Experts told about breastfeeding with undetectable HIV load
Today there is an urgent need to provide clear recommendations on breastfeeding among mothers living with HIV and having undetectable viral load, a group of scientists in the journal Lancet said. Experts say that in fact "there is still insufficient evidence that H = H in the context of breastfeeding." Although the risk of transmission is probably small, if HIV-positive women have an undetectable viral load, the authors suggest a number of issues that need to be addressed.
As the authors note, in a context of limited resources, the World Health Organization (WHO) recommends that women with HIV be breast-fed. In this case, mothers should continue to undergo antiretroviral therapy as before, and children should receive ARV prophylaxis.
In high-income countries, the guidelines do not allow breastfeeding in women who are on ARVT. Nevertheless, the latest recommendations of the British Association for HIV, the European Clinical AIDS Society and the US Department of Health and Human Services confirm that women with undetectable viral load may not give up breastfeeding, subject to regular monitoring of adherence.
However, the authors of the review again dwell on the fact that in practice there are still no data determining the forms of control of HIV-positive women breast-feeding and the possible risks that may remain despite an undetectable viral load.
The authors of the article believe that it is necessary to answer several key questions in order to provide women with the fullest possible information about the possible consequences of breastfeeding and to establish what needs to be monitored during this period.
Is there a level of HIV in plasma or breast milk below which the virus can not be transmitted?
A number of studies have shown that lactating women can detect HIV in breast milk, even if they have undetectable viral load in the plasma.
A team of specialists in the study of breastfeeding, antiretroviral drugs and nutrition (BAN) concluded that maintaining a viral load in the plasma below 100 copies / ml is sufficient to prevent the transmission of HIV through breast milk.
However, a study in Botswana revealed two transmission cases that probably occurred during breastfeeding, when each mother had a viral load in the plasma below 50 copies / ml, both in a month and three months after childbirth (the infection of the children was recorded in each case about 90 days after delivery).
Also, one case was reported in Malawi, where HIV was transmitted through breastfeeding despite the fact that the mother had an undetectable viral load (<37 copies / ml) both in plasma and in breast milk.
The results of mathematical modeling conducted by UNAIDS on the basis of all the available clinical research data up to 2012 showed that the risk of HIV transmission through breast milk is about 0.16% (about 1/750) per month if the mother started antiretroviral treatment yet before giving birth.
These data show that the risk of HIV transmission is small, but not excluded. Researchers recommend the creation of an international registry, which will include the results of all infants of mothers with HIV. In addition to analyzing the safety of ARVs in infants, the registry will provide detailed information on any transmission cases and improve risk assessments.
Can antiretroviral drugs suppress cellular HIV?
According to experts, the risk of HIV transmission through breast milk, despite the suppression of the virus in the plasma, is probably a consequence of the cellular virus in breast milk.
HIV can be either cell-free or cellular, if it is contained in a cell of the immune system, such as a CD4-lymphocyte, in the form of viral DNA.
Breast milk contains several types of cells that can be latently infected with HIV. They include long-lived CD4 cells containing proviral DNA, which is not replicated and therefore is not sensitive to antiretroviral drugs.
Scientists say that more research is needed to determine whether long-term antiretroviral treatment before breastfeeding is a way to reduce the level of the cellular virus in breast milk.
What monitoring should HIV-positive women be breast-feeding?
The British Association for HIV (BHIVA) recommends that women who breastfeed during the ARV treatment should visit the clinic once a month to undergo a viral load test for themselves and their child. In the US recommendations, the test period is also 1-2 months.
Despite the fact that BHIVA guidelines do not support breastfeeding, they nevertheless recognize that some women decide to abandon artificial feeding. In order to minimize the risk of HIV transmission, BHIVA recommends adherence to a harm reduction strategy:
- to minimize the time during which the feeding takes place,
- do not breast-feed if the child has any symptoms of impaired gastrointestinal function, or if the mother has a breast infection,
- at least once a month during breastfeeding to undergo testing for viral load.