Women’s Health Today

Pamela Morrison, IBCLC, explores the research that has helped form policy and answers the questions surrounding whether HIV+ mothers should breastfeed.

Global recommendations endorse exclusive breastfeeding for all babies for the first six months of life and continued partial breastfeeding for up to two years or beyond. Yet it is commonly believed that one exception is the baby of a mother who has been diagnosed as HIV-infected, due to the fear that she may pass the virus to her baby in her milk (Horvath, Madi, Iuppa, Kennedy, Rutherford, & Read, 2009).   

Most HIV-exposed babies are born in places where breastfeeding is the cultural norm and where formula-feeding is particularly unwelcome, unnatural and stigmatizing (see the UNAIDS (2013) report on the global AIDS epidemic).

Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first 6 months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival. In other words, research suggests that formula-feeding is more risky than breastfeeding with HIV. As more knowledge is gathered, increasing numbers of HIV-positive (HIV+) 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 not, whether they too can breastfeed?   (NEW: July 2018. WABA. Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource.)

What information will help these mothers to make an informed decision on whether breastfeeding will be safe for their babies?

What research can they discuss with their doctors and HIV clinicians as they express their ambitions and ask for support? How is the risk of breastfeeding-associated HIV transmission measured?

Since 1985, breastfeeding in the context of HIV has received very bad press. Fear about early high risk estimates persists. But there is a great difference in transmission risk between a mother receiving effective antiretroviral therapy (ART) and the unfortunate mother of several decades ago for whom no drug therapy was available and the risk of postnatal transmission through any breastfeeding vs no breastfeeding was estimated to be 15–30% (Dunn, Newell, Ades, & Peckham, 1992).

The transforming effect of effective antiretroviral therapy (ART)

A growing body of research shows that effective ART can not only improve the health of an infected individual so that he or she can enjoy a normal life-span (Samji, Cescon, Hogg, Modur, Althoff, Buchacz, et al., 2013) but that treatment also constitutes an effective form of prevention between infected and uninfected members of a couple, and between an infected mother and her infant during pregnancy, birth or breastfeeding.   

No cases of transmission of HIV were found during two years of follow-up of sero-discordant couples when the HIV-infected partner received and took antiretroviral medications (Rodger, et al., 2014). Up-to-date World Health Organization guidance recommends that all women diagnosed as HIV-infected should receive immediate ART which should be continued for life. HIV-infected expectant mothers who are diagnosed as HIV+ during early pregnancy can receive a long enough course of ART to ensure that the number of viral copies in their blood becomes undetectable by their due date, posing a negligible risk of transmission of the virus during labor and delivery, and allowing them to have a normal vaginal birth. The duration of treatment is important: a study published in 2011 showed that ART needs to be taken for approximately 13 weeks to reduce the number of viral copies to levels that are no longer detectable on a standard HIV test; mothers who received ART for less than 4 weeks had a 5-fold increased risk of HIV transmission to their babies (Chibwesha et al., 2011).

Exclusive breastfeeding

The importance of exclusive breastfeeding in reducing the risk of postnatal HIV transmission was first established in a South African study (Coutsoudis, Pillay, Spooner, Kuhn, & Coovadia, 1999) and subsequently confirmed amongst Zimbabwean infants in 2005 (Iliff et al., 2005). 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 6 months. It was hypothesized that too-early feeding with other foods and liquids besides breast milk may disturb the normal infant gastrointestinal flora (Smith & Kuhn, 2009). 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 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, e.g. epidermal growth factor, can help the intestinal epithelial barrier to mature, thus helping to protect against infection with HIV.

Normal mixed feeding after 6 months

As a result of the findings about the protective effects of exclusive breastfeeding during the first 6 months, concern was initially expressed about the possible dangers of HIV-transmission during normal mixed feeding after 6 months. As a result, HIV+ mothers who elected to breastfeed were advised to practice what was called “early cessation of breastfeeding,” or premature weaning, as soon as practicable (Ekpini et al.,1997; WHO, 2005).

Subsequent studies have confirmed that after the recommended period of 6 months’ exclusive breastfeeding, continued partial breastfeeding with the addition of other foods and liquids, as recommended for babies outside the context of HIV, resulted in an extremely low risk of transmission in the 6–12 month period (Kuhn et al., 2007; Ngoma et al., 2011). Further studies from Zambia, where maternal ART was initiated in early pregnancy and continued to 12 months postpartum, while infants were exclusively breastfed to 6 months and continued breastfeeding with complementary feeding from 6–12 months resulted in postpartum HIV transmission rates of 1–2% at 12 months (Ngoma et al., 2011; Gartland et al., 2013). Confirmatory results showed that the only postnatal transmissions occurred in one infant at 2 weeks postpartum, which most likely occurred in utero (Gartland et al., 2013) or after 6 months in women who were non-adherent to their medications (Silverman, 2011; Ngoma et al., 2015). The multicenter PROMISE study results released in 2016 involving nearly 2500 babies showed that estimates of mother-to-child transmission through breastfeeding at ages 6, 9 and 12 months were 0.3%, 0.5% and 0.6% (Taha, T. et al., 2016). Consequently, current WHO guidance was updated in 2016 to recommend continued breastfeeding to 24 months.

What is the risk of not breastfeeding?

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 results (Smith, Dunstone, & Elliott-Rudder, 2009) but in fact, formula-fed babies experience higher rates of morbidity and mortality than their breastfed counterparts, even in industrialized countries (Bachrach, Schwarz, & Bachrach, 2003; Bartick, & Reinhold, 2010; Chen, & Rogan, 2004; Duijts, Jaddoe, Hofman, & Moll, 2010; Glass, Lew, Gangarosa, LeBaron, & Ho, 1991; Ip, Mei Chung, Gowri Raman, Trikalinos, & Lau, 2009; Quigley, Kelly, & Sacker, 2007).

Current guidance in developed countries

In the industrialized countries of the UK, Europe, Australia and Canada, a high percentage of mothers diagnosed as HIV+ 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+ mother with an undetectable viral load wishes to breastfeed, then she should be supported to do so (Taylor et al., 2011). BHIVA recommend that mothers who choose this option should practise exclusive breastfeeding for the first six months of life while receiving regular monitoring of maternal viral load and infant HIV status.  BHIVA is currently working on a revision of its 2011 guidance.

A similar relaxation of a former 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+ mothers as long as mothers are adherent to ART, achieve an undetectable viral load, when breastfeeding is exclusive for the first six months and when the health of mother and baby are closely monitored and optimized.

Breastfeeding support in the context of HIV

Breastfeeding in the context of HIV is best planned meticulously. Prenatally, HIV+ 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 on-going adherence to their medications. They would also be well advised to inform themselves about local and/or national HIV and infant feeding policy and to query any misinterpretation of current national policy where it occurs, e.g. a recently published booklet translated in Swahili for HIV+ mothers living in the UK erroneously suggests the only recommendation is for formula-feeding 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.

If the decision is made to breastfeed, HIV+ mothers should receive competent and well-informed breastfeeding assistance from a recognized health provider 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 without the need for invasive oral surgery such as tongue or buccal tie revision which would allow contact between the virus in breast milk and the infant’s bloodstream. Mothers may also need advice and on-going follow-up to  avoid, minimize and quickly resolve any postpartum breast or nipple problems, e.g. 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 3 months after breastfeeding ends (Taylor et al., 2011; AAP, 2013).

Finally, it is not possible to overstate the need for lactation consultants 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.   

Hope for the future

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+ women to give up all hope of breastfeeding. Up-to-date evidence-based research suggests that when HIV+ 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.
2. Breastfeeding should be practised exclusively during the first six months of life.

When these two pre-conditions 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.

July 2018. WABA. Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource.

References

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Pamela Morrison lived the first 45 years of her life in East and Southern Africa. She has worked with breastfeeding mothers since 1987 and became the first IBCLC in Zimbabwe in 1990. She has also lived in Australia and is now living in England. She has been a long-term member of the Zimbabwean National Breastfeeding Committee, the BFHI Task Force and Co-coordinator of the WABA Task Forces on Infant Nutrition Rights, Breastfeeding and HIV. Pamela  supports mothers to breastfeed and specialises in helping with latching difficulties, babies with low weight gain and faltering growth and mothers who are struggling to make enough milk. Pamela speaks passionately on breastfeeding and is a well-loved mentor and friend to many in the lactation field.