Support for Establishing Best Practices for Breastfeeding in the Current HIV/ART Era.

Abstract

In this issue of the Journal of the Pediatric Infectious Diseases Society, Yusuf et al describe an initiative to support women living with HIV (WLHIV) who chose to breastfeed at Johns Hopkins Hospital. The authors successfully developed and implemented a comprehensive harm reduction program in response to recent changes in Department of Health and Human Services (DHHS) perinatal HIV guidelines. Yusuf et al are the first to report outcome data in the United States of 10 infants born to WLHIV who started antiretroviral therapy (ART) preconception. None acquired HIV infection after breastfeeding for a median duration of 4.4 months. There is a growing body of evidence to suggest that postnatal HIV transmission during breastfeeding is exceedingly rare among mothers who maintain sustained viral suppression while on ART throughout pregnancy and breastfeeding. Among 4 studies of breastfeeding WLHIV on ART (N = 2392), overall infant HIV transmission at 6 months was 0.37% (95% CI 0.17%-0.71%), and all breastfeeding transmissions occurred in the context of either maternal detectable viremia (n = 5), reported ART adherence challenges (n = 2), or late initiation of ART (≤3 months prior to delivery) (n = 2) [1–4]. In light of these international data, the benefits of breastfeeding and the risks to the infant of not breastfeeding must be considered. Breastfeeding lowers risk for major drivers of infant mortality (sudden infant death syndrome [SIDS], necrotizing enterocolitis [NEC], and sepsis) and is associated with lower rates of childhood obesity, asthma, and diabetes [5]. Early immune development is shaped by breastmilk-associated gut microbiome, which can lower risk for autoimmunity later in life [6]. Many infants born to WLHIV in the United States already face disproportionate risk for adverse health outcomes linked with lower socioeconomic status. Breastfeeding restrictions may unintentionally increase the odds of poor health outcomes in this vulnerable population.