Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings

Waitt, Catriona; Low, Nicola; Perre, Philippe Van de; Lyons, F; Loutfy, Mona; Aebi‐Popp, Karoline

doi:10.1016/s2352-3018(18)30098-5

Cited by 68 publications

(59 citation statements)

References 43 publications

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“…These findings are consistent with Waitt et al . 's viewpoint piece that thoroughly outlined the biomedical evidence and important gaps in our knowledge of optimal clinical care to support a WLHIV with breastfeeding . The tension between current recommendations to avoid breastfeeding and patient desires may continue to inhibit the patient‐provider relationship, which many providers fear may lead some WLHIV to engage in riskier infant feeding behaviours.…”

Section: Discussionmentioning

confidence: 99%

“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

et al. 2019

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IntroductionCurrently, the United States (U.S.) recommends that infants born to women living with HIV (WLHIV) be fed formula, whereas many low‐resource settings follow the World Health Organization's recommendation to exclusively breastfeed with ongoing antiretroviral therapy. Evidence on infant feeding among WLHIV in high‐resource countries suggest that these contrasting recommendations create challenges for providers and patients. Our study used multiple methods to understand providers’ infant feeding perspectives on caring for their pregnant and post‐partum WLHIV in the U.S.MethodsWe sent a survey (n = 93) to providers across the U.S. who have cared for WLHIV. A subset of survey participants opted into a follow‐up qualitative interview (n = 21). These methods allowed us to capture a broad understanding of provider attitudes via the survey and more nuanced qualitative interviews. The study was completed prior to an updated breastfeeding section of the U.S. Perinatal Guidelines.ResultsThe majority of providers (66.7%) discussed infant feeding intent with their patients using open‐ended questions. Many also discussed alternative feeding methods (37.6%) and disclosure avoidance strategies (34.4%). Over 75% (95% confidence interval (CI): 65.1 to 84.2) of participants reported that a WLHIV asked if she could breastfeed her child, and 29% (95% CI 20 to 40.3) reported caring for a patient who breastfed despite recommendations against breastfeeding. Providers reported that their patients’ primary concern was stigma associated with not breastfeeding (58%), while providers were primarily concerned about medication adherence during breastfeeding (70%). Through qualitative analysis, four overarching categories emerged that reflect providers’ sentiments, including (1) U.S. guidelines inadequately addressing WLHIV's desire to breastfeed; (2) negotiating patient autonomy amidst complex feeding situations; (3) harm reduction approaches to supporting WLHIV in breastfeeding; and (4) providers anticipating multilayered patient stigmatization.ConclusionsThe majority of provider respondents cared for a WLHIV who desired to breastfeed, and a third had WLHIV who breastfed despite recommendations against it. Providers found that the status of U.S. guidelines and their incongruity with WHO guidelines left them without adequate resources to support WLHIV's infant feeding decisions. Our findings provide important insight to inform professional associations’ discussions about public health policy as they consider future directions for infant feeding guidelines among WLHIV.

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Section: Discussionmentioning

confidence: 99%

“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

et al. 2019

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“…The undetectable=untransmissable (U=U) statement applies only to sexual transmission, and we currently lack data to apply this to breastfeeding. Other considerations are the lack of lactation studies for most antiretroviral agents, meaning that the pharmacokinetic properties of ART in breastmilk are poorly understood, and the potential effects of exposure to ART in the breastmilk on infants who do not acquire HIV .…”

Section: Neonatal Managementmentioning

confidence: 99%

British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

et al. 2019

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“…However, although extremely reduced, zero risk has never been observed with safe breastfeeding, contrary to artificial feeding. Some authors have highlighted the specific risk of infection of the child with intracellular virus, despite the control of viral replication, as being able to cause cases of contamination of children while viral replication in milk was undetectable [32]. These components (large-scale screening and early and prolonged treatment with HAART during pregnancy and breastfeeding) have all substantially reduced the number of infected children worldwide.…”

Section: Breastfeedingmentioning

confidence: 99%

Mini review: Prevention of mother–child transmission of HIV: 25 years of continuous progress toward the eradication of pediatric AIDS?

Blanche

2019

Virulence

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Prevention of mother-to-child transmission with antiretrovirals is extraordinarily effective. When medically well followed, a mother living with human immunodeficiency virus can now expect to avoid transmitting the virus to her child. Despite the immense difficulties inherent in the global implementation of this treatment, the virtual disappearance of pediatric AIDS can be considered in the long term. ARTICLE HISTORY

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Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings

Cited by 68 publications

References 43 publications

“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

Mini review: Prevention of mother–child transmission of HIV: 25 years of continuous progress toward the eradication of pediatric AIDS?

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