Re: [pronut-hiv] Breast feeding and HIV (8)

["Rachel Stern" <sternworks@verizon.net>]

Tom - Yes I agree with you that formula/replacement feeding carries its own risks. Mothers or parents should be educated about those risks, just as they should be about breastfeeding, whether mixed or exclusive. Greatly 
understating transmission risk does not do that; neither does downplaying 
formula risks.  Rachel


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


> 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
>
>
>
>