Postnatal HIV transmission in breastfed infants of HIV‐infected women on ART: a systematic review and meta‐analysis

Abstract

Introduction: To systematically review the literature on mother-to-child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART. Methods: We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta-analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle-Ottawa Scale (NOS) and GRADE. Results and discussion: Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk. Conclusions: There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life-long ART for all.

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

“…There are no data on the risk of HIV transmission via breast milk in high‐income countries. In low‐ to middle‐income settings, the overall postnatal risk of HIV transmission via breast milk when women are treated with cART has been reported as 1.08% (95% CI 0.32–1.85) at 6 months and 2.93% (95% CI 0.68–5.18) at 12 months, however in these studies women only received cART for 6 months and often breastfed for longer . In the more recent PROMISE trial, women received cART throughout the breastfeeding period, and the transmission rate was 0.3% (95% CI 0.1–0.6) at 6 months and 0.6% (95% CI 0.4–1.1) at 12 months .…”

How mandatory is the mandatory reporting of children at risk?

“…Before ART was available, about 16% of infants of HIV‐positive mothers acquired HIV infection by breastfeeding . If the mother takes ART and has an undetectable HIV viral load, however, the risk of breast milk transmission of HIV is very low, probably <1% . The British HIV Association (BHIVA) recommends that HIV‐positive mothers in industrialised countries bottle‐feed but says that breastfeeding is an acceptable alternative .…”

“…Prior to delivery, she said she wanted to breastfeed because, in her community, failure to breastfeed was assumed to indicate HIV infection, a recognised phenomenon known as ‘HIV by association’. This was discussed with a paediatric ID consultant, who reviewed the literature and agreed this would be reasonable. The baby was born at full term and was well.…”

“…However, she failed to attend at 6 weeks when the baby's blood test was due, and she did not reply to phone or text messages. The clinicians were concerned that the mother might stop taking her ART and continue breastfeeding, which would be associated with a risk of up to 16% of the baby becoming HIV infected . A community health care worker tried to visit the mother at home, but there was no reply.…”

Mental health predictors of breastfeeding initiation and continuation among HIV infected and uninfected women in a South African birth cohort study

“…The World Health Organization’s (WHO) infant feeding guidelines emphasize exclusive breastfeeding for the first 6 months of life as a cost-effective, safe source of nutrition 3 . In LMICs with large HIV epidemics such as South Africa, in the presence of national ART programmes with high coverage of pregnant and breastfeeding women, breastfeeding benefits outweigh risks of vertical HIV transmission 4 . As such, WHO recommends HIV-infected mothers exclusively breastfeed from birth to 6 months and receive antiretroviral therapy (ARV) to limit mother to child (PMTCT) HIV transmission; breastfeeding is recommended until 12 months 5,6 .…”