A recent article published in the The Lancet HIV posed the question, “[d]oes U=U for Breastfeeding
Mothers and Infants?” In a time when medical advancement has provided more
tolerable and effective methodologies for HIV treatment, more and more
HIV-positive patients are considered to be undetectable. This has begun to
raise the question: can these mothers safely do what other mothers do and
breastfeed their children? Adding to the growing debate is the 2016 guideline
offered by the World Health Organization which states: “mothers living with HIV
should breastfeed for at least 12 months and may continue breastfeeding
for up to 24 months or longer while being fully supported for cART
adherence” – that is, in low-resource
settings where the reduction of overall child morbidity and mortality are
the main driving forces. This is necessary where access to formula and clean
water to mix the formula are not guaranteed. However, in direct contrast, European
and American guidelines actively discourage breast feeding among the maternal
population.
Given the
rising number of women who are vocalizing their desire to breastfeed, the discussion
in more developed countries has gained traction. Unfortunately, there are no
robust studies which considered HIV-positive breast-feeding women on cART
therapy within developed nations to weigh in on the subject. However, the
viewpoint article “Does U=U” in breastfeeding revealed that there have been
studies of mothers who were able to transmit HIV to their children, despite
having undetectable HIV levels in the breastmilk. In a large case-control study of vertical transmission
in KwaZulu Natal, South Africa, the estimated total breastmilk exposure to HIV
RNA was strongly associated with postnatal transmission. There was
also documented postnatal HIV
transmission from a woman who had both plasma and breastmilk HIV RNA less than
37 copies per mL at the timepoint closest to transmission. With evidence of
transmission despite undetectable levels, is this enough to say that women who
are HIV-positive and on appropriate cART run the risk of transmitting the virus
to their children, one could certainly argue so. More recently, the Promise study of 2018 has
evidence that showed despite the postpartum prevention strategies in
breastfed children, maternal cART versus daily single dose
nevirapine to the child for 18 months, there is still a risk of mother to
child transmission of the virus via breastmilk. The study showed the risk of HIV mother to child transmission via
breastfeeding incidence increased with increasing exposure to breastmilk:
6 mos = 0.3% (95% confidence interval [CI]
0.1–0.8)
9 mos= 0.6% (95% CI 0.3–1.3)
12 mos
=0.7% (95% CI 0.3–1.4).
With
evidence demonstrating that it is possible to transmit HIV via breastfeeding
from HIV-positive mothers to their children, while on medial therapy, it
appears that the argument has become does this transmission change in high
income settings? The problem is that looking at transmission rates in this
“high income” setting is incredibly unrepresented. Therefore, one can suggest
that given what we know now, which is that HIV can be transmitted from mother
to child despite having undetectable viral loads, the argument at the moment is, is breastfeeding worth the
risk of transmission?
Who
is to determine the worthiness of the risk becomes the next task. The answer
certainly is not a simple one and could use a well exercised ethical
discussion. Most importantly, deciding who is the better advocate/voice for the
child is of the utmost importance when entering this conversation. I would
argue that the most objective and well-informed person is best suited for this
position which in the majority of cases is likely to be the physician. However, it is imperative that the physician
maintain the shared decision-making process in mind, ensuring that HIV-infected
mother receives comprehensive and unbiased information that empowers her to
understand the risks and benefits of each decision. However, when it comes to understanding
and respect the woman’s preference and autonomy,
how much autonomy is ethical?
Brittney Bruno
Kahlert,
Christian, et al. “Is Breastfeeding an Equipoise Option in Effectively Treated
HIV-Infected Mothers in a High-Income Setting?” Swiss Medical Weekly,
2018, doi:10.4414/smw.2018.14648.
Waitt,
Catriona, et al. “Does U=U for Breastfeeding Mothers and Infants? Breastfeeding
by Mothers on Effective Treatment for HIV Infection in High-Income
Settings.” The Lancet HIV, vol. 5, no. 9, 27 June 2018, doi:10.1016/s2352-3018(18)30098-5.
I had been reflecting
on this experience recently after reading an article on education of migrant
children in shelters in the United States. The article was published in the New York Times and entitled, “In a
Migrant Shelter Classroom, ‘It’s Always like the First Day of School.’”3
While the students that I was working with were United States citizens, the
challenges related to transiency and a background of childhood trauma were
similar. Despite all of the challenges, the children I worked with were always
happy to see me and eager to work together. I am no longer volunteering at the
shelter, but am grateful for the opportunity to work with this population of
resilient children and their mothers as they navigated challenging life
experiences. It highlights the importance of the family unit and social
support, which is so critical to healing and improved heath4.