However, the limited evidence on HIV transmission in the context of undetectability is a deterrent for many women to opt for this option
According to a study published in AIDS Patient Care and STDs, women with HIV who take antiretroviral therapy (ART) are 13 times more likely than nine years ago to talk to their doctors about breastfeeding during pregnancy. These new data come from a retrospective survey conducted in Germany and reinforce a recent consensus statement by women living with HIV, clinicians and activists advocating for greater participation of women with HIV in informed decision-making about HIV. feeding their babies.
The World Health Organization (WHO) declared in 2016 that women with HIV could use breastfeeding as an option for feeding their babies in the same way as women without HIV. These guidelines were aimed mainly at those countries with high HIV prevalences and with limited resources where access to safe water is rare and it is necessary to weigh the risk of HIV transmission through breast milk against the risks of malnutrition, infections and mortality associated with formula feeding in these settings.
Although science has been able to show that people with HIV, who take antiretroviral treatment and have an undetectable viral load do not transmit the infection during sexual intercourse, at the moment, there is not enough evidence to make it possible to affirm with the same force that undetectable equals nontransmissible in the context of breastfeeding. For this reason, countries that do not have to weigh between the risk of HIV transmission against other risks for babies - as is the case in Canada, the USA or European countries - continue to recommend formula or formula feeding to women with HIV .
The guidelines are so insistent on eliminating any risk of transmitting the virus to the baby that women with HIV are often hesitant to tell their doctors that they have decided to breastfeed their babies. Therefore, the extent of breastfeeding among these HIV-positive women is not entirely clear. In order to shed more light on this question, a group of German researchers conducted the first national study on breastfeeding in women with HIV in Germany.
The researchers reviewed the medical records between November 2018 and July 2020 to find out whether the conversations between doctors and patients since 2009 had discussed breastfeeding since 2009. The women had received care in 20 hospitals in Germany and the study collected data on the duration of breastfeeding, the antiretroviral regimen taken by the mothers, the viral load, and the subsequent post-exposure prophylaxis against HIV that the newborns received.
In total, 42 women with HIV spoke to their doctors between 2009 and 2020 about breastfeeding. Their average age was 33 years and 82% came from countries in sub-Saharan Africa. There was no AIDS-defining illness nor did his CD4 count lead to a diagnosis of AIDS. Of all of them, 7% were in Stage B of HIV while the rest were in Stage A, that is, in good health. Of the babies, one in three was born in the country while the rest were born abroad.
Almost all the women (93%) were in stage A of the classification of HIV infection, which equates to good health; the remainder were stage B. None of the women had AIDS-defining illnesses or CD4 cell counts that could lead to an AIDS diagnosis. What's more, the frequency of conversations about breastfeeding gained momentum over time. Only one woman spoke to a doctor about breastfeeding in 2009, yet 13 did so nine years later.
92% of women spoke before delivery about breastfeeding. 58% exclusively breastfed their baby. The mean duration of breastfeeding was 20 weeks and both extremes were recorded in the case of a woman who breastfed up to 104 weeks and the case of another who breastfed her baby only once, with colostrum.
All the women were taking antiretroviral treatment except one who was an elite controller. Their antiretroviral regimens included regimens based on ritonavir-boosted protease inhibitors (20%), integrase inhibitors (37%), and non-nucleoside analogs (39%).
Viral load was also measured in different ways during lactation: 42% had a viral load determination through an HIV RNA PCR every four weeks; 23% every eight weeks; and at 19%, every twelve weeks. Viral load remained undetectable at the time of delivery in 40 women and in 35 during lactation. This data was not available in two women during childbirth and in five during lactation. Two cases of viral rebound were recorded: one in a woman who had 76 copies / mL at 12 weeks after delivery and who subsequently discontinued treatment; and another, in a woman four weeks after delivery, whose viral load was 867 copies / mL and who returned to undetectable levels at her next appointment with the doctor. The two women indicated that they stopped breastfeeding their babies once they discovered that their viral load was not undetectable.
Although no data were found on whether the babies born to these women acquired HIV, HIV surveillance systems in Germany have reported no cases of perinatal transmission in the study period.
The researchers note that the increase in the number of women with HIV who are choosing to breastfeed reflects a growing need for normalcy in the context of HIV and pregnancy. Furthermore, they add that the diversity of breastfeeding cases, especially in terms of duration, antiretroviral treatment, and breastfeeding monitoring reflects the need for a standardized procedure. And that, for this reason, recommendations on breastfeeding should be urgently implemented in national guidelines for the clinical management of pregnancy in women with HIV, which includes providing patients with information that allows them to be involved in decision-making along with your doctors.
Source: POZ / Elaboración propia (gTt-VIH)
References: Haberl L, Audebert F, Feiterna-Sperling C, et a.. Not Recommended, But Done: Breastfeeding with HIV in Germany. AIDS Patient Care STDS. 2021 Feb;35(2):33-38. doi: 10.1089/apc.2020.0223.