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Prevention of HIV transmission during breastfeeding in resource-limited settings

Author
Grace John-Stewart, MD
Section Editor
Lynne M Mofenson, MD
Deputy Editor
Allyson Bloom, MD

INTRODUCTION

Mother-to-child HIV-1 transmission occurs in utero, peripartum, and postnatally via breastfeeding; without interventions the risk of perinatal HIV-1 transmission is 20 to 45 percent [1].

Over the past two decades, clinical trials have demonstrated that the risk of mother-to-child transmission can be significantly reduced with the administration of antiretroviral medications during pregnancy, delivery, and the early postpartum period (eg, two to four weeks after delivery) [2-5]. However, excess HIV transmission has been observed among breastfeeding infants after short-term prophylactic strategies are completed following delivery. Since breastfeeding is important for the nutritional and overall health of the infant, subsequent studies have been designed to evaluate the role of antiretroviral medications during the postnatal period in preventing HIV transmission during breastfeeding.

This topic will discuss clinical data from resource-limited settings on the prevention of HIV transmission during the breastfeeding period. Advice on the use of antepartum and intrapartum antiretroviral prophylaxis for prevention of mother-to-child HIV transmission in low- to mid-resource countries are discussed in detail elsewhere and in the 2016 World Health Organization consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. (See "Prevention of mother-to-child HIV transmission in resource-limited settings".)

EPIDEMIOLOGY OF HIV TRANSMISSION THROUGH BREASTFEEDING

Transmission risk during breastfeeding — Early evidence for HIV transmission via breast milk included detection of virus in breast milk, higher rates of mother-to-infant HIV transmission in regions where women mostly breastfed (eg, Africa) than in areas where they mainly replacement fed (eg, the United States and Europe), observational studies in which breastfed infants had higher transmission than non-breastfed infants, and cases in which women acquired HIV after pregnancy and then transmitted to their breastfeeding infant [1]. There have also been reports of infection in infants born to HIV-uninfected mothers but breastfed by HIV-infected surrogates [6]. Additionally, there have been rare reports of HIV transmission in the opposite direction from nosocomially-infected (eg, through blood transfusion) infants to HIV-uninfected mothers through breastfeeding [7]. In such cases, transmission likely occurs as a result of breastfeeding contact during a period of epithelial disruption such as maternal skin fissures or infant stomatitis.

HIV detection in infants during the first two weeks of life may represent transmission that has occurred in utero, during delivery, or within the early days of breastfeeding [8]. This complicates estimation of early breast milk HIV transmission risk during the first month of life. Most studies that have evaluated the risk of infant acquisition of HIV infection through breastfeeding have begun data collection at one month of life to avoid this overlap of potential transmission routes.

                              

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