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HIV Transmission Through Breastfeeding, with a Focus on Information Made Available Between 2001 and 2007

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HIV Transmission Through Breastfeeding, with a Focus on Information Made Available Between 2001 and 2007 This publication is an update of the review of current knowledge on HIV transmission through breastfeeding, with a focus on information made available between 2001 and 2007. It re- views scientific evidence on the risk of HIV transmission through breastfeeding, the impact of different feeding options on child health outcomes, and conceivable strategies to reduce HIV transmission through breastfeeding with an emphasis on the developing world. HIV Transmission Through Breastfeeding For further information, please contact: World Health Organization Department of Child and Adolescent Health and Development ([email protected]) or Department of HIV/AIDS ([email protected]) or Department of Nutrition for Health and Development ([email protected]) 20 Avenue Appia, 1211 Geneva 27, Switzerland website: http://www.who.int UNICEF Nutrition Section – Programme Division 3 United Nations Plaza A REVIEW OF AVAILABLE EVIDENCE New York, New York 10017, United States of America 2007 Update Tel +1 212 326 7000 ISBN 978 92 4 159659 6 HIV Transmission Through Breastfeeding A Review of Available Evidence 2007 Update HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007 WHO Library Cataloguing-in-Publication Data HIV transmission through breastfeeding : a review of available evidence : 2007 update. 1.HIV infections - transmission. 2.Acquired immunodeficiency syndrome - Transmission. 3.Breast feeding - adverse effects. 4.Disease transmission, Vertical - prevention and control 5.Review litera- ture. I.World Health Organization. ISBN 978 92 4 159659 6 (NLM classification: WC 503.3) © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be ad- dressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization or of the United Nations Children's Fund concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps repre- sent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization or the United Nations Children's Fund in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization and the United Na- tions Children's Fund to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The respon- sibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or the United Nations Children's Fund be liable for damages arising from its use. Printed in France. ii Table of contents Preface v Acknowledgements vii Acronyms viii Glossary ix Executive summary 1 Introduction 3 Mother-to-child transmission of HIV 5 HIV infection in women 5 Rates of, and risk factors for, overall mother-to-child transmission 5 Prevention of mother-to-child transmission of HIV 6 HIV transmission through breastfeeding 9 Pathogenesis and mechanisms of breastfeeding transmission 9 Risk of postnatal transmission through breastfeeding 10 Timing of postnatal transmission through breastfeeding 10 Early postnatal transmission through breastfeeding 10 Late postnatal transmission through breastfeeding 11 Factors associated with risk of transmission through breastfeeding 12 Maternal factors 12 Infant factors 16 Benefits of breastfeeding 19 Health benefits of breastfeeding in the general population 19 Maternal health benefits 19 Child health benefits 19 Health benefits of breastfeeding in children born to HIV-infected mothers 21 HIV-exposed children, regardless of HIV status 21 HIV-infected children 21 Global breastfeeding practices 22 Strategies to reduce HIV transmission through breastfeeding 23 Primary prevention of HIV in women of childbearing age 23 Framework to assess interventions to prevent postnatal transmission 24 iii HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007 Modifying infant feeding options for HIV-infected women: replacement feeding 24 Adverse outcomes of alternatives to breastfeeding practices 25 Social acceptability of feeding practices 25 HIV-infection 32 HIV-free survival 32 Discussion 32 Strategies for HIV-infected women who breastfed 33 Exclusive breastfeeding 33 Early cessation of breastfeeding 35 Heat treatment or pasteurization of expressed breast milk. 36 Microbicide treatment of expressed breast milk 36 Antiretroviral therapy during breastfeeding 37 Immunization of breastfed newborns 39 From research to public health recommendations on infant feeding: consequences for practice 39 Ongoing or planned research addressing the breastfeeding period 41 Conclusion 43 References 44 iv Preface his Review was originally prepared as a back acquisition without gains for survival. It remains Tground paper for the Technical Consulta- important to identify means of making breastfee- tion on HIV and Infant Feeding that took place ding safer for HIV-infected women who have no in Geneva in October 2006. It was updated dur- choice other than to continue breastfeeding. ing 2007 to include relevant new information. In a study on mastitis in Zambia (abstract As the Review was going to print at the begin- #650), breast milk samples were collected from ning of 2008, several trials were underway to 38 women who had clinical symptoms of masti- assess use of extended maternal or infant tis. The study found that during mastitis, eleva- antiretrovirals to reduce transmission among tions of breast milk viral load are restricted to HIV-exposed breastfed infants. Relevant find- the mastitic breast and eventually return to base- ings were presented at the 15th Conference on line levels, supporting current recommendations Retroviruses and Opportunistic Infections for women with mastitis to breastfeed from the (CROI) held from 3 to 5 February 2008 and are unaffected breast. summarized here.1 Maternal outcomes and infant feeding Postnatal HIV transmission, infant practices outcomes and infant feeding practices In the Ditrame-Plus cohort study in Abidjan In a pooled analysis of individual data from (abstract #73), the risk of pregnancy before 12 a South African and a West African cohort months post-partum was comparable in replace- study (abstract #46), the overall risk of post- ment feeding and breastfeeding groups: 4%. Be- natal HIV infection was 3.9% among children tween 12 and 24 months post-partum, the risk breastfed for <6 months and 8.7% among chil- of pregnancy was significantly lower among re- dren breastfed for >6 months (adjusted hazard placement feeders than breastfeeders. Replace- ratio: 1.8). Breastfeeding duration, as well as ment feeding was not responsible for a greater maternal immune status, appear to be major incidence of pregnancies in this West African determinants of HIV transmission. The risk did urban context, probably due to the systematic not differ between exclusively and predominantly offer and the frequent use of contraceptive serv- breastfed children. Exposure to breastfeeding ices. mixed with solids during the first 2 months in- creased the postnatal risk of acquisition of HIV Antiretrovirals in breastfeeding women (adjusted hazard ratio: 2.9). The Kisumu Breastfeeding Study in Kenya (abstract #45LB) was an observational prospec- In the Vertical Transmission Study in South tive cohort of children of lactating women tak- Africa (abstract #636), 18-month HIV-free sur- ing antiretroviral treatment (ART) to prevent vival of children of HIV-infected women shows mother-to-child transmission (MTCT). Overall that breastfeeding of HIV-uninfected infants transmission rates were 3.9% at 6 weeks, 5% at beyond 6 months of age increases the risk of HIV 6 months, 5.9% at 12 months and 6.7% at 18 1 CROI abstracts are available at http:/www.retroconference. org, accessed February 15, 2008. v HIV TRANSMISSION THROUGH BREASTFEEDING: A REVIEW OF AVAILABLE EVIDENCE - AN UPDATE FROM 2001 TO 2007 months. There was no difference in HIV trans- well below levels required for treatment, suggest- mission by baseline maternal CD4 count. For ing minimal risk for drug toxicity. Lamivudine those infants who became infected during the (3TC) and nelfinavir exposure in infants would first 6 weeks of life, resistance was initially not suggest minimal risk for resistance in HIV-in- detected (abstract #84LB), but emerged during fected children; however, low-level nevirapine the breastfeeding period. (NVP) exposure via breast milk may predispose HIV-infected infants to resistance. In the MASHI trial in Botswana (abstract #637), the MTCT rate at one month was 1.2% Antiretrovirals in breastfed children among breastfeeders and 1.1%
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