HIV+ women and breastfeeding

As my patients are almost all women living with HIV and from an African background who are very keen to breastfeed, this session was number one on my priorities to attend despite being yet an another 7:30am presentation. 

The presentation was set up as a debate with three speakers although in the end, they all came to a similar conclusion!

First was Dr Karoline Aebi-Popp (Obstetrician & Gynecologist (German Certification), MSc Infectious Diseases – Specialized in Sexually Transmitted Diseases, University Hospital Bern,Switzerland) who presented the ‘no’ side to the question of whether all women is Europe living with HIV should breastfeed. 

Worldwide, 150,000 child acquired HIV in 2015 and 1/3 of these acquired their infection from breastfeeding. Karoline did point out that most of this data is African data. Although ART reduces the HIV RNA levels in breastmilk it does not reduce the HIV DNA levels. There is also evidence that some of the ARTs get into the breastmilk such as dolutegravir which has a number of potential problems. 

There is a risk of resistance if the infant is exposed to monotherapy via breastmilk. Also there is a risk of delayed diagnosis if the baby is positive but ART suppresses virus replication.

Overall from meta-analysis of all evidence of breast feeding in HIV, the risk of MTCT ranges from 0.9%-4%.  Is this acceptable given in high income countries we have access to a safe alternative which has a 0% risk of MTCT?

Dr Fiona Lyons (consultant in Genitourinary and HIV Medicine at the GUIDE clinic, St. James’s Hospital, Dublin, Ireland)spoke next on the ‘yes’ side supporting breastfeeding in maternal HIV. 

Fiona made the important point that we need to not just look at MTCT but also benefits of breastfeeding for the mother including breast cancer reduction. She produced evidence that MTCT in an ideal world is less than 1%. All the evidence we have about breastfeeding in maternal HIV Infection includes low and middle income countries which may not reflect the potential in high income countries with safe access to bottle feeding and high quality HIV care and follow up. 

She emphasised a patient-centred approach with an individual assessment of each patient and their circumstances. 

Dr Karina Butler O’Connell (UCD Clinical Professor of Paediatrics, Consultant Paediatrician and Infectious Diseases Specialist at Our Lady's Children's Hospital and The Children's University Hospital, Temple Street, Dublin, Ireland) spoke on behalf of the child. She presented the evidence that in low and middle income countries breastfeeding actually decreases mortality due to reduction in diarrheal diseases. However even in high income countries, the MTCT rate was not zero. This risk goes up when we look at actual behaviour not just ideal behaviour (reduced adherence to medication, lost to follow up etc). For the child, she felt this was not an acceptable risk. 

I look forward to the prospective cohort study that Karoline is involved in looking at transmission rates in breastfeeding. 

In summary

• have an individualised approach
• Better to allow the mother to discuss in an open environment. 
• We need more research particularly around models for supporting breastfeeding

Below is a link to Lancet review and discussion of evidence in HIV and breastfeeding. 

http://www.evidentlycochrane.net/lancet-breastfeeding-series/

I found this session particularly good and relevant to my practice. I also ran into my mentor for HIV prescribing Dr Olga Vujovic from The Alfred hospital in Melbourne at this session which was great!