Why is Breast-feeding a risk factor for HIV-1 transmission despite HIV-1 infected mothers receiving combination ART (cART)?

Anuttara Bhadra

doi:10.2218/resmedica.v23i1.1239

Abstract

Mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) is an important source of HIV-1 infection in infants, and can occur at any point, including in utero, at the time of delivery, and via breastfeeding. In the absence of intervention, such as the use of antiretroviral therapy (ART), MTCT of HIV-1 during pregnancy or delivery can affect approximately 15–25% of infants, with a further 5–20% of infants becoming infected postnatally during breastfeeding. The use of maternal ART while breastfeeding reduces the MTCT risk from 35% without any intervention to less than 5%. Although a significant improvement, 5% of infants continue to be infected.i Maternal factors that contribute to this continued risk of transmission despite taking ART include the method of feeding, breast health, RNA and DNA viral load in breast milk and plasma, and maternal nutrition. Infantfactors such as the disruption in the integrity of the gastrointestinal mucosal surfaces also contribute to an increased rate of MTCT.Aims: This literature review aimed to investigate why breastfeeding is still a risk factor despite HIV-1-infected mothers being on effective combination ART (cART)? This review will explore the associated factors that contribute to the increased risk of HIV-1 transmission to the infant via breastfeeding.

Highlights

Breastfeeding is recognized for its effective role in significantly decreasing the risk of childhood morbidity, which includes gastrointestinal and respiratory infections. 2 The World Health Organization (WHO) recommends that, on a population basis, infants should be breastfed exclusively for the first 6 months of life for optimal health benefits.[3]
Exclusive breastfeeding for 6 months has been associated with a threefold decreased risk of Mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) when compared with non-exclusive.[5]
Since HIV1 can be transmitted via breast milk, prevention of MTCT of HIV-1 through breastfeeding remains a pressing public health challenge

Summary

Introduction

Breastfeeding is recognized for its effective role in significantly decreasing the risk of childhood morbidity, which includes gastrointestinal and respiratory infections. 2 The World Health Organization (WHO) recommends that, on a population basis, infants should be breastfed exclusively for the first 6 months of life for optimal health benefits.[3]. For mothers in low- and middle-income countries, the WHO recommended that, in the absence of antiretroviral therapy (ART), breastfeeding should be implemented for the “first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants”.3. The CDC recommended that HIV-1infected women in high-income countries should refrain from breastfeeding and provide safe replacement feeding, even when taking ART.[6] Exclusive breastfeeding for 6 months has been associated with a threefold decreased risk of MTCT of HIV-1 when compared with non-exclusive (mixed feeding or non-exclusive breastfeeding).[5] promoting and encouraging the most appropriate feeding will help control and minimize this important risk factor

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