AIDS Care Psychological and Socio-medical Aspects of AIDS/HIV
ISSN: 0954-0121 (Print) 1360-0451 (Online) Journal homepage: http://www.tandfonline.com/loi/caic20
HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma Mark H. Yudin, V. Logan Kennedy & S. Jay MacGillivray To cite this article: Mark H. Yudin, V. Logan Kennedy & S. Jay MacGillivray (2016): HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma, AIDS Care, DOI: 10.1080/09540121.2016.1140885 To link to this article: http://dx.doi.org/10.1080/09540121.2016.1140885
Published online: 10 Feb 2016.
Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=caic20 Download by: [Gazi University]
Date: 29 March 2016, At: 21:41
AIDS CARE, 2016 http://dx.doi.org/10.1080/09540121.2016.1140885
HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma Mark H. Yudina,b, V. Logan Kennedyc and S. Jay MacGillivraya Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, Canada; bDepartment of Obstetrics and Gynecology, University of Toronto, Toronto, Canada; cWomen’s College Research Institute, Toronto, Canada
Downloaded by [Gazi University] at 21:41 29 March 2016
a
ABSTRACT
ARTICLE HISTORY
With advances in the care of HIV-positive pregnant women, the likelihood of perinatal transmission is now less than 1%. In resource-rich settings women are instructed to abstain from breastfeeding, as studies have shown that breastfeeding increases the likelihood of infant acquisition of HIV. As practitioners caring for HIV-positive parents, we are now facing growing tension about the complex issues that inform decisions about infant feeding. In the face of changing guidelines and global immigration patterns, simply telling women that breastfeeding is contraindicated may no longer be good enough. We must fully open the lines of communication regarding this important and evolving issue. This commentary will review the clinical, social and cultural considerations that impact decisions regarding infant feeding in the context of HIV.
Received 8 June 2015 Accepted 6 January 2016
Introduction The greatest success of reproductive HIV care has been, without argument, the dramatic decrease in perinatally acquired HIV. Many can recall the days when HIVpositive men and women desiring pregnancy lived with the reality of an approximately one in four risk of having a positive baby (Connor et al., 1994). In the current Canadian setting with the combination of successful maternal antiretroviral drug therapy (ART), elective Cesarean section where appropriate, infant ART and strict avoidance of breastfeeding, we now tell parents that the chance of their baby becoming HIV-positive is less than 1% (Forbes et al., 2012; Townsend et al., 2008). We are now, however, facing growing tension about the complex clinical, social and cultural considerations that inform recommendations, and parental decisions, about infant-feeding choices. As care providers, we feel we may have become complacent about our assumptions of parents’ automatic acceptance of exclusive formula feeding. The time has come where we feel we have reached a fork in the clinical road where simply dictating to parents that breastfeeding is contraindicated may no longer be sufficient. We urgently need to re-open the dialogue on this topic so that both families and care providers have the clinical data to together navigate the issue and the emotional, ethical, social and legal safety to frankly discuss all its implications. This commentary will explore CONTACT Mark H. Yudin Canada © 2016 Taylor & Francis
[email protected]
KEYWORDS
HIV; AIDS; infant feeding; breastfeeding; perinatal transmission
the often complicated and nuanced issue of infant feeding for HIV-positive mothers and families.
Infant feeding: a global perspective As service providers in Canada, we work within the context of recommendations for North America and other high-resource settings, in which HIV-positive parents are told that breastfeeding is contraindicated (American Academy of Pediatrics [AAP], 2013; Money et al., 2014). This recommendation is based on literature showing that breastfed infants had a higher rate of seroconversion than those bottle-fed formula (Leroy et al., 1998; Miotti et al., 1999). Recent data have shown that early ART combined with exclusive breastfeeding for up to the first six months of life decreases the postnatal HIV transmission rate to 0–1% (Morrison, Israel-Ballard, & Greiner et al., 2011). These data were part of the basis of the 2010 World Health Organization Guidelines on HIV and Infant Feeding (World Health Organization [WHO], 2010), which were reaffirmed in a 2013 guideline on ART (World Health Organization [WHO], 2013). For families in lower resource settings, these guidelines recommend maternal ART throughout pregnancy and breastfeeding or maternal therapy during pregnancy and infant therapy during breastfeeding. They also recommend exclusive breastfeeding for six months with continuation
Department of Obstetrics and Gynecology, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8,
Downloaded by [Gazi University] at 21:41 29 March 2016
2
M.H. YUDIN ET AL.
until 12 months of age while food is introduced. Weaning should occur at 12 months and be done over at least one month as rapid weaning has been associated with a spike in breast milk viral load (Kuhn et al., 2013). These recommendations may be a reassuring option for parents in jurisdictions without access to clean water and formula, but this strategy has not been advocated for families in resource-rich settings. A recent Cochrane review reached similar conclusions. Seven randomized controlled trials were included, and the authors concluded that ART, whether used by the mother or the infant while breastfeeding, is efficacious in preventing transmission. They go on to state that breastfeeding is not recommended in settings where affordable, feasible, acceptable, sustainable and safe (AFASS) alternatives are available. In those settings, exclusive breastfeeding is recommended, with the addition of ART where possible (White, Mirjahangir, Horvath, Anglemyer, & Read et al., 2014). Despite these data, guidelines for HIV-positive women living in resource-rich settings continue to recommend complete avoidance of breastfeeding. One
Table 1. Infant feeding recommendations from selected global guidelines. Organization
Date of publication
Recommendations
World Health Organization (WHO)
2010
.
Mothers known to be HIVinfected should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life
Canada – Society of Obstetricians and Gynaecologists of Canada (SOGC)
2014
.
Breast feeding is not recommended regardless of plasma HIV viral load and use of antiretroviral therapy
United States – American Academy of Pediatrics (AAP)
2013
.
In the United States, where clean water and affordable replacement feeding are available, the AAP recommends that HIVinfected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy
United Kingdom – British HIV Association and Children’s HIV Association (BHIVA/CHIVA)
2011
.
Mothers known to be HIVinfected, regardless of maternal viral load and antiretroviral therapy, refrain from breastfeeding from birth
exception to this is the guideline from the UK, which recommends formula feeding for all women. It does state, however, that a woman on effective combined ART with a repeated undetectable viral load may, after careful consideration, choose to exclusively breastfeed for six months (Taylor et al., 2011). In 2015, the WHO released a guideline stating that ART should be initiated in everyone living with HIV at any CD4 cell count (World Health Organization [WHO], 2015). If this becomes possible to implement worldwide, it may allow guidelines for infant feeding in different global jurisdictions to become more harmonized. Table 1 presents the recommendations from various global guidelines with respect to infant feeding.
Discussion Guidelines recommending complete avoidance of breastfeeding in resource-rich settings are data-driven and rightfully are focused on the goal of eliminating the risk of HIV transmission to the infant. In places with clean water and access to affordable or program-provided formula, we continue to instruct parents that formula feeding is the best. This recommendation is also grounded in the knowledge that low transmission rates are dependent on high adherence to HIV care and drug regimens, and this adherence may be suboptimal in the postpartum period (Adams, Brady, Michael, Yehia & Momplaisir, 2015). However, as providers engaged in the care of HIV-positive families, we must recognize that the decision to abstain from breastfeeding may be difficult. Indeed, in recent years it has been our experience that parents have started to actively challenge our recommendations of exclusive formula feeding. As care providers for HIV-positive women in Toronto, a large proportion of the parents we see in our clinic are immigrants or recent refugees from the global south. The conversations that we have with families in our care regarding infant feeding are often informed by their knowledge of, or experiences with, breastfeeding in their home countries. As a result, support and counseling related to infant feeding can be quite different when compared to parents with less firsthand knowledge of global variations in infant-feeding practices. The HIV-positive families in our care who have emigrated from Sub-Saharan Africa have often witnessed the widespread reality of antiretroviral drugs combined with exclusive breastfeeding as the gold standard of care in their home countries. Indeed, some of our clients have previously breastfed HIV-negative children specifically because of accepted guidelines and on direct recommendation from healthcare providers. This dichotomy both in information and recommendation can create
Downloaded by [Gazi University] at 21:41 29 March 2016
AIDS CARE
substantial confusion for clinicians and parents alike regarding decisions about HIV and infant feeding in the North American setting. It can be difficult for parents especially to reconcile the conflicting infant-feeding recommendations between their original home countries and their new home. Tension created by conflicting cultural, social and clinical messages about breastfeeding poses unique dilemmas for HIV-positive parents. Despite recommendations to avoid breastfeeding, some living in resource-rich countries may still wish to breastfeed, and may do this with, or without, the knowledge of healthcare providers. This may be especially true for those who have moved from countries where the WHO recommendations were explicitly to breastfeed. In Toronto, 75% of HIV-positive pregnant patients in one program are of African descent (Caprara, Shah, MacGillivray, Urquia & Yudin, 2014). In many other parts of the country, a large proportion of HIV-positive pregnant women are similarly immigrants from resource-poor settings (Forbes et al., 2012). For women living with HIV, there are many factors which may impact infant-feeding decisions, including internal, family and societal pressures. One way that those living with HIV may be revealed as positive is if they do not breastfeed their babies. For many from different African communities, an avoidance of breastfeeding is tantamount to admitting HIV-positive status. New mothers with HIV are bombarded with many issues, including strong pressure from family members and friends unaware of their HIV status to breastfeed, conflicting breastfeeding and HIV clinical recommendations between different regions of the world, weighted cultural norms of breastfeeding, international campaigns championing the benefits of breastfeeding, and the overarching need not to be stigmatized. In addition to these external pressures, many HIVpositive people have their own internal struggles related to this issue. While informed that breastfeeding carries with it the risk of transmission, they want to experience the closeness and bonding that breastfeeding can bring. As well, they are well aware of the many established health benefits of breastfeeding. In Toronto, a community forum on this issue was organized in 2013 and was attended by more than 50 HIV-positive parents and their friends. It was obvious that this was a very important issue for many families, and one about which they were extremely passionate. It was made abundantly clear to us that the old message of simply “avoid breastfeeding” is no longer good enough, and families want to be given the full range of options available accompanied by a clear and non-judgmental understanding of all risks and benefits of each.
3
Clearly, there are myriad reasons for clients to feel conflict regarding decisions about infant feeding. As providers involved in the care of HIV-positive pregnant parents, we must fully open the lines of communication regarding this issue. It has been an indelible learning experience for us to realize that simply telling parents to formula feed is not sufficient, and that there needs to be ongoing and meaningful inclusive dialogue about infant-feeding options and decisions. HIV-positive families need a safe space to discuss this issue with us and must be adequately informed about all of the risks and benefits associated with all different modes of infant feeding. We must ensure that they have all the knowledge and the tools they need to make fully informed choices for themselves and for their families.
Disclosure statement No potential conflict of interest was reported by the authors.
References Adams, J. W., Brady, K. A., Michael, Y. L., Yehia, B. R., & Momplaisir, F. M. (2015). Postpartum engagement in HIV care: An important predictor of long-term retention in care and viral suppression. Clinical Infectious Diseases, 61, 1880–1887. doi:10.1093/cid/civ678 American Academy of Pediatrics Policy Statement. (2013). Infant feeding and the transmission of human immunodeficiency virus in the United States. Pediatrics, 131, 391– 396. doi:10.1542/peds.2012-3543 Caprara, D., Shah, R., MacGillivray, S. J., Urquia, M., & Yudin, M. H. (2014). Demographic and management trends among HIV-positive pregnant women over 10 years at one Canadian urban hospital. Journal of Obstetrics and Gynaecology Canada, 36(2), 123–127. Retrieved from http://www.jogc.ca Connor, E. M., Sperling, R. S., Gelber, R., Kiselev, P., Scott, G., O’Sullivan, M., … Balsley, J. (1994). Reduction of maternalinfant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. New England Journal of Medicine, 331, 1173–1180. Retrieved from http://www. nejm.org Forbes, J. C., Alimenti, A. M., Singer, J., Brophy, J. C., Bitnun, A., Samson, L., … Read, S. E. (2012). 21-year review of vertical HIV transmission in Canada (1990 to 2010). AIDS, 26, 757–763. Kuhn, L., Kim, H. Y., Walter, J., Thea, D. M., Sinkala, M., Mwiya, M., … Aldrovandi, G. M. (2013). HIV-1 concentrations in human breast milk before and after weaning. Science Translational Medicine, 5, 1–13. Leroy, V., Newell, M.-L., Dabis, F., Peckham, C., Van de Perre, P., Bulterys, M., … Msellati, P. (1998). International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-1 infection. Lancet, 352, 597–600. Retrieved from http://www.thelancet.com
Downloaded by [Gazi University] at 21:41 29 March 2016
4
M.H. YUDIN ET AL.
Miotti, P. G., Taha, T. E. T., Kumwenda, N. I., Booadhead, R., Mtimavalye, L. A. R., Van der Hoeven, L., … Biggar, R. J. (1999). HIV transmission through breastfeeding: A study in Malawi. JAMA, 282, 744–749. Retrieved from http:// www.jamanetwork.com Money, D., Tulloch, K., Boucoiran, I., Caddy, S., Yudin, M. H., Allen, V., … van Schalkwyk, J. (2014). Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission. Journal of obstetrics and gynaecology Canada, 36(8 eSuppl A), S1–S46. Retrieved from http://www.sogc.org/clinical-practice-guidelines Morrison, P., Israel-Ballard, K., & Greiner, T. (2011). Informed choice in infant feeding decisions can be supported for HIVinfected women even in industrialized countries. AIDS, 25, 1807–1811. doi:10.1097/QAD.0b013e32834b3519 Taylor, G. P., Anderson, J., Clayden, P., Gazzard, B. G., Fortin, J., Kennedy, J., … de Ruiter, A. (2011) British HIV Association and Children’s HIV Association position statement on infant feeding in the UK. HIV Medicine, 12, 389– 393. Townsend, C., Cortina-Borja, M., Peckham, C., de Ruiter, A., Lyall, H., & Tookey, P. (2008). Low rates of mother-tochild transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2
006. AIDS, 22, 973–981. doi:10.1097/QAD.0b013e3282 f9b67a White, A. B., Mirjahangir, J. F., Horvath, H., Anglemyer, A., & Read, J. S. (2014). Antiretroviral interventions for preventing breast milk transmission of HIV (Review). Cochrane Database of Systematic Reviews 2014, 10, 1–137. doi:10. 1002/14651858.CD011323 World Health Organization (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. Retrieved March 20, 2014, from http:// www.who.int/maternal_child_adolescent/documents/9789 241599535/en/ World Health Organization (WHO). (2013). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 2013: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Retrieved December 8, 2015, from http://www.who.int/hiv/pub/guidelines/arv2013/download/ en/ World Health Organization (WHO). (2015). Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Retrieved December 8, 2015, from http:// www.who.int/hiv/pub/guidelines/earlyrelease-arv/en
ISSN: 0954-0121 (Print) 1360-0451 (Online) Journal homepage: http://www.tandfonline.com/loi/caic20
HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma Mark H. Yudin, V. Logan Kennedy & S. Jay MacGillivray To cite this article: Mark H. Yudin, V. Logan Kennedy & S. Jay MacGillivray (2016): HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma, AIDS Care, DOI: 10.1080/09540121.2016.1140885 To link to this article: http://dx.doi.org/10.1080/09540121.2016.1140885
Published online: 10 Feb 2016.
Submit your article to this journal
Article views: 35
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=caic20 Download by: [Gazi University]
Date: 29 March 2016, At: 21:41
AIDS CARE, 2016 http://dx.doi.org/10.1080/09540121.2016.1140885
HIV and infant feeding in resource-rich settings: considering the clinical significance of a complicated dilemma Mark H. Yudina,b, V. Logan Kennedyc and S. Jay MacGillivraya Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, Canada; bDepartment of Obstetrics and Gynecology, University of Toronto, Toronto, Canada; cWomen’s College Research Institute, Toronto, Canada
Downloaded by [Gazi University] at 21:41 29 March 2016
a
ABSTRACT
ARTICLE HISTORY
With advances in the care of HIV-positive pregnant women, the likelihood of perinatal transmission is now less than 1%. In resource-rich settings women are instructed to abstain from breastfeeding, as studies have shown that breastfeeding increases the likelihood of infant acquisition of HIV. As practitioners caring for HIV-positive parents, we are now facing growing tension about the complex issues that inform decisions about infant feeding. In the face of changing guidelines and global immigration patterns, simply telling women that breastfeeding is contraindicated may no longer be good enough. We must fully open the lines of communication regarding this important and evolving issue. This commentary will review the clinical, social and cultural considerations that impact decisions regarding infant feeding in the context of HIV.
Received 8 June 2015 Accepted 6 January 2016
Introduction The greatest success of reproductive HIV care has been, without argument, the dramatic decrease in perinatally acquired HIV. Many can recall the days when HIVpositive men and women desiring pregnancy lived with the reality of an approximately one in four risk of having a positive baby (Connor et al., 1994). In the current Canadian setting with the combination of successful maternal antiretroviral drug therapy (ART), elective Cesarean section where appropriate, infant ART and strict avoidance of breastfeeding, we now tell parents that the chance of their baby becoming HIV-positive is less than 1% (Forbes et al., 2012; Townsend et al., 2008). We are now, however, facing growing tension about the complex clinical, social and cultural considerations that inform recommendations, and parental decisions, about infant-feeding choices. As care providers, we feel we may have become complacent about our assumptions of parents’ automatic acceptance of exclusive formula feeding. The time has come where we feel we have reached a fork in the clinical road where simply dictating to parents that breastfeeding is contraindicated may no longer be sufficient. We urgently need to re-open the dialogue on this topic so that both families and care providers have the clinical data to together navigate the issue and the emotional, ethical, social and legal safety to frankly discuss all its implications. This commentary will explore CONTACT Mark H. Yudin Canada © 2016 Taylor & Francis
[email protected]
KEYWORDS
HIV; AIDS; infant feeding; breastfeeding; perinatal transmission
the often complicated and nuanced issue of infant feeding for HIV-positive mothers and families.
Infant feeding: a global perspective As service providers in Canada, we work within the context of recommendations for North America and other high-resource settings, in which HIV-positive parents are told that breastfeeding is contraindicated (American Academy of Pediatrics [AAP], 2013; Money et al., 2014). This recommendation is based on literature showing that breastfed infants had a higher rate of seroconversion than those bottle-fed formula (Leroy et al., 1998; Miotti et al., 1999). Recent data have shown that early ART combined with exclusive breastfeeding for up to the first six months of life decreases the postnatal HIV transmission rate to 0–1% (Morrison, Israel-Ballard, & Greiner et al., 2011). These data were part of the basis of the 2010 World Health Organization Guidelines on HIV and Infant Feeding (World Health Organization [WHO], 2010), which were reaffirmed in a 2013 guideline on ART (World Health Organization [WHO], 2013). For families in lower resource settings, these guidelines recommend maternal ART throughout pregnancy and breastfeeding or maternal therapy during pregnancy and infant therapy during breastfeeding. They also recommend exclusive breastfeeding for six months with continuation
Department of Obstetrics and Gynecology, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8,
Downloaded by [Gazi University] at 21:41 29 March 2016
2
M.H. YUDIN ET AL.
until 12 months of age while food is introduced. Weaning should occur at 12 months and be done over at least one month as rapid weaning has been associated with a spike in breast milk viral load (Kuhn et al., 2013). These recommendations may be a reassuring option for parents in jurisdictions without access to clean water and formula, but this strategy has not been advocated for families in resource-rich settings. A recent Cochrane review reached similar conclusions. Seven randomized controlled trials were included, and the authors concluded that ART, whether used by the mother or the infant while breastfeeding, is efficacious in preventing transmission. They go on to state that breastfeeding is not recommended in settings where affordable, feasible, acceptable, sustainable and safe (AFASS) alternatives are available. In those settings, exclusive breastfeeding is recommended, with the addition of ART where possible (White, Mirjahangir, Horvath, Anglemyer, & Read et al., 2014). Despite these data, guidelines for HIV-positive women living in resource-rich settings continue to recommend complete avoidance of breastfeeding. One
Table 1. Infant feeding recommendations from selected global guidelines. Organization
Date of publication
Recommendations
World Health Organization (WHO)
2010
.
Mothers known to be HIVinfected should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life
Canada – Society of Obstetricians and Gynaecologists of Canada (SOGC)
2014
.
Breast feeding is not recommended regardless of plasma HIV viral load and use of antiretroviral therapy
United States – American Academy of Pediatrics (AAP)
2013
.
In the United States, where clean water and affordable replacement feeding are available, the AAP recommends that HIVinfected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy
United Kingdom – British HIV Association and Children’s HIV Association (BHIVA/CHIVA)
2011
.
Mothers known to be HIVinfected, regardless of maternal viral load and antiretroviral therapy, refrain from breastfeeding from birth
exception to this is the guideline from the UK, which recommends formula feeding for all women. It does state, however, that a woman on effective combined ART with a repeated undetectable viral load may, after careful consideration, choose to exclusively breastfeed for six months (Taylor et al., 2011). In 2015, the WHO released a guideline stating that ART should be initiated in everyone living with HIV at any CD4 cell count (World Health Organization [WHO], 2015). If this becomes possible to implement worldwide, it may allow guidelines for infant feeding in different global jurisdictions to become more harmonized. Table 1 presents the recommendations from various global guidelines with respect to infant feeding.
Discussion Guidelines recommending complete avoidance of breastfeeding in resource-rich settings are data-driven and rightfully are focused on the goal of eliminating the risk of HIV transmission to the infant. In places with clean water and access to affordable or program-provided formula, we continue to instruct parents that formula feeding is the best. This recommendation is also grounded in the knowledge that low transmission rates are dependent on high adherence to HIV care and drug regimens, and this adherence may be suboptimal in the postpartum period (Adams, Brady, Michael, Yehia & Momplaisir, 2015). However, as providers engaged in the care of HIV-positive families, we must recognize that the decision to abstain from breastfeeding may be difficult. Indeed, in recent years it has been our experience that parents have started to actively challenge our recommendations of exclusive formula feeding. As care providers for HIV-positive women in Toronto, a large proportion of the parents we see in our clinic are immigrants or recent refugees from the global south. The conversations that we have with families in our care regarding infant feeding are often informed by their knowledge of, or experiences with, breastfeeding in their home countries. As a result, support and counseling related to infant feeding can be quite different when compared to parents with less firsthand knowledge of global variations in infant-feeding practices. The HIV-positive families in our care who have emigrated from Sub-Saharan Africa have often witnessed the widespread reality of antiretroviral drugs combined with exclusive breastfeeding as the gold standard of care in their home countries. Indeed, some of our clients have previously breastfed HIV-negative children specifically because of accepted guidelines and on direct recommendation from healthcare providers. This dichotomy both in information and recommendation can create
Downloaded by [Gazi University] at 21:41 29 March 2016
AIDS CARE
substantial confusion for clinicians and parents alike regarding decisions about HIV and infant feeding in the North American setting. It can be difficult for parents especially to reconcile the conflicting infant-feeding recommendations between their original home countries and their new home. Tension created by conflicting cultural, social and clinical messages about breastfeeding poses unique dilemmas for HIV-positive parents. Despite recommendations to avoid breastfeeding, some living in resource-rich countries may still wish to breastfeed, and may do this with, or without, the knowledge of healthcare providers. This may be especially true for those who have moved from countries where the WHO recommendations were explicitly to breastfeed. In Toronto, 75% of HIV-positive pregnant patients in one program are of African descent (Caprara, Shah, MacGillivray, Urquia & Yudin, 2014). In many other parts of the country, a large proportion of HIV-positive pregnant women are similarly immigrants from resource-poor settings (Forbes et al., 2012). For women living with HIV, there are many factors which may impact infant-feeding decisions, including internal, family and societal pressures. One way that those living with HIV may be revealed as positive is if they do not breastfeed their babies. For many from different African communities, an avoidance of breastfeeding is tantamount to admitting HIV-positive status. New mothers with HIV are bombarded with many issues, including strong pressure from family members and friends unaware of their HIV status to breastfeed, conflicting breastfeeding and HIV clinical recommendations between different regions of the world, weighted cultural norms of breastfeeding, international campaigns championing the benefits of breastfeeding, and the overarching need not to be stigmatized. In addition to these external pressures, many HIVpositive people have their own internal struggles related to this issue. While informed that breastfeeding carries with it the risk of transmission, they want to experience the closeness and bonding that breastfeeding can bring. As well, they are well aware of the many established health benefits of breastfeeding. In Toronto, a community forum on this issue was organized in 2013 and was attended by more than 50 HIV-positive parents and their friends. It was obvious that this was a very important issue for many families, and one about which they were extremely passionate. It was made abundantly clear to us that the old message of simply “avoid breastfeeding” is no longer good enough, and families want to be given the full range of options available accompanied by a clear and non-judgmental understanding of all risks and benefits of each.
3
Clearly, there are myriad reasons for clients to feel conflict regarding decisions about infant feeding. As providers involved in the care of HIV-positive pregnant parents, we must fully open the lines of communication regarding this issue. It has been an indelible learning experience for us to realize that simply telling parents to formula feed is not sufficient, and that there needs to be ongoing and meaningful inclusive dialogue about infant-feeding options and decisions. HIV-positive families need a safe space to discuss this issue with us and must be adequately informed about all of the risks and benefits associated with all different modes of infant feeding. We must ensure that they have all the knowledge and the tools they need to make fully informed choices for themselves and for their families.
Disclosure statement No potential conflict of interest was reported by the authors.
References Adams, J. W., Brady, K. A., Michael, Y. L., Yehia, B. R., & Momplaisir, F. M. (2015). Postpartum engagement in HIV care: An important predictor of long-term retention in care and viral suppression. Clinical Infectious Diseases, 61, 1880–1887. doi:10.1093/cid/civ678 American Academy of Pediatrics Policy Statement. (2013). Infant feeding and the transmission of human immunodeficiency virus in the United States. Pediatrics, 131, 391– 396. doi:10.1542/peds.2012-3543 Caprara, D., Shah, R., MacGillivray, S. J., Urquia, M., & Yudin, M. H. (2014). Demographic and management trends among HIV-positive pregnant women over 10 years at one Canadian urban hospital. Journal of Obstetrics and Gynaecology Canada, 36(2), 123–127. Retrieved from http://www.jogc.ca Connor, E. M., Sperling, R. S., Gelber, R., Kiselev, P., Scott, G., O’Sullivan, M., … Balsley, J. (1994). Reduction of maternalinfant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. New England Journal of Medicine, 331, 1173–1180. Retrieved from http://www. nejm.org Forbes, J. C., Alimenti, A. M., Singer, J., Brophy, J. C., Bitnun, A., Samson, L., … Read, S. E. (2012). 21-year review of vertical HIV transmission in Canada (1990 to 2010). AIDS, 26, 757–763. Kuhn, L., Kim, H. Y., Walter, J., Thea, D. M., Sinkala, M., Mwiya, M., … Aldrovandi, G. M. (2013). HIV-1 concentrations in human breast milk before and after weaning. Science Translational Medicine, 5, 1–13. Leroy, V., Newell, M.-L., Dabis, F., Peckham, C., Van de Perre, P., Bulterys, M., … Msellati, P. (1998). International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-1 infection. Lancet, 352, 597–600. Retrieved from http://www.thelancet.com
Downloaded by [Gazi University] at 21:41 29 March 2016
4
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Miotti, P. G., Taha, T. E. T., Kumwenda, N. I., Booadhead, R., Mtimavalye, L. A. R., Van der Hoeven, L., … Biggar, R. J. (1999). HIV transmission through breastfeeding: A study in Malawi. JAMA, 282, 744–749. Retrieved from http:// www.jamanetwork.com Money, D., Tulloch, K., Boucoiran, I., Caddy, S., Yudin, M. H., Allen, V., … van Schalkwyk, J. (2014). Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission. Journal of obstetrics and gynaecology Canada, 36(8 eSuppl A), S1–S46. Retrieved from http://www.sogc.org/clinical-practice-guidelines Morrison, P., Israel-Ballard, K., & Greiner, T. (2011). Informed choice in infant feeding decisions can be supported for HIVinfected women even in industrialized countries. AIDS, 25, 1807–1811. doi:10.1097/QAD.0b013e32834b3519 Taylor, G. P., Anderson, J., Clayden, P., Gazzard, B. G., Fortin, J., Kennedy, J., … de Ruiter, A. (2011) British HIV Association and Children’s HIV Association position statement on infant feeding in the UK. HIV Medicine, 12, 389– 393. Townsend, C., Cortina-Borja, M., Peckham, C., de Ruiter, A., Lyall, H., & Tookey, P. (2008). Low rates of mother-tochild transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2
006. AIDS, 22, 973–981. doi:10.1097/QAD.0b013e3282 f9b67a White, A. B., Mirjahangir, J. F., Horvath, H., Anglemyer, A., & Read, J. S. (2014). Antiretroviral interventions for preventing breast milk transmission of HIV (Review). Cochrane Database of Systematic Reviews 2014, 10, 1–137. doi:10. 1002/14651858.CD011323 World Health Organization (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. Retrieved March 20, 2014, from http:// www.who.int/maternal_child_adolescent/documents/9789 241599535/en/ World Health Organization (WHO). (2013). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 2013: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Retrieved December 8, 2015, from http://www.who.int/hiv/pub/guidelines/arv2013/download/ en/ World Health Organization (WHO). (2015). Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Retrieved December 8, 2015, from http:// www.who.int/hiv/pub/guidelines/earlyrelease-arv/en
