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Getting to Zero: Maximising Infant HIV-free Survival through Breastfeeding
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The World Alliance for Breastfeeding Action (WABA) celebrates World AIDS Day on 1 December each year with colleagues and friends to bring attention to the global AIDS epidemic and emphasise the critical need for a committed, meaningful and sustained response.
2014 marks the final opportunity for celebration of the theme “Getting to Zero”, adopted for the last five years to focus on the targets of zero new infections and zero AIDS related deaths.[1] Progressively improved access to antiretroviral therapy (ART) between 2002 and 2012 has averted an estimated 4.2 million deaths in low- and middle-income countries. [2]
Research conducted before ART became available showed the risk of vertical transmission – from an HIV-infected mother to her baby during pregnancy, during birth and during mixed breastfeeding - to be between 15-45% [3]. It was also shown that the risks of increased morbidity, mortality and malnutrition due to replacement feeding exceed the risks of HIV transmission during breastfeeding. [4]
Today, however, the possibility of reducing pediatric infections to virtually zero and improving HIV-free survival is within sight. Up to date World Health Organisation guidance recommends that all women diagnosed as HIV-infected should receive immediate ART which should be continued for life.[5] When appropriate combinations of ART are given to HIV-positive women and/or their babies, so that viral load is effectively suppressed, then the risk of postpartum transmission has been shown to be <1% during 6 months’ exclusive breastfeeding and continued breastfeeding with adequate complementary foods to at least 12 months.[6][7][8] These findings lead researchers to suggest that the elimination of HIV infection in infants is attainable. [9]
The duration of antenatal ART is crucial; compared to women initiating ART at least 13 weeks prior to delivery, women on ART for ≤ 4 weeks had a 5.2-fold increased odds of HIV transmission[10]. Thus, if a pregnant woman is diagnosed as being HIV-positive early enough in pregnancy she will be able to receive a sufficiently long course of antenatal ART to ensure that the number of viral copies in her blood become undetectable on a standard test by the time her baby is due to be born. This will greatly reduce the risk that the infant will be infected with HIV during labour and the birth process, or during breastfeeding.
These developments mean that HIV-positive women today receiving ART and adherent to their treatment can follow the same infant feeding recommendations as their uninfected counterparts. This not only maximises their babies’ health but also reduces the stigma associated with the use of breastmilk substitutes. Thus in the context of HIV, appropriate maternal ART and exclusive breastfeeding for six months, and continued breastfeeding with adequate complementary foods to at least 12 months, is the safest feeding option to optimise infant and young child HIV-free survival.
Current ART regimens not only allow HIV-infected individuals to live a normal life-span[11], but also permit renewed confidence in universal support for breastfeeding, even in the face of HIV. Currently recommended HIV and infant feeding practices are designed not just to prevent HIV transmission, but also to ensure better HIV-free survival [4]. Provision of a safe and adequate diet to HIV-exposed babies is assured, and the goal of achieving zero transmissions during breastfeeding looks to be within reach.
More information can be found in the WABA HIV Kit, "Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource" at www.hivbreastfeeding.org This set of documents aims to clarify the confusion which has arisen during the last decade due to changing HIV and infant feeding guidance. It summarises up-to-date scientific evidence as at the end of 2012 and will be updated in 2015.
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References
[2] Ford N, Vitoria M, Hirnschall G and Doherty M. Getting to zero HIV deaths: progress, challenges and ways forward. Journal of the International AIDS Society 2013, 16:18927
[3] De Cock KM, Fowler MG, Mercier E, De Vincenzi I, Saba J, Hoff E, Alnwick DJ, Rogers M, Shaffer N, Prevention of mother-to-child HIV transmission in resource-poor countries; translation research into policy and practice. JAMA 2000;283:1175-1182
[4] WHO 2010. Guidelines on HIV and infant feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. 1.Breast feeding 2.Infant nutrition 3.HIV infections – in infancy and childhood. 4.HIV infections – transmission. 5.Disease transmission, Vertical – prevention and control. 6.Infant formula. 7.Guidelines. I.World Health Organisation. ISBN 978 92 4 159953 5 information available at http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html
[6] Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E, Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C, Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L and Essex M. Antiretroviral Regimens in Pregnancy
and Breast-Feeding in Botswana. New England Journal of Medicine 2010;362:2282-94.
Available at http://content.nejm.org/cgi/rechprint/362/24/2282.pdf
[7] Silverman MS (2011). Interim Results of HIV Transmission Rates Using a Lopinavir/ritonavir based regimen and the New WHO Breast Feeding Guidelines for PMTCT of HIV [abstr. H1-1153] Presented at: International Congress of Antimicrobial Agents and Chemotherapy (ICAAC) Chicago IL.
[8] Gartland MG, Chintu NT, Li MS, Lembalemba MK, Mulenga SN, Bweupe M, Musonda P, Stringer EM, Stringer JS, Chi BH, Field effectiveness of combination antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission in rural Zambia. AIDS. 2013 May 15; 27(8): doi:10.1097/QAD.0b013e32835e3937. Full-text free download available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836017/pdf/nihms521144.pdf
[9] Horwood C, Vermaak K, Butler L, Haskins L, Phakathi S and Rollins N. Elimination of paediatric Hiv in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-=child transmission. Bulletin of the World Health Organisation 2012;90:168-175. doi: 10.2471/BLT.11.092056, see http://www.who.int/bulletin/volumes/90/3/11-092056.pdf?ua=1
[10] Chibwesha CJ, Giganti MJ, Putta N, et al. Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr. 2011;58(2):224-8. doi: 10.1097/QAI.0b013e318229147e
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For more information, please contact:
WABA Liaison Person:
Pei Ching
peiching.chuah@waba.org.my
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