Wolfson.tvu.ac.uk

Breast feeding and HIV transmission:
Current state of the evidence
Robert Pratt BA, MSc, RN, RNT, FRCN, Professor of Nursing, Richard Wells Research Centre, Thames Valley University London
Carol Pellowe BA (Hons), MA (Ed), RN, RNT, Principal Lecturer (Research), Richard Wells Research Centre, Thames Valley University
London
Women now account for at least half of the total global number of adults living with HIV/AIDS. Most of them are of
childbearing age and, as more and more women have become infected with HIV, an increasing number of their newborn
infants are also at risk of becoming infected from them before, during or soon after childbirth. This article looks at
the feasibility of preventing mother-to-child transmission of HIV, particularly in the industrially developing regions
of the world.
Keywords: breast feeding; breast milk; human immunodeficiency virus; vertical transmission; prevention
Introduction
By the beginning of 2003, more than 3.2 million children
under the age of 15 years throughout the world were living
with HIV/AIDS (Figure 1). During the previous year, more
than 800,000 children were newly infected with HIV (more
than 2,250 every day) and at least 1,700 children died every
day (Figures 2 and 3)(UNAIDS/WHO, 2002).
Figure 3. Estimated number of children (<15 years) newly infect-ed with HIV during 2002. Courtesy of UNAIDS (2002). may soon dwarf the current tragedy being experienced today insouthern Africa. In addition, the force of national epidemics ofHIV infection in resource-poor countries in eastern Europecontinue to build, setting the stage for increased risk tochildren (UNAIDS/WHO, 2002).
In contrast in the richer nations of the industrially Figure 1. Children (<15 years) estimated to be living with HIV- developed world, comprehensive prevention strategies have AIDS as of end 2002. Courtesy of UNAIDS (2002). dramatically decreased the number of HIV-infected newbornchildren to the point where it is becoming uncommon forchildren to become infected from their mothers. Key points
Pratt, R. and Pellowe, C. (2003) Breast feeding and HIV
transmission: Current state of the evidence. Journal of Neonatal Nursing 9(4): 133-39.
1. Over 800 000 children throughout the world acquire HIV infection from their mothers every year.
2. Those children living in the impoverished countries of Figure 2. Estimated deaths in children (<15 years) from HIV/AIDS the developing world are at greatest risk of infection.
during 2002. Courtesy of UNAIDS (2002). 3. There is conclusive evidence that HIV is transmitted by The risk of becoming infected with HIV depends mainly on 4. Modification of infant feeding practices, where appropri- where the child is born. Most HIV-infected children (90%) are ate, can significantly reduce the risk of mother-to-child born in impoverished countries in the industrially developing world, mainly sub-Saharan Africa. However, as national HIV 5. For most newborn children in the developing world, epidemics escalate in South and Southeast Asia, the number of breast feeding should continue to be recommended and HIV-infected infants born in these densely populated regions JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 Breast feeding and HIV transmission 133
Maternal Factors
Primary HIV infection and symptomatic HIV disease, both associated with high levels of HIV in the plasma (viral load) and low numbersof CD4+ T-lymphocytes, are associated with an increased risk for MTCT (Garcia et al, 1999; Anderson, 2001). High plasma and genital tract viral load is associated with an increased risk for MTCT (Garcia et al, 1999; Anderson, 2001; Fang et al, 1998). Low CD4+ T-lymphocyte count or decreased CD4+:CD8+ ratio are both associated with an increased risk for MTCT (Anderson, 2001). Antiretroviral treatment and prophylaxis The use of antiretroviral drugs (zidovudine, lamivudine, nevirapine) in treatment regimens for the mother or as chemoprophylaxis for the neonate have been shown to significantly decrease the risk for MTCT (Anderson, 2001). Vitamin A deficiency is associated with an increased risk of pre-term delivery which increases the risk of MTCT (Coutsoudis et al, 1999a). Severe deficiency may also adversely affect the integrity of the vaginal mucosa and increase HIV vaginal shedding (John et al, 1997). A history of unprotected penetrative sexual intercourse with several partners has been associated with an increased risk for MTCT (Anderson, 2001; Bulterys et al, 1997). The presence of other sexually transmitted infections increases plasma viraemia (viral load). These infections also increase the number of genital tract inflammatory cells which stimulates HIV shedding, increasing the risk for MTCT (Anderson, 2001; Plummer, 1998). The use of illicit drugs during pregnancy increases the risk for MTCT(Anderson, 2001; Rodriguez et al, 1996; Lyman, 1993). Obstetric Factors
Pre-term delivery has been shown to increase the risk for MTCT. (Anderson, 2001; Kuhn et al, 1997; Kuhn et al, 1999) The risk of MTCT increases linearly with increasing duration of ruptured membranes with a 2% increase in risk for each hour increment. Women with late symptomatic HIV disease (AIDS) have a31% probability of MTCT after 24 hours of ruptured membranes. (Read, 2000) Placental disruption-abruption, chorioammionitis Chorioammionitis increases the risk of MTCT (Goldenbert et al, 1998) and placental abruption causing disruption of the placental-fetal barrier, may increase fetal exposure to maternal blood and increases the risk of MTCT (Anderson, 2001). Use of fetal scalp electrodes, fetal scalp sampling, amnioscopy and amniocentesis increases the risk for MTCT (Maiques et al, 1999; Mandelbrot et al, 1996).
Use of episiotomy, vacuum extraction or forceps may increase the risk for MTCT by exposing the fetus to maternal blood and genital secretions. However, careful use may shorten duration of labour or ruptured membranes with vaginal delivery and this may decrease risk of MTCT (Anderson, 2001). External version should be avoided because of the increased risk for maternal-fetal bleeding. Caesarean delivery performed before the onset of labour and rupture of membranes can reduce the risk of MTCT by 55-88% (EMDC, 1999; IPHIVG, 1999).
Postnatal factors
The risk of MTCT from breast feeding is greatest in early infancy (before 6 months of age) and persists as long as breast feeding continues (Miotti et al, 1999; Nduati et al, 2000; John et al, 2001). The longer the duration of breast feeding, the greater the risk of MTCT(Leroy et al, 1998; Embree et al, 2000; Read et al, 2002). Mothers may initially become infected with HIV as a result of an unscreened blood transfusion during the peripartum period. During maternal primary HIV infection, when the plasma viral load is high, there is a significantly increased risk for MTCT from breast feeding.
Table 1. Factors that influence the risk for MTCT of HIV 134 Breast feeding and HIV transmission
JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 Prevent further sexually transmitted infections during pregnancy by reducing the number of sexual partners Reduce the frequency of unprotected sexual intercourse Discontinue the use of illicit drugs during pregnancy Commence mother on antiretroviral therapy or Effectively treat any co-existing sexually transmitted infections If vitamin A deficient, provide vitamin supplementation Avoid invasive tests or monitoring during the antenatal and intrapartum period Consider the benefits of caesarean delivery Cease breast feeding as early as possible Use only blood and blood components that have been screened for HIV infection Table 2. Methods for preventing MTCT.
Mother-to-child transmission
becoming infected in the first place. All other interventionsdesigned to prevent newborn children becoming infected from Mother-to-child transmission (MTCT), also known as vertical their mothers depend upon maternal infection being detected or perinatal transmission, can occur during pregnancy (in before the child is born. Antenatal screening for HIV infection utero), during birth (intrapartum) when the newborn infant is an essential element of a comprehensive strategy for comes into contact with infected maternal birth fluids during preventing women giving birth to HIV-infected children (Pratt, the birth process, and shortly after birth (postpartum) or during the early months of life while being breast fed. Most European Consensus Guidelines on the management of children (75%) become infected during the peripartum HIV infection during pregnancy (Newell and Rogers, 2002) are period, i.e. during or shortly after delivery (Microchnick et al, available and these are summarised in Table 3. UK-specific guidelines(Lyall et al, 2001) are also available and regularlyupdated and these can be downloaded from the internet at: Risk factors
http://www.bhiva.org/guidelines.htm Finally, guidelines from Women are potentially at risk of initial infection during sexual the USA National Institutes for Health (NIH, 2002) are intercourse with HIV-infected men, from sharing HIV- available as a ‘Living Document’ on the internet at: contaminated injecting equipment, or following treatment with http://www.aidsinfo.nih.gov/guidelines/perinatal/Perinatal.pdfAll three of these guidelines are in general agreement on how transfusions of unscreened whole human blood or blood best to prevent MTCT of HIV and nurses, midwives and other healthcare professionals working within this field need to be Once infected, several maternal, obstetric and postnatal familiar with their recommendations and advice.
factors can increase the likelihood of mothers transmitting HIVinfection to their child before, during and immediatelyfollowing birth. Some of the most important risk factors are Risk to infants of HIV transmission
described in Table 1 and further discussed elsewhere (Pratt, from breast feeding
2003). Understanding these risks has led to the development of The importance of antenatal screening for HIV infection and the evidence for the efficacy of antiretroviral chemoprophylaxisand caesarean section delivery for reducing the risk of MTCT Risk reduction strategies
has previously been described in this journal and Among the several options that have been described for elsewhere.(Pratt, 1999; 2000; 2003) However, there remains preventing MTCT (Table 2)(Pratt, 1999; 2003) the following some confusion over the recommendations(Newell and Rogers, 2002; Lyall et al, 2001; NIH, 2002) for modifying infant feeding practices to prevent viral transmission. There are considerable advantages to both mother and infant in breast feeding, especially during the first six months • mothers refraining from breast feeding of life. Throughout the world, breast feeding protects against In western Europe, where these interventions are available, the respiratory infections and diarrhoeal disease, two of the most rate of MTCT has fallen from an average of 15% to 2% or less important causes of childhood mortality, and it has significant by 1999(ECS, 2001). This pattern is replicated in other economical, social, psychological and family planning advantages. However, in HIV-infected mothers, both cell-free Equally important, any effective strategy aimed at reducing and cell-associated virus have been consistently identified in the risk of MTCT must first focus on preventing women from colostrum and mature milk and the transmission of HIV in JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 Breast feeding and HIV transmission 135
All pregnant women, and ideally, those planning a pregnancy, are offered and recommended to have an HIV test. HIV testing should also be offered to their sexual partner(s). HIV-infected women should be given the option of delivering their child through a CS performed before labour and before rupture of membranes (usually at 38 weeks’ gestation). All HIV-infected women should be offered therapy during pregnancy fortheir own health depending on their clinical status and prognostic markers. Antiretroviral treatment can begin after the first trimester.
Most antiretroviral drugs have not been shown to be associated with an increased risk for birth defects (teratogenicity) except efavirenz, zalcitabine and hydroxyurea, which are contraindicated during pregnancy.
A 3-part zidovudine (ZDN) regimen is used as the standard chemoprophylaxis to prevent MTCT; ZDN is given during pregnancy, during labour and in the neonatal period, commencing at 28-32 weeks’ gestation (with elective CS delivery at 38 weeks gestation). If CS delivery is not an option, in addition to ZDN: two doses of nevirapine may be given once labour has been established lamivudine (3TC) may also be given with ZDN HIV-infected women are strongly advised to refrain from breast feeding where safe infant-feeding alternatives are available. Women who cannot refrain from breast feeding should be advised to: Exclusively breast feed and not introduce other foods or drinks for4-6 months; Breast feed for as short a time as possible, with rapid cessation. Follow-up of children born to HIV-infected mothers Long-term follow-up of all children born to HIV-infected mothers should continue, at least until school age.
Table 3. Summary of European Consensus Guidelines on the Management of HIV Infection in Pregnancy (Newall and Rogers, 2002).
breast milk, occurring at any point during lactation, has been life (Fautaini, 1997; Simonon at al, 1994). Avoidance of breast feeding and the use of breast milk Several factors are involved in or associated with HIV substitutes will substantially reduce postnatal mother-to-child transmission via breast milk. High levels of maternal viraemia HIV transmission and this strategy is recommended in (high viral load) will increase the amount of HIV secreted in industrialised countries, including the UK, where safe breast milk and, consequently, increase the amount and alternatives to breast feeding are available (Newell and Rogers, duration of HIV exposure to the infant. Vitamin A deficiency in 2002; Lyall et al, 2001; NIH, 2002). Globally, however, most HIV-infected mothers is associated with cracked nipples (and infants at risk of postnatal mother-to-child HIV transmission increased vaginal shedding of HIV) which may be an additional are breast fed. In many cultures and in many regions of the source of viral exposure to the infant (John et al, 1997). Infant developing world, it is neither possible nor acceptable for prematurity results in an immature neonatal immune system unable to mount an effective cell-mediated response to HIVand is associated with an increased risk of viral acquisition from Exclusive breast feeding
breast feeding (John et al, 1997; Ekpini et al, 1997). The actual mechanism of HIV transmission by breast milk is Studies conducted in South Africa found evidence that women not fully understood. However, neonatal mucus membranes who exclusively breast feed had a lower rate of MTCT than cannot effectively prevent HIV infection and exposure to HIV those mothers who also fed their babies other fluids or food in breast milk may result in viral infection directly through oral together with breast feeding (mixed infant feeding) and gastric mucosa (Nduati, 1998). Other conditions that may (Coutsoudis et al, 1999b; 2001). Potential mechanisms that disrupt the integrity of neonatal oral mucosa, e.g., candidiasis, might explain a reduced risk for MTCT when children are have been associated with an increased risk of HIV infection exclusively breast fed include (Smith and Kuhn, 2000) • reduction in dietary antigens and enteric pathogens from The amount of HIV secreted in breast milk is highest during fluids and food, helping to maintain the integrity of the the first few months following delivery and 70% of postnatal intestinal mucosal barrier and limit the inflammatory transmission takes places within the first four to six months of 136 Breast feeding and HIV transmission
JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 • promotion of beneficial intestinal microflora that may HIV-infected woman and children must be part of the regular increase resistance to infection and enhance the infant’s programme so that staff can feel confident and competent to care for and support these mothers and their infants in the best • the beneficial antimicrobial, anti-inflammatory and immuno-modulating properties of breast milk. Conclusion
Consequently, if there are no consistently safer alternatives to In most countries, the children of HIV-infected mothers will breast feeding for HIV-infected mothers, exclusive breast find themselves born into a world where they are immediately feeding is the second best option for reducing the risk of disadvantaged. Most will eventually be orphaned as the result MTCT in the postnatal period. However, it must be realised of the AIDS-related deaths of their parents and by 2010, more that many mothers in resource poor countries of the world, than 25 million children are projected to lose one or both suffering malnutrition and poor health themselves, may not parents due to HIV disease (USAID, 2002). The majority of produce enough breast milk to be able to exclusively breast these children will be stigmatised, impoverished and deprived feed their babies and they will manage the best they can by of even basic needs for food, water, shelter and protection.
Their chances of survival will be diminished even further if theyhave also become infected from their mothers before, during Practical considerations
With the current emphasis on breast feeding in UK maternity In this discussion we have seen that we have the ability to units, it is important that women choosing to bottle feed do not prevent MTCT of HIV to infants. However, the necessary feel stigmatised (DoH, 2003; UNICEF, 2003). African women counselling, testing and treatment needed to do this is resident in the UK, and women from many other ethnic hampered by a geographical lottery, where children born in groups, traditionally breast feed their babies. A decision to countries with poorly organised and starkly under-resourced bottle feed, especially if associated with a delivery by caesarean prenatal healthcare services will be at most risk. Already section, may raise suspicion of their HIV status among other millions of children have been infected and thousands more members of their family, neighbours and in their community.
are becoming infected every day (UNAIDS/WHO, 2002). Because of this, it is important that the decision about infant References
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138 Breast feeding and HIV transmission
JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 U.S. Agency for International Development, United Nations
CBE for TVU Professor
Children’s Fund, Joint United Nations Programme on HIV/AIDS.
(2002) Children on the Brink 2002: A Joint Report on Orphan
Congratulations to one of our authors, Robert Pratt, Estimates and Program Strategies. Washington DC; TvTAssociates/The Synergy Project.
Professor of Nursing and Director of the Richard http://www.synergyaids.com/documents/COB2002.pdf Internet resources
Valley University’sFaculty of Health and • Anderson JR (ed.). A Guide to the Clinical Care of Women with HIV 2001 ed. U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. This excellent practical text comprehensively describes the care and treatment of HIV- infected women is available free (online, CD and hard copy available.) and is regularly updated. Hard copy can be obtained free of charge by contacting: Womencare, Parklawn Bldg., Rm 11A-33, 5600 Fishers Lane, Rockville, Maryland 20857, USA; Fax: +1-301-443-0791; or e-mail: • Questions and Answers on MTCT are available from the Professor Pratt has been a prominent and influential figure developing care strategies for persons with http://www.unaids.org/publications/documents/mtct/qaw HIV disease since the beginning of the global pandemic. During the last five years, he and his • The Baby Friendly Initiative is a global programme of group have developed a series of national UNICEF and the World Health Organization which works evidence-based guidelines for preventing with the health services to improve practice so that parents healthcare-associated infections on behalf of the are enabled and supported to make informed choices about Department of Health and the National Institute how they feed and care for their babies.
A Photographic Memory
The Child Bereavement Trust has recently produced a booklet entitled “A photographic memory”, which isdesigned as guidance for professionals responsible for offering parents photographs at the time of their baby’sdeath. As the booklet states “A picture paints a thousand words” and the guide encourages professionalscaring for parents whose baby is dying or has died, to think about the importance of photographs as part ofthe care offered to families.
The content of the booklet is based on what bereaved parents have appreciated about the photographs taken byprofessionals when their baby died. Parents share their precious photographs and feelings about their children. The value of the booklet is in the way it sensitively demonstrateshow to take photographs of a dead baby that parents will treasure.
For example photographs of tiny, perfect little hands or feet; a pictureof a little boy holding his dead sister; a photograph of a dead twinbeside her living sibling. At the back of the booklet practical information is given includingusing polaroid and digital cameras, as well as the use of black andwhite photography.
Copies of the booklet have already been distributed free of
charge to each maternity and neonatal unit in the UK and further
copies are available for purchase from The Child Bereavement
Trust at a cost of £7.50 or 4 copies for £25. Contact CBT on
[email protected] or 0845 357 1000.
JOURNAL OF neonatal NURSING VOLUME 9 ISSUE 4 2003 Breast feeding and HIV transmission 139

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