHCS); Swiss Mother & Child HIV Cohort Study (MoCHiV). Antiretroviral therapy during pregnancy and premature birth: analysis of Swiss data. HIV Med. 2011;12(4):228–35. doi:.https://doi.org/10.1111/j.1468-1293.2010.00876.x
- WHO. Archived: Guidelines on HIV and infant feeding 2010 [Internet]. [cited 2018 Mar 22]. Available from: http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/
- Tariq S, Elford J, Tookey P, Anderson J, de Ruiter A, O’Connell R, et al. “It pains me because as a woman you have to breastfeed your baby”: decision-making about infant feeding among African women living with HIV in the UK. Sex Transm Infect. 2016;92(5):331–6. doi:.https://doi.org/10.1136/sextrans-2015-052224
- Aebi-Popp K, Kouyos R, Bertisch B, Staehelin C, Rudin C, Hoesli I, et al.; Swiss Mother and Child HIV Cohort Study; Swiss HIV Cohort Study. Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period. HIV Med. 2016;17(4):280–8. doi:.https://doi.org/10.1111/hiv.12299
- Levison J, Weber S, Cohan D. Breastfeeding and HIV-infected women in the United States: harm reduction counseling strategies. Clin Infect Dis. 2014;59(2):304–9. doi:.https://doi.org/10.1093/cid/ciu272
- Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010;362(24):2282–94. doi:.https://doi.org/10.1056/NEJMoa0907736
- Shapiro RL, Kitch D, Ogwu A, Hughes MD, Lockman S, Powis K, et al. HIV transmission and 24-month survival in a randomized trial of HAART to prevent MTCT during pregnancy and breastfeeding in Botswana. AIDS. 2013;27(12):1911–20. doi:.https://doi.org/10.1097/QAD.0b013e32836158b0
- de Vincenzi I ; Kesho Bora Study Group. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. Lancet Infect Dis. 2011;11(3):171–80. doi:.https://doi.org/10.1016/S1473-3099(10)70288-7
- Jamieson DJ, Chasela CS, Hudgens MG, King CC, Kourtis AP, Kayira D, et al.; BAN study team. Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial. Lancet. 2012;379(9835):2449–58. doi:.https://doi.org/10.1016/S0140-6736(12)60321-3
- White AB, Mirjahangir JF, Horvath H, Anglemyer A, Read JS. Antiretroviral interventions for preventing breast milk transmission of HIV. Cochrane Database Syst Rev. 2014;10(10):CD011323.
- Gamell A, Luwanda LB, Kalinjuma AV, Samson L, Ntamatungiro AJ, Weisser M, et al.; KIULARCO Study Group. Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: The One Stop Clinic model. PLoS One. 2017;12(7):e0181096. doi:.https://doi.org/10.1371/journal.pone.0181096
- Portman M, Parker H, Poole O, Wilson J. Two HIV-positive breastfeeding mothers in the UK – their story. Abstracts of the 19th Annual Conference of the British HIV Association (BHIVA) 2013; 16–19 April; Manchester UK. Poster no. 76. HIV Med. 2013;14(2):35. Available at: http://www.bhiva.org/documents/Conferences/2013Manchester/AbstractBook.pdf, https://www.ncbi.nim.nih.gov/pubmed?term=2355137.
- 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. doi:.https://doi.org/10.1097/QAI.0000000000001758
- Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al.; Rakai Project Study Group. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342(13):921–9. doi:.https://doi.org/10.1056/NEJM200003303421303
- van der Ende ME, Regez RM, Schreij G, van der Meer JTM, Danner SA ; Dutch PEP registration. Post-exposure prophylaxis. Int J STD AIDS. 2002;13(1_suppl, Suppl 2):30–4. doi:.https://doi.org/10.1258/095646202762226137
- Sturt AS, Dokubo EK, Sint TT. Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women. Cochrane Database Syst Rev. 2010;(3):CD008440.
- Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al.; HPTN 052 Study Team. Antiretroviral Therapy for the Prevention of HIV-1 Transmission. N Engl J Med. 2016;375(9):830–9. doi:.https://doi.org/10.1056/NEJMoa1600693
- Webster DP. Is HIV post-exposure prophylaxis required following occupational exposure to a source patient who is virologically suppressed on antiretroviral therapy? HIV Med. 2015;16(2):73–5. doi:.https://doi.org/10.1111/hiv.12187
- 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:.https://doi.org/10.1097/QAD.0000000000000212
- Willumsen JF, Filteau SM, Coutsoudis A, Newell M-L, Rollins NC, Coovadia HM, et al. Breastmilk RNA viral load in HIV-infected South African women: effects of subclinical mastitis and infant feeding. AIDS. 2003;17(3):407–14. doi:.https://doi.org/10.1097/00002030-200302140-00015
- Lunney KM, Iliff P, Mutasa K, Ntozini R, Magder LS, Moulton LH, et al. Associations between breast milk viral load, mastitis, exclusive breast-feeding, and postnatal transmission of HIV. Clin Infect Dis. 2010;50(5):762–9.
- Bae WH, Wester C, Smeaton LM, Shapiro RL, Lockman S, Onyait K, et al. Hematologic and hepatic toxicities associated with antenatal and postnatal exposure to maternal highly active antiretroviral therapy among infants. AIDS. 2008;22(13):1633–40. doi:.https://doi.org/10.1097/QAD.0b013e328307a029
- Thorne C, Newell M-L. Safety of agents used to prevent mother-to-child transmission of HIV: is there any cause for concern? Drug Saf. 2007;30(3):203–13. doi:.https://doi.org/10.2165/00002018-200730030-00004
- Williams PL, Hazra R, Van Dyke RB, Yildirim C, Crain MJ, Seage GR, 3rd, et al.; Pediatric HIV/AIDS Cohort Study. Antiretroviral exposure during pregnancy and adverse outcomes in HIV-exposed uninfected infants and children using a trigger-based design. AIDS. 2016;30(1):133–44.
- Heidari S, Mofenson L, Cotton MF, Marlink R, Cahn P, Katabira E. Antiretroviral drugs for preventing mother-to-child transmission of HIV: a review of potential effects on HIV-exposed but uninfected children. J Acquir Immune Defic Syndr. 2011;57(4):290–6. doi:.https://doi.org/10.1097/QAI.0b013e318221c56a
- Waitt CJ, Garner P, Bonnett LJ, Khoo SH, Else LJ. Is infant exposure to antiretroviral drugs during breastfeeding quantitatively important? A systematic review and meta-analysis of pharmacokinetic studies. J Antimicrob Chemother. 2015;70(7):1928–41.
- Harrigan PR, Hogg RS, Dong WWY, Yip B, Wynhoven B, Woodward J, et al. Predictors of HIV drug-resistance mutations in a large antiretroviral-naive cohort initiating triple antiretroviral therapy. J Infect Dis. 2005;191(3):339–47. doi:.https://doi.org/10.1086/427192
- Van de Perre P, Rubbo P-A, Viljoen J, Nagot N, Tylleskär T, Lepage P, et al. HIV-1 reservoirs in breast milk and challenges to elimination of breast-feeding transmission of HIV-1. Sci Transl Med. 2012;4(143):143sr3. doi:.https://doi.org/10.1126/scitranslmed.3003327
- Prazuck T, Chaillon A, Avettand-Fènoël V, Caplan A-L, Sayang C, Guigon A, et al. HIV-DNA in the genital tract of women on long-term effective therapy is associated to residual viremia and previous AIDS-defining illnesses. PLoS One. 2013;8(8):e69686. doi:.https://doi.org/10.1371/journal.pone.0069686
- King CC, Ellington SR, Davis NL, Coombs RW, Pyra M, Hong T, et al.; Partners in Prevention HSV/HIV Transmission Study and Partners PrEP Study Teams. Prevalence, Magnitude, and Correlates of HIV-1 Genital Shedding in Women on Antiretroviral Therapy. J Infect Dis. 2017;216(12):1534–40. doi:.https://doi.org/10.1093/infdis/jix550
- Agostoni C, Braegger C, Decsi T, Kolacek S, Koletzko B, Michaelsen KF, et al.; ESPGHAN Committee on Nutrition. Breast-feeding: A commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2009;49(1):112–25. doi:.https://doi.org/10.1097/MPG.0b013e31819f1e05
- Jakaitis BM, Denning PW. Human breast milk and the gastrointestinal innate immune system. Clin Perinatol. 2014;41(2):423–35. doi:.https://doi.org/10.1016/j.clp.2014.02.011
- Marchant A, Sadarangani M, Garand M, Dauby N, Verhasselt V, Pereira L, et al. Maternal immunisation: collaborating with mother nature. Lancet Infect Dis. 2017;17(7):e197–208. doi:.https://doi.org/10.1016/S1473-3099(17)30229-3
- Wang M, Li M, Wu S, Lebrilla CB, Chapkin RS, Ivanov I, et al. Fecal microbiota composition of breast-fed infants is correlated with human milk oligosaccharides consumed. J Pediatr Gastroenterol Nutr. 2015;60(6):825–33. doi:.https://doi.org/10.1097/MPG.0000000000000752
- Kuhn L, Kim H-Y, Hsiao L, Nissan C, Kankasa C, Mwiya M, et al. Oligosaccharide composition of breast milk influences survival of uninfected children born to HIV-infected mothers in Lusaka, Zambia. J Nutr. 2015;145(1):66–72. doi:.https://doi.org/10.3945/jn.114.199794
- Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012;97(12):1019–26. doi:.https://doi.org/10.1136/archdischild-2012-302263
- Bowatte G, Tham R, Allen KJ, Tan DJ, Lau M, Dai X, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):85–95. doi:.https://doi.org/10.1111/apa.13151
- Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014;(4):CD002971.
- Christensson K, Nilsson BA, Stock S, Matthiesen AS, Uvnäs-Moberg K. Effect of nipple stimulation on uterine activity and on plasma levels of oxytocin in full term, healthy, pregnant women. Acta Obstet Gynecol Scand. 1989;68(3):205–10. doi:.https://doi.org/10.3109/00016348909020990
- Watkins S, Meltzer-Brody S, Zolnoun D, Stuebe A. Early breastfeeding experiences and postpartum depression. Obstet Gynecol. 2011;118(2 Pt 1):214–21. doi:.https://doi.org/10.1097/AOG.0b013e3182260a2d
- Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96–113. doi:.https://doi.org/10.1111/apa.13102
- Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. Duration of lactation and incidence of type 2 diabetes. JAMA. 2005;294(20):2601–10. doi:.https://doi.org/10.1001/jama.294.20.2601
- Gunderson EP, Hurston SR, Ning X, Lo JC, Crites Y, Walton D, et al.; Study of Women, Infant Feeding and Type 2 Diabetes After GDM Pregnancy Investigators. Lactation and Progression to Type 2 Diabetes Mellitus After Gestational Diabetes Mellitus: A Prospective Cohort Study. Ann Intern Med. 2015;163(12):889–98. doi:.https://doi.org/10.7326/M15-0807
- Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implement Sci. 2009;4(1):75. doi:.https://doi.org/10.1186/1748-5908-4-75
- Johnson G, Levison J, Malek J. Should Providers Discuss Breastfeeding With Women Living With HIV in High-Income Countries? An Ethical Analysis. Clin Infect Dis. 2016;63(10):1368–72. doi:.https://doi.org/10.1093/cid/ciw587
- Nachega JB, Uthman OA, Anderson J, Peltzer K, Wampold S, Cotton MF, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS. 2012;26(16):2039–52. doi:.https://doi.org/10.1097/QAD.0b013e328359590f
- Huntington S, Thorne C, Newell M-L, Anderson J, Taylor GP, Pillay D, et al.; UK Collaborative HIV Cohort (UK CHIC) Study and the UK and Ireland National Study of HIV in Pregnancy and Childhood (NSHPC). The risk of viral rebound in the year after delivery in women remaining on antiretroviral therapy. AIDS. 2015;29(17):2269–78. doi:.https://doi.org/10.1097/QAD.0000000000000826