RE: [pronut-hiv] Breast feeding and HIV (7)

["Schaetzel, Tom" <tschaetzel@path.org>]

Hi Rachel,

If one considers only what affects transmission of HIV through breastfeeding, ignoring other factors (e.g., mixed vs exclusive breastfeeding, breast conditions, etc.) I suppose either viral load or the duration of breastfeeding would be the major factors. 

I'm uncomfortable with this sort discussion, though, because it focuses exclusively on MTCT. If MTCT were the only risk that mattered, replacement feeding would be the obvious choice because, as you say, breastfeeding carries some MTCT risk no matter how low the viral load is. The problem is that while formula feeding eliminates the breastfeeding MTCT risk, it also increases mortality risk. In settings with high infant mortality, formula feeding and early breastfeeding cessation are associated with several times higher risk of mortality for the infant/child. It's important not to focus just on the level of MTCT risk.




Tom Schaetzel
USAID IYCN 
Infant and Young Child Nutrition Project


-----Rachel Stern wrote:

Hi, Martin. Actually my intent was not to imply that viral load should be 
tested before prescribing exclusive breastfeeding, although I do believe 
either her viral load or CD4-T cells should be determined so she can get 
treatment if it's called for and hopefully available.

The point I tried to make is that women - or potential parents - should not be misled about the rates of HIV transmission via breast milk. They need  accurate information so they can hopefully make reasoned decisions about feeding choices, family planning, and therapies. Although exclusive 
breastfeeding vs mixed feeding may reduce transmission rates somewhat, 
grossly understating those rates is irresponsible, and I have to believe 
that the doctor was misquoted in the article.

As Tom said, recent studies suggest that antiretroviral therapy which 
reduces maternal viral load during breastfeeding, greatly reduces 
transmission rates, and I hope that this approach proves relatively 
effective and safe. That would help solve this current dilemma of infant 
feeding. Although there are concerns about possible distant adverse effects to infants who are exposed long term to these drugs through breastmilk, and although protection from transmission is not perfect (Tom mentions <5%), it seems promising.

Tom, would you agree that viral load or CD4 counts are the single biggest 
factor in breastfeeding transmission? Oh yes, there are many other factors 
like mastitis, weaning practices, infant thrush, etc along with mixed 
feeding. In one large study (I can't remember exactly, but can find it is 
you want me to) on mixed vs exclusive feeding, no infant whose mom had >350 T cells became infected - mixed feeding or not.

Rachel Stern


----- "Schaetzel, Tom" wrote: 

Responding to both Martin Kumbe and Rachel Stern...

Martin Kumbe wrote...

"Rachel  Stern's  position implies that for exclusive breasting to be 
prescribed for a baby born of an HIV positive mother, the monther's  viral 
load should be checked to determine the potential of transmission of the 
virus to the baby during exclusive breast feeding.

Is this the practice?

Should this be the practice?"

=========
"Prescribing" a feeding choice would never be an appropriate practice. A 
provider's role should be to help a mother decide the best feeding option 
for her own situation, and then to support her in carrying out her feeding 
choice.

A higher viral load is indeed associated with increased risk of transmitting 
HIV through breastfeeding, but it is by no means the only factor. For 
example, mixed feeding greatly elevates the risk of transmission for 
breastfeeding mothers even if they do not have "high" viral loads. On the 
other hand, many things kill babies in addition to HIV, and replacement 
feeding may expose the infant to these threats. The best feeding choice is 
the one the mother can practice that carries the lowest risk of death, 
whether that risk is from HIV infection or from infections/malnutrition 
associated with formula feeding. Replacement feeding is the safest option 
only when it is, for the mother, acceptable, feasible, affordable, 
sustainable and safe--otherwise exclusive breastfeeding is recommended.

For more information on what should be the practice, please see the WHO 
consensus statement on HIV and infant feeding 
(http://www.who.int/child_adolescent_health/documents/if_consensus/en/), or 
visit our website (www.IYCN.org, especially 
http://www.iycn.org/resources-infant-feeding.php ).

Re: a high viral load being associated with an increased risk of MTCT. 
Two-thirds of MTCT through breastfeeding occurs when the mother's CD4 count 
is < 350. However, a high viral load (or low CD4 count) also is an 
indication for HAART. Studies from Mozambique, Tanzania, Kenya and Cote 
d'Ivoire have observed low rates (<5%) of MTCT among women prescribed HAART 
even though breastfeeding continues. Perhaps the best "prescription" for 
preventing MTCT for a mother with a high viral load would be HAART, and 
perhaps soon we may see new recommendations for HAART initiation at higher 
CD4 counts for pregnant/lactating mothers.


Tom Schaetzel
USAID/IYCN Infant and Young Child Feeding Project


-----Martin kumbe wrote:

Martin Kumbe's response to Rachel Stern's comments

Rachel Stern wrote:

"Smit, who works with the Prevention of Mother to Child Transmission (PMTCT) 
project for BOTUSA in Francistown, told the workshop: 'Breast milk is not as 
bad as we thought because research has shown that (only) four percent of 
children can get infected through breastfeeding.'"

I don't believe this is true, and the statement - if it is accurately
reported -seems irresponsible.

The most important determinant of HIV transmission via breast milk is the
mother's viral load in her blood or milk

Rachel Stern
------------------------------------ 

Am responding to Rachel Stern comments on Smit's statement above. Rachel 
Stern's position implies that for exclusive breasting to be prescribed for a 
baby born of an HIV positive mother, the monther's viral load should be 
checked to determine the potential of transmission of the virus to the baby 
during exclusive breast feeding.

Is this the practice?

Should this be the practice?

Martin Kumbe,

Nutritionist,


Kenya