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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