Breastfeeding and HIV

WABA (World Alliance for Breastfeeding Action) recently published a resource document on HIV and breastfeeding – “Understanding International Policy on HIV and Breastfeeding: a comprehensive resource” – intending to outline the research and recommendations regarding HIV and infant feeding. You can access the full document here. Below I offer an overview of the resource.

HIV (Human Immunodeficiency Virus) is a viral infection that destroys parts of the body’s immune system. In its final stages, HIV leads to AIDS (Acquired Immunodeficiency Syndrome), an active pathological condition that is often terminal. HIV can be transmitted three different ways. A horizontal infection is the most common form of transmission. A horizontal infection occurs during unprotected sex. A blood-borne infection occurs from a contaminated blood transfusion, needle, syringe, or knife. A vertical infection occurs when a baby becomes infected with HIV from his/her mother. This transmission of the virus can occur during the pregnancy, during the birth, or while breastfeeding. Although not often acknowledged, it is also possible for a baby to infect his/her mother during breastfeeding when the infant is infected with HIV through blood-borne transmission. This type of transmission occurs most frequently when both mother and baby have sores or wounds on the nipples and in the mouth, respectively.

In an attempt to reduce the number of babies infected with HIV, research has been conducted to determine what is the safest method of infant feeding. With the understanding that the virus can be transmitted through breastmilk, it has been recommended in the past that mothers provide replacement feeding (formula) for their babies instead of breastmilk. More recent research has altered this recommendation. Now the World Health Organization recommends exclusive breastfeeding for the first six months of the baby’s life continuing through one year or more unless circumstances make replacement feeding safe. Exclusive and continued breastfeeding in conjunction with maternal and infant antiretroviral* (ARV) regimens during pregnancy and breastfeeding greatly reduces vertical transmission of HIV and improves HIV-free survival. If ARVs are unavailable, the recommendation for exclusive breastfeeding remains the same. If the mother cannot breastfeed exclusively, the recommendation changes to avoid all breastfeeding entirely. This is why:

Mixed feeding (replacement feeding and breastfeeding) causes damage to the intestinal mucosa of the baby. This damage allows the virus to pass through into the baby’s body. Exclusive breastfeeding protects the integrity of the gastrointestinal tract, creating a barrier so even though the virus may be present in the breastmilk, it cannot gain access to the baby’s body. Exclusive breastfeeding has shown a 3-4-fold decreased risk of HIV-transmission in the first six months of a baby’s life when compared to mixed feeding.

The current recommendation for exclusive breastfeeding during the first six months of a baby’s life also comes from the rising infant morbidity and mortality rates that occurred with the increase in replacement feeding. In developing countries, the dangers presented with formula create a greater risk than those presented with the possibility of vertical transmission through breastfeeding. Every year, 1.5 million young children die because they are not breastfed appropriately; 300,000 die of HIV transmitted through breastfeeding. And with the use of ARVs for both the mother and the baby from early on in the pregnancy, vertical transmission of HIV is far less likely. In addition, the mother’s health improves with the treatment, further improving the baby’s chance of survival. For babies infected with HIV during the pregnancy, breastfeeding greatly increases their life expectancy.

Interestingly, there are many components in breastmilk that actually protect against HIV. (Of course there are!) Immunoglobulin-secreting ß cells have antimicrobial properties that protect infants from pathogens within the gastrointestinal tract. A glycosamine   inhibits the binding of HIV to CD4 cells**, effectively stopping the first step toward infecting the target cell. Human milk oligosaccharides (HMOs), the third most abundant component of breastmilk, cluster in the GI tract and promote the growth of probiotics to inhibit HIV binding and prevent transmission. In addition, a number of specific identified protective factors against HIV (secretory antibodies, lipids, lysozyme, and more) have been found in breastmilk. Colostrum contains mucosally-derived antibodies to HIV that protect against transmission at mucosal surfaces, and the colostrum of HIV+ mothers contains anti-HIV IgG and IgA antibodies. (These antibodies have not been found in the colostrum of HIV- mothers.) I am continuously amazed at the protective and healing properties of breastmilk.

There are specific conditions that increase the risk of vertical transmission during pregnancy, birth, or breastfeeding. These conditions should be understood, and an effort to reduce their prevalence will help achieve HIV-free survival. If the mother is HIV+ and is untreated or if she has a high viral load, the risk of transmission to her baby increases. A mother may have a high viral load from a recent infection, a long-standing infection with a low CD4 count, or ARV therapy that was cut off. If the mother has any breast pathology, such as mastitis, a bacterial or fungal nipple infection, or damaged nipples, the risk of transmission through breastfeeding is increased. If the baby has oral thrush or damage to his/her intestinal mucosa, the risk of transmission through breastfeeding is also increased. Certain birth practices should be avoided for HIV+ mothers in order to reduce the risk of vaginal secretions infecting the baby, such as ruptured membranes for more than four hours, the use of a vacuum extractor or forceps, an episiotomy or other breakage in the skin, fetal monitoring that breaks the infant’s skin (usually on the scalp), and suctioning the newborn after the birth.

In developed countries, the vertical transmission rate is only 1-2%. These women generally have routine prenatal testing, consistent and continuous maternal and infant ARV treatment, birth by cesarean section, and breastfeeding avoidance. Without these interventions, 30-40% of infants born to HIV+ mothers may be infected with HIV.

Breastfeeding avoidance and the use of replacement feeding is safe only under ALL of the following conditions: (1) access to safe water and sanitation at home and in the community; (2) the ability to provide sufficient formula for normal growth and development; (3) the ability to prepare the formula cleanly and frequently so it is safe with low risk of diarrhea and malnutrition; (4) the ability to give formula exclusively for the first six months of the baby’s life; (5) a supportive family; and (6) easy access to health care that offers comprehensive child health services. All six of these conditions must be met for replacement feeding to be considered a safe option for a mother with HIV. Shortened to AFASS, replacement feeding must be acceptable, feasible, affordable, sustainable, and safe.

*Antiretrovirals are drugs that disrupt the action of HIV and reduce the amount of the virus in the body. There is no cure for HIV so ARVs should be taken for life.

**CD4 cells are white blood cells that help fight infection. HIV binds to CD4 cells and destroys them so the body cannot effectively fight against the infection.