Sarah
Thank you for your comment on my response to the HIV portion of the
First Five California Book. Someone has just alerted me to your
comment and I'm sorry I didn't see it before (I get digests, and
missed reading one...)
I think we've disagreed before on the interpretation of various HIV
and infant feeding recommendations. I am indeed saying that the AAP
are OK'ing exclusive breastfeeding with full maternal ART as an
approved second-line option, as do the British HIV Association guidelines.
Firstly, both organizations suggest that calling in CPS to harrass
mothers who express an interest in breastfeeding is no longer
appropriate. Secondly, yes, while the AAP do indeed not recommend
that HIV+ mothers breastfeed as a first option, "even with
undetectable viral load" due to the fear that there is still a risk
of transmission, they cite as evidence a great study done by Roger
Shapiro and colleagues in Botswana, where only 2 of 709 mothers who
received ART and exclusively breastfed transmitted the virus to their
babies (Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat
C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner
J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E,
Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C,
Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L and Essex
M. Antiretroviral Regimens in Pregnancy and Breast-Feeding in
Botswana. New England Journal of Medicine 2010;362:2282-94.Available
at
<http://content.nejm.org/cgi/reprint/362/24/2282.pdf>http://content.nejm.org/cgi/rechprint/362/24/2282.pdf
).
The interesting thing about this research is that there were special
circumstances for the only two transmitting mothers. One simply
stopped taking her ART. And the other gave birth to a premature
baby, having only been prescribed ART from 34 weeks, so she had a
very short duration of treatment. According to a 2011 study, it
seems that the duration of maternal ART is critical - it needs to be
received for a minimum of 13 weeks in order to reduce viral levels to
undetectable. (Chibwesha CJ, Giganti MJ, Putta N, Chintu N, Mulindwa
J, Dorton BJ, Chi BH, Stringer JS, Stringer EM. Optimal Time on HAART
for Prevention of Mother-to-Child Transmission of HIV. J Acquir
Immune Defic Syndr. 2011 Oct 1;58(2):224-8. doi:
10.1097/QAI.0b013e318229147e,
<http://www.ncbi.nlm.nih.gov/pubmed/21709566>http://www.ncbi.nlm.nih.gov/pubmed/21709566
) So this would explain why poor adherence to, or insufficient
duration of maternal antiretroviral therapy can lead to continued
elevated viral levels which of course is what makes breastfeeding
risky. Studies on provision of ART in sero-discordant couples have
shown that the mechanism is very similar to horizontal transmission -
high viral load = risk; undetectable viral load = extremely low/no risk.
The logical conclusion would be not to stop HIV+ mothers who want to
breastfeed from fulfilling this ambition, (as we don't stop
sero-discordant couples from having sex) but to ensure that they
receive prompt testing during early pregnancy followed by effective
ART for long enough to ensure that their viral levels go down to
undetectable, that they meticulously adhere to their meds, and then
that they exclusively breastfeed for the first six months. Early
testing and prompt ART is actually the standard of care in both the
US and the UK. As it is also the global recommendation.
Finally, I would like to refer you to the letter written by my
colleague Ted Greiner and myself which appears as a rapid response
under the AAP guidance, giving more info on the above. (Greiner T and
Morrison P, Breastfeeding by HIV-infected women in the USA,
Pediatrics published online March 5, 2013, available
at
<http://pediatrics.aappublications.org/content/131/2/391.short/reply#pediatrics_el_55196>http://pediatrics.aappublications.org/content/131/2/391.short/reply#pediatrics_el_55196
)
Pamela Morrison IBCLC
Rustington, England
-------------------------------------------------------------
Date: Sun, 28 Jun 2015 03:29:16 -0400
From: Sarah Vaughan <[log in to unmask]>
Subject: Re: First Five California Book
Pamela Morrison wrote:
<There is a problem with this statement:
"Absolutely do not breastfeed your baby if: You are HIV-positive or have AIDS"
The AAP have set out very clear guidance on HIV
and infant feeding which - while it makes a first
recommendation for no breastfeeding, then goes on
to recognize that some HIV+ mothers may wish to
do so, and when that happens they should be
supported to breastfeed in as safe a manner as
possible. >
They also make it clear that they *do not recommend* that a mother
does this, even with undetectable viral load, and that there is still
a risk of transmission. Your phrasing here does seem a bit
disingenous to me, in that (whether intentionally or otherwise) you
seem to be implying that the AAP are OK'ing this as an approved
second-line option. Read in context, it's clear that what they're
actually talking about is how to handle the problem of a mother going
ahead with this potentially risky option despite best medical advice,
and that supporting them to breastfeed as safely as possible is a
matter of damage limitation, lesser-of-two-evils situation.
Yes, some HIV-positive mothers where formula is AFASS do insist on
breastfeeding despite all medical advice to the contrary. In that
situation, depending on whether the viral load is undetectable or not
and on various other factors, supporting them to do so in as low-risk
a way as possible may well be a less potentially harmful option for
the child than removing child from mother via CPS (which, AFAICS, is
the only other option if mum really is insistent). But that does
*not* mean that it is a *recommended* option or that an official
advice guide should be saying/implying that if mothers really want to
do this then it's OK.
Dr Sarah Vaughan, GP
GMC no. 4193096
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