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Abuogi L, Noble L, Smith C. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics 2024; 153:e2024066843. [PMID: 38766700 DOI: 10.1542/peds.2024-066843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
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Affiliation(s)
- Lisa Abuogi
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York
| | - Christiana Smith
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Akpan U, Omoronyia E, Arogundade K, Asibong U, Nwagbata A, Akpanika C, Etuk S. Infant-Feeding Practices Among Women Living With Human Immunodeficiency Virus (HIV) in a Southern Nigerian Region: A Mixed Comparative Study. Cureus 2023; 15:e35483. [PMID: 36999099 PMCID: PMC10044241 DOI: 10.7759/cureus.35483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 02/27/2023] Open
Abstract
Background and objective Infant survival depends on proper nutrition. Breastfeeding enhances infant health and offers some benefits to the mother as well. However, in the setting of the HIV pandemic, it is important to assess the benefits and the risk for each individual in choosing a feeding option. The purpose of this research was to determine the infant-feeding practices among women living with HIV/AIDS (WLWHA) and compare them with the general population of women. Methods A mixed comparative survey was conducted among 246 HIV-positive mothers nursing infants of at least one year of age. An equal number of matched HIV-negative women from the same locality were selected as controls. Quantitative data were analyzed using IBM SPSS Statistics version 23 (IBM Corp., Armonk, NY) while qualitative findings were presented in a thematic approach. Results The prevalence of exclusive breastfeeding (EBF) among WLWHA was 73.6% compared to 55.2% in the controls [p=0.002; chi-square (X2)=5.264]. Only 6.5% of WLWHA practiced exclusive replacement feeding (ERF). Vaginal birth was associated with increased odds for early initiation of breastfeeding [p=0.001; odds ratio (OR): 3.135; 95% confidence interval (CI): 2.130 to 4.616]. Also, urban dwellers commenced breastfeeding earlier than women residing in rural communities (p=0.002; OR: 5.58; 95% CI: 3.85 to 8.07). Based on in-depth interviews, cultural influences and non-disclosure of HIV status to family members promoted mixed feeding. Concomitant intake of anti-tuberculosis drugs was a major reason for adopting ERF in some women. Conclusion There was a high prevalence of EBF among WLWHA. Counseling on infant feeding is an effective component of the Prevention of Mother-to-Child Transmission (PMTCT) programs. Cultural beliefs and fear of stigmatization are major challenges to infant nutrition in sero-exposed babies.
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Adelekan B, Harry-Erin B, Okposo M, Aliyu A, Ndembi N, Dakum P, Sam-Agudu NA. Final HIV status outcome for HIV-exposed infants at 18 months of age in nine states and the Federal Capital Territory, Nigeria. PLoS One 2022; 17:e0263921. [PMID: 35157737 PMCID: PMC8843197 DOI: 10.1371/journal.pone.0263921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/29/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction While antiretroviral therapy (ART) coverage for pregnant women has undergone steady scale-up, Nigeria’s final mother- to-child transmission of HIV (MTCT) rate remains unacceptably high at 10%. This study aimed to determine final outcomes (MTCT rates) and their correlates among HIV-exposed infants (HEI) in nine states and the Federal Capital Territory, Nigeria. Methods This retrospective, cross-sectional study was conducted at 96 primary, secondary and tertiary health facilities supported by the Institute of Human Virology Nigeria. Data was abstracted for a birth cohort of HEI born between October 30, 2014 and April 30, 2015 whose 18–24 month final outcome was assessed by October 30, 2016. Only infants with a six-week first DNA PCR result, and a rapid HIV antibody test result at age 18 to 24 months were included. Multivariate logistic regression (adjusted odds ratios [aORs]) evaluated for predictors of HIV positivity at ≥18 months. Results After testing at ≥18 months, 68 (2.8%) of the 2,405 exposed infants in the birth cohort were HIV-positive. After a minimum of 18 months of follow-up, 51 (75%) HIV-positive infants were alive on ART; 7 (10%) had died, 5 (7.3%) were lost to follow-up and 5 (7.3%) were transferred out. Rural maternal residence, lack of maternal ART/ARV prophylaxis, mixed infant feeding and infant birth weight less than 2.5 kg correlated with an HIV-positive status for infant final outcomes. Conclusion The final HIV positivity rate of 2.8% is encouraging, but is not population-based. Nevertheless, supported by our findings, we recommend continued programmatic focus on early access to quality prenatal care and maternal ART for pregnant women, especially for women living with HIV in rural areas. Furthermore, implementation of nationwide sensitization and education on six-months’ exclusive infant breastfeeding with concurrent maternal ART should be strengthened and sustained to reduce MTCT rates.
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Affiliation(s)
- Babatunde Adelekan
- Strategic Information, Institute of Human Virology Nigeria, Abuja, Nigeria
- * E-mail:
| | - Bidemi Harry-Erin
- Strategic Information, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Martha Okposo
- Strategic Information, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Ahmad Aliyu
- Strategic Information, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Nicaise Ndembi
- Laboratory Research, Institute of Human Virology Nigeria, Abuja, Nigeria
- Department of Pediatrics, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Patrick Dakum
- Department of Pediatrics, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Prevention, Care and Treatment Unit, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Nadia A. Sam-Agudu
- Department of Pediatrics, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Prevention, Care and Treatment Unit, Institute of Human Virology Nigeria, Abuja, Nigeria
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
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Mennecier A, Kankasa C, Fao P, Moles JP, Eymard-Duvernay S, Mwiya M, Kania D, Chunda-Liyoka C, Sakana L, Rutagwera D, Tassembedo S, Wilfred-Tonga MM, Mosqueira B, Tylleskär T, Nagot N, Van de Perre P. Design and challenges of a large HIV prevention clinical study on mother-to-child transmission: ANRS 12397 PROMISE-EPI study in Zambia and Burkina Faso. Contemp Clin Trials 2021; 105:106402. [PMID: 33872801 DOI: 10.1016/j.cct.2021.106402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
Post-natal HIV infection through breastfeeding remains a challenge in many low and middle-income countries, particularly due to non-availability of alternative infant feeding options and the suboptimal Prevention of Mother to Child Transmission of HIV-1 (PMTCT) cascade implementation and monitoring. The PROMISE-EPI study aims to address the latter by identifying HIV infected mothers during an almost never-missed visit for their infant, the second extended program on immunization visit at 6-8 weeks of age (EPI-2). The study is divided into 3 components inclusive of an open-label randomized controlled trial aiming to assess the efficacy of a responsive preventive intervention compared to routine intervention based on the national PMTCT guidelines for HIV-1 uninfected exposed breastfeeding infants. The preventive intervention includes: a) Point of care testing for early infant HIV diagnosis and maternal viral load; b) infant, single-drug Pre-Exposure Prophylaxis (PrEP) (lamivudine) if mothers are virally unsuppressed. The primary outcome is HIV-transmission rate from EPI-2 to 12 months. The study targets to screen 37,000 mother/infant pairs in Zambia and Burkina Faso to identify 2000 mother/infant pairs for the clinical trial. The study design and challenges faced during study implementation are described, including the COVID-19 pandemic and the amended HIV guidelines in Zambia in 2020 (triple-drug PrEP in HIV exposed infants guided by quarterly maternal viral load). The changes in the Zambian guidelines raised several questions including the equipoise of PrEP options, the standard of care-triple-drug (control arm in Zambia) versus the study-single-drug (intervention arm). Trial registration number (www.clinicaltrials.gov): NCT03869944. Submission category: Study Design, Statistical Design, Study Protocols.
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Affiliation(s)
- Anaïs Mennecier
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France.
| | - Chipepo Kankasa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Paulin Fao
- Centre MURAZ, Bobo-Dioulasso, Burkina Faso
| | - Jean-Pierre Moles
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Sabrina Eymard-Duvernay
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Mwiya Mwiya
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - David Rutagwera
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Beatriz Mosqueira
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | | | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
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The risk of infectious pathogens in breast-feeding, donated human milk and breast milk substitutes. Public Health Nutr 2020; 24:1725-1740. [PMID: 32539885 DOI: 10.1017/s1368980020000555] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This review collates the published reports that focus on microbial and viral illnesses that can be transmitted by breast milk, donor milk and powdered infant formula (PIF). In this context, we attempt to define a risk framework encompassing those hazards, exposure scenarios, vulnerability and protective factors. DESIGN A literature search was performed for reported cases of morbidity and mortality associated with different infant feeding modes. SETTING Exclusive breast-feeding is the recommended for infant feeding under 6 months, or failing that, provision of donated human milk. However, the use of PIF remains high despite its intrinsic and extrinsic risk of microbial contamination, as well as the potential for adverse physiological effects, including infant gut dysbiosis. RESULTS Viable pathogen transmission via breast-feeding or donor milk (pasteurised and unpasteurised) is rare. However, transmission of HIV and human T-cell lymphotropic virus-1 is a concern for breast-feeding mothers, particularly for mothers undertaking a mixed feeding mode (PIF and breast-feeding). In PIF, intrinsic and extrinsic microbial contamination, such as Cronobacter and Salmonella, remain significant identifiable causes of infant morbidity and mortality. CONCLUSIONS Disease transmission through breast-feeding or donor human milk is rare, most likely owing to its complex intrinsically protective composition of human milk and protection of the infant gut lining. Contamination of PIF and the morbidity associated with this is likely underappreciated in terms of community risk. A better system of safe donor milk sharing that also establishes security of supply for non-hospitalised healthy infants in need of breast milk would reduce the reliance on PIF.
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Abstract
Uvod: Tandemsko dojenje ali dojenje sorojencev je slabo poznan koncept. Matere, ki tandemsko dojijo, se srečujejo s socialno stigmo in slabo oporo s strani zdravstvenih strokovnjakov. Namen raziskave je bil proučiti znanje o tandemskem dojenju med študenti zdravstvenih ved.Metode: Uporabljen je bil kvantitativni eksplorativni neeksperimentalni raziskovalni dizajn. V priložnostni vzorec so bili vključeni študenti zdravstvene nege (n = 66) in dietetike (n = 24). Podatki so bili zbrani s strukturiranim vprašalnikom (Cronbach α = 0,914). Uporabljena je bila opisna statistika, test hi-kvadrat in analiza variance.Rezultati: Da je popolnoma fiziološko, da ženska prekine dojenje starejšega otroka, če rodi naslednjega otroka, meni 50,7 % (n = 36) žensk in 84,2 % (n = 16) moških (χ2 = 6,898, p = 0,009). Kaj je izključno dojenje v prvih šestih mesecih, ve 79,2 % (n = 19) študentov dietetike in le 54,5 % (n = 36) študentov zdravstvene nege (χ2 = 4,489, p = 0,034). Nepravilnost trditve, da dojenčki v primeru tandemskega dojenja težje pridobivajo telesno težo, je prepoznalo 86,3 % (n = 44) žensk in 13,7 % (n = 7) moških.Diskusija in zaključek: V raziskavo vključeni študentje so izkazali pomanjkljivo znanje tako o dojenju na splošno kakor tudi o tandemskem dojenju. V študijski program bi bilo treba vnesti več vsebin o dojenju.
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Maternal HIV-1 Env Vaccination for Systemic and Breast Milk Immunity To Prevent Oral SHIV Acquisition in Infant Macaques. mSphere 2018; 3:mSphere00505-17. [PMID: 29359183 PMCID: PMC5760748 DOI: 10.1128/msphere.00505-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/11/2017] [Indexed: 01/20/2023] Open
Abstract
Without novel strategies to prevent mother-to-child HIV-1 transmission, more than 5% of HIV-1-exposed infants will continue to acquire HIV-1, most through breastfeeding. This study of rhesus macaque dam-and-infant pairs is the first preclinical study to investigate the protective role of transplacentally transferred HIV-1 vaccine-elicited antibodies and HIV-1 vaccine-elicited breast milk antibody responses in infant oral virus acquisition. It revealed highly variable placental transfer of potentially protective antibodies and emphasized the importance of pregnancy immunization timing to reach peak antibody levels prior to delivery. While there was no discernible impact of maternal immunization on late infant oral virus acquisition, we observed a strong correlation between the percentage of activated CD4+ T cells in infant peripheral blood and a reduced number of challenges to infection. This finding highlights an important consideration for future studies evaluating alternative strategies to further reduce the vertical HIV-1 transmission risk. Mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) contributes to an estimated 150,000 new infections annually. Maternal vaccination has proven safe and effective at mitigating the impact of other neonatal pathogens and is one avenue toward generating the potentially protective immune responses necessary to inhibit HIV-1 infection of infants through breastfeeding. In the present study, we tested the efficacy of a maternal vaccine regimen consisting of a modified vaccinia virus Ankara (MVA) 1086.C gp120 prime-combined intramuscular-intranasal gp120 boost administered during pregnancy and postpartum to confer passive protection on infant rhesus macaques against weekly oral exposure to subtype C simian-human immunodeficiency virus 1157ipd3N4 (SHIV1157ipd3N4) starting 6 weeks after birth. Despite eliciting a robust systemic envelope (Env)-specific IgG response, as well as durable milk IgA responses, the maternal vaccine did not have a discernible impact on infant oral SHIV acquisition. This study revealed considerable variation in vaccine-elicited IgG placental transfer and a swift decline of both Env-specific antibodies (Abs) and functional Ab responses in the infants prior to the first challenge, illustrating the importance of pregnancy immunization timing to elicit optimal systemic Ab levels at birth. Interestingly, the strongest correlation to the number of challenges required to infect the infants was the percentage of activated CD4+ T cells in the infant peripheral blood at the time of the first challenge. These findings suggest that, in addition to maternal immunization, interventions that limit the activation of target cells that contribute to susceptibility to oral HIV-1 acquisition independently of vaccination may be required to reduce infant HIV-1 acquisition via breastfeeding. IMPORTANCE Without novel strategies to prevent mother-to-child HIV-1 transmission, more than 5% of HIV-1-exposed infants will continue to acquire HIV-1, most through breastfeeding. This study of rhesus macaque dam-and-infant pairs is the first preclinical study to investigate the protective role of transplacentally transferred HIV-1 vaccine-elicited antibodies and HIV-1 vaccine-elicited breast milk antibody responses in infant oral virus acquisition. It revealed highly variable placental transfer of potentially protective antibodies and emphasized the importance of pregnancy immunization timing to reach peak antibody levels prior to delivery. While there was no discernible impact of maternal immunization on late infant oral virus acquisition, we observed a strong correlation between the percentage of activated CD4+ T cells in infant peripheral blood and a reduced number of challenges to infection. This finding highlights an important consideration for future studies evaluating alternative strategies to further reduce the vertical HIV-1 transmission risk.
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Shen R, Achenbach J, Shen Y, Palaia J, Rahkola JT, Nick HJ, Smythies LE, McConnell M, Fowler MG, Smith PD, Janoff EN. Mother-to-Child HIV-1 Transmission Events Are Differentially Impacted by Breast Milk and Its Components from HIV-1-Infected Women. PLoS One 2015; 10:e0145150. [PMID: 26680219 PMCID: PMC4683070 DOI: 10.1371/journal.pone.0145150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/01/2015] [Indexed: 11/21/2022] Open
Abstract
Breast milk is a vehicle of infection and source of protection in post-natal mother-to-child HIV-1 transmission (MTCT). Understanding the mechanism by which breast milk limits vertical transmission will provide critical insight into the design of preventive and therapeutic approaches to interrupt HIV-1 mucosal transmission. However, characterization of the inhibitory activity of breast milk in human intestinal mucosa, the portal of entry in postnatal MTCT, has been constrained by the limited availability of primary mucosal target cells and tissues to recapitulate mucosal transmission ex vivo. Here, we characterized the impact of skimmed breast milk, breast milk antibodies (Igs) and non-Ig components from HIV-1-infected Ugandan women on the major events of HIV-1 mucosal transmission using primary human intestinal cells and tissues. HIV-1-specific IgG antibodies and non-Ig components in breast milk inhibited the uptake of Ugandan HIV-1 isolates by primary human intestinal epithelial cells, viral replication in and transport of HIV-1- bearing dendritic cells through the human intestinal mucosa. Breast milk HIV-1-specific IgG and IgA, as well as innate factors, blocked the uptake and transport of HIV-1 through intestinal mucosa. Thus, breast milk components have distinct and complementary effects in reducing HIV-1 uptake, transport through and replication in the intestinal mucosa and, therefore, likely contribute to preventing postnatal HIV-1 transmission. Our data suggests that a successful preventive or therapeutic approach would require multiple immune factors acting at multiple steps in the HIV-1 mucosal transmission process.
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Affiliation(s)
- Ruizhong Shen
- Department of Medicine (Division of Gastroenterology), University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail: (ENJ); (RS)
| | - Jenna Achenbach
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, United States of America
| | - Yue Shen
- Department of Biological Sciences, Auburn University, Auburn, Alabama United States of America
| | - Jana Palaia
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, United States of America
| | - Jeremy T. Rahkola
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, United States of America
- Denver Veterans Affairs Medical Center, Denver, Colorado, United States of America
| | - Heidi J. Nick
- Department of Medicine (Division of Gastroenterology), University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Lesley E. Smythies
- Department of Medicine (Division of Gastroenterology), University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Michelle McConnell
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Mary G. Fowler
- The Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Phillip D. Smith
- Department of Medicine (Division of Gastroenterology), University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Veterans Affairs Medical Center, Birmingham, Alabama, United States of America
| | - Edward N. Janoff
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, United States of America
- Denver Veterans Affairs Medical Center, Denver, Colorado, United States of America
- * E-mail: (ENJ); (RS)
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Shen R, Smith PD. Mucosal correlates of protection in HIV-1-exposed sero-negative persons. Am J Reprod Immunol 2014; 72:219-27. [PMID: 24428610 DOI: 10.1111/aji.12202] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/17/2013] [Indexed: 01/31/2023] Open
Abstract
Resistance to HIV-1 infection in HIV-1-exposed sero-negative (HESN) persons offers a promising opportunity to identify mechanisms of 'natural' protection. Unique features of the mucosa in particular may contribute to this protection. Here, we highlight several key issues pertaining to the mucosal correlates of protection in HESN persons, including humoral immune responses, mechanisms of mucosal HIV-1 neutralization, immune cell activation, and role of the microbiota in mucosal responses. We also discuss mucosal model systems that can be used to investigate the mechanisms of resistance in HESN subjects. A clear understanding of the mucosal correlates of protection against HIV-1 in HESN persons will provide critical new insights for the development of effective vaccine and microbicide strategies for the prevention of HIV-1 transmission.
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Affiliation(s)
- Ruizhong Shen
- Department of Medicine (Gastroenterology), University of Alabama at Birmingham, Birmingham, AL, USA
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Feasibility and safety of ALVAC-HIV vCP1521 vaccine in HIV-exposed infants in Uganda: results from the first HIV vaccine trial in infants in Africa. J Acquir Immune Defic Syndr 2013; 63:1-8. [PMID: 23221981 DOI: 10.1097/qai.0b013e31827f1c2d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The development of a safe and effective vaccine against HIV type 1 for the prevention of mother-to-child transmission of HIV would significantly advance the goal of eliminating HIV infection in children. Safety and feasibility results from phase 1, randomized, double-blind, placebo-controlled trial of ALVAC-HIV vCP1521 in infants born to HIV type 1-infected women in Uganda are reported. METHODS HIV-exposed infants were enrolled at birth and randomized (4:1) to receive vaccine or saline placebo intramuscular injections at birth, 4, 8, and 12 weeks of age. Vaccine reactogenicity was assessed at vaccination and days 1 and 2 postvaccination. Infants were followed until 24 months of age. HIV infection status was determined by HIV DNA polymerase chain reaction. RESULTS From October 2006 to May 2007, 60 infants (48 vaccine and 12 placebo) were enrolled with 98% retention at 24 months. One infant was withdrawn, but there were no missed visits or vaccinations among the 59 infants retained. Immune responses elicited by diphtheria, polio, hepatitis B, haemophilus influenzae type B, and measles vaccination were similar in the 2 arms. The vaccine was well tolerated with no severe or life-threatening reactogenicity events. Adverse events were equally distributed across both study arms. Four infants were diagnosed as HIV infected [3 at birth (2 vaccine and 1 placebo) and 1 in vaccine arm at 2 weeks of age]. CONCLUSION The ALVAC-HIV vCP1521 vaccination was feasible and safe in infants born to HIV-infected women in Uganda. The conduct of high-quality infant HIV vaccine trials is achievable in Africa.
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Natchu UCM, Liu E, Duggan C, Msamanga G, Peterson K, Aboud S, Spiegelman D, Fawzi WW. Exclusive breastfeeding reduces risk of mortality in infants up to 6 mo of age born to HIV-positive Tanzanian women. Am J Clin Nutr 2012; 96:1071-8. [PMID: 23053555 PMCID: PMC3471196 DOI: 10.3945/ajcn.111.024356] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite the benefits of exclusive breastfeeding (EBF), exposure to HIV from breast milk has relegated EBF to an option only when formula feeding is not affordable, feasible, safe, and sustainable. Mixed feeding remains the norm in sub-Saharan Africa. OBJECTIVE We evaluated whether the duration of EBF was associated with mortality and HIV infection in children followed to ≤5 y of age. METHODS A total of 690 mother-infant pairs from the Trial of Vitamins with information on infant feeding, HIV status, and at least one visit in the first year were included in the analysis. The duration of EBF was defined in months as a time-varying covariate at each follow-up visit. Associations of the duration of EBF with mortality, HIV infection, and HIV infection or death were estimated by using Cox proportional hazards models and Kaplan-Meier survival curves. RESULTS A 1-mo increase in EBF was associated with a 49% reduction in early infant mortality in the first 6 mo of life (RR: 0.51; 95% CI: 0.28, 0.93) and a nonsignificant 15% reduction in risk of HIV infection or death (RR: 0.85; 95% CI: 0.71, 1.01; P = 0.07) over the first 5 y of life. EBF was not associated with HIV infection (RR: 0.93; 95% CI: 0.76, 1.15). CONCLUSION Longer EBF by HIV-positive mothers was associated with reduced mortality in the first 6 mo of life without increased HIV infection, which makes EBF the best option for women who cannot sustain exclusive formula feeding. This trial was registered at clinicaltrials.gov as NCT00197743.
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Affiliation(s)
- Uma Chandra Mouli Natchu
- Department of Nutrition, Harvard School of Public Health, 655 Huntington Avenue, Building II Room 329A, Boston, MA 02115, USA.
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The human milk microbiota: origin and potential roles in health and disease. Pharmacol Res 2012; 69:1-10. [PMID: 22974824 DOI: 10.1016/j.phrs.2012.09.001] [Citation(s) in RCA: 489] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/23/2012] [Accepted: 09/01/2012] [Indexed: 12/18/2022]
Abstract
Human milk has been traditionally considered sterile; however, recent studies have shown that it represents a continuous supply of commensal, mutualistic and/or potentially probiotic bacteria to the infant gut. Culture-dependent and -independent techniques have revealed the dominance of staphylococci, streptococci, lactic acid bacteria and bifidobacteria in this biological fluid, and their role on the colonization of the infant gut. These bacteria could protect the infant against infections and contribute to the maturation of the immune system, among other functions. Different studies suggest that some bacteria present in the maternal gut could reach the mammary gland during late pregnancy and lactation through a mechanism involving gut monocytes. Thus, modulation of maternal gut microbiota during pregnancy and lactation could have a direct effect on infant health. On the other hand, mammary dysbiosis may lead to mastitis, a condition that represents the first medical cause for undesired weaning. Selected strains isolated from breast milk can be good candidates for use as probiotics. In this review, their potential uses for the treatment of mastitis and to inhibit mother-to-infant transfer of HIV are discussed.
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Rossenkhan R, Novitsky V, Sebunya TK, Leidner J, Hagan JE, Moyo S, Smeaton L, Lockman S, Musonda R, Ndung'u T, Gaseitsiwe S, Thior I, Mmalane M, Makhema J, Essex M, Shapiro R. Infant feeding practices were not associated with breast milk HIV-1 RNA levels in a randomized clinical trial in Botswana. AIDS Behav 2012; 16:1260-4. [PMID: 21901486 DOI: 10.1007/s10461-011-0035-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Exclusive breastfeeding has been associated with a reduced risk of late vertical HIV transmission as compared to an infant diet composed of breast milk mixed with supplemental foods or liquids. Hypothesized mechanisms include increased infectivity of breast milk from mothers who practice mixed breastfeeding (MBF), or mechanisms such as increased gastrointestinal permeability in the infant caused by mixed feeding. It has been proposed that MBF may result in subclinical mastitis and higher breast milk HIV titers. However, little is known about the relationship between feeding strategy and breast milk viral load. We measured the HIV-1 concentration in breast milk in a sub-cohort of women enrolled in a mother-to-child HIV transmission prevention trial (the "Mashi" study). We report no observed relationship between MBF and measured breast milk viral RNA load. Our findings suggest that the increased transmission risk associated with higher breast milk HIV-1 RNA during MBF is unlikely.
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Mother's CD4+ count moderates the risk associated with higher parity for late postnatal HIV-free survival of breastfed children: an individual patient data meta-analysis of randomized controlled trials. AIDS Behav 2012; 16:79-85. [PMID: 21739289 DOI: 10.1007/s10461-011-9989-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Risk association studies of late postnatal outcomes for children breastfed by HIV-1 positive mothers have had inconsistent findings and have not explored interactions among risk factors. This study addresses these limitations through an individual patient data (IPD) meta-analysis of HIV-free survival outcomes of nine randomized controlled trials to prevent early mother-to-child transmission of HIV-1. The pooled sample consisted of 3,324 African children in resource-limited settings who survived to age 28 days and were at-risk of acquiring HIV through breast milk. Based on a proportional hazards mixed effects meta-analysis, the composite endpoint of HIV-1 infection and all-cause mortality was found to be significantly associated with maternal immune status (CD4(+) ≥350 cells/mm(3), HR 0.59 95% CI (0.39, 0.87)), infant preterm delivery (gestational age <37 weeks, 1.40 (1.03, 1.89)), infant oral candidiasis infection (1.87, (1.53, 2.29)), and occurrence of breast abnormality before breastfeeding cessation (2.56 (1.90, 3.46)). A significant interaction between mother's parity (any previous pregnancy) and CD4(+) count ≥350 (HR 0.63 (0.40, 0.99), P-value = 0.045) suggested that higher CD4(+) count offsets the risk associated with higher parity. Further research is needed to elucidate the moderating effect of immune status on the risk associated with high parity and adverse late postnatal outcomes for infants breastfed by HIV-infected mothers in the absence of antiretroviral treatment.
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Semrau K, Kuhn L, Brooks DR, Cabral H, Sinkala M, Kankasa C, Thea DM, Aldrovandi GM. Exclusive breastfeeding, maternal HIV disease, and the risk of clinical breast pathology in HIV-infected, breastfeeding women. Am J Obstet Gynecol 2011; 205:344.e1-8. [PMID: 21784403 DOI: 10.1016/j.ajog.2011.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 03/07/2011] [Accepted: 06/06/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of the study was to examine the relationship between breastfeeding patterns, markers of maternal human immunodeficiency virus (HIV) disease, and woman's breast pathology. STUDY DESIGN Secondary data analysis from a randomized breastfeeding trial including 947 HIV-infected women (n = 5982 visits) from breastfeeding initiation until 6 months postpartum; 1 month after breastfeeding cessation; or loss to follow-up or death. Generalized estimating equations assessed the effects of breastfeeding pattern and maternal HIV status on breast pathology. RESULTS One hundred ninety women (20.1%) had a breast problem; 86 (9.1%) had mastitis; and 31 (3.3%) had abscess. After confounder adjustment, nonexclusively breastfeeding women had an increased risk of breast problems (odds ratio, 1.98; 95% confidence interval, 1.33-2.95) and mastitis (odds ratio, 2.87, 95% confidence interval, 1.69-4.88) compared with exclusive breastfeeders. Women with a CD4 count less than 200 cells/μL tended to have an increased risk of abscess. CONCLUSION Nonexclusive breastfeeding significantly increased the risk of breast pathology. Exclusive breastfeeding is not only optimal for infant health but it also benefits mothers by reducing breast problems.
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Mouse mammary tumor like virus sequences in breast milk from healthy lactating women. Breast Cancer Res Treat 2011; 129:149-55. [PMID: 21365265 DOI: 10.1007/s10549-011-1421-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 02/21/2011] [Indexed: 10/18/2022]
Abstract
Mouse mammary tumor virus (MMTV) has been a long standing candidate as a potential cause of some human breast cancers. Forty years ago, electron microscopic images of MMTV-like particles were identified in milk from 5% of healthy lactating women. These observations, however, have not been confirmed by modern methods. The purpose of this study was to confirm the presence of MMTV-like DNA sequences in human milk from normal lactating women. Standard and in situ PCR analyses were conducted on DNA extracted from fresh breast milk samples collected from a group of 91 healthy lactating women volunteers. The MMTV-like viral positive PCR products were sequenced and a phylogenetic tree was constructed to compare these sequences. Immunohistochemistry analyses were performed on breast milk cells using polyclonal rabbit antibodies against affinity-purified MMTV envelope glycoproteins 52/36. MMTV-like envelope gene sequences were identified by PCR in 5% (4/91) of breast milk samples from healthy lactating women volunteers. These observations were confirmed by in situ PCR and immunohistochemistry using MMTV gp52/36 antibodies. These findings confirm the presence of MMTV-like gene sequences in human milk. As MMTV is transmitted via milk from mouse mothers to their newborn pups to cause mammary tumors when they become adults, this indicates a means of transmission of this virus in humans.
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Nlend AEN, Ekani BB. Preliminary assessment of breastfeeding practices in HIV 1-infected mothers (prior to weaning) under the Djoungolo programme on the prevention of mother-to-child transmission of HIV. J Trop Pediatr 2010; 56:436-9. [PMID: 20332220 DOI: 10.1093/tropej/fmq018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Human Immunodeficiency virus (HIV) transmission in a breastfeeding population varies from 20% to 45%. OBJECTIVE To evaluate breastfeeding practices and the early basic HIV transmission rate in HIV-exposed children in the Djoungolo health district (prevention of mother-to-child transmission HIV programme). METHODS A cross-sectional survey was conducted, targeting breastfeeding mothers recruited from an observational cohort of HIV-positive pregnant women intending to breastfeed. Routine immunological assessment was carried out for all pregnant HIV-positive women coupled with initiation to highly active anti-retroviral therapy (HAART) in those with CD4 cell counts below 350 mm(-3). Early virological diagnosis of HIV infection was done using real-time Polymerase Chain reaction (PCR) RNA for infants aged between 6 weeks and 6 months. Breastfeeding intervention and counselling support were also provided to respondents. RESULTS Out of 545 women, 287 births were registered of which 64 of the HIV-infected mothers opted for breastfeeding. The mean CD4 cell count was 446 mm(-3); 34.4% of women were taking HAART. The rate of initiation to breastfeeding was observed to be 53% within 1 h following delivery. At 13 weeks, 96.1% were still exclusively breastfeeding on demand with an average of six feedings in the daytime and three feedings during the night. Of the mothers, 18.5% reported at least one episode of breast and/or nipple pain and 4.9% of mothers were practicing mixed feeding. The early rate of HIV transmission among 47 infants assessed was observed to be 4.3% [95% confidence interval 1-10.1]. CONCLUSION In an HIV context, routine breastfeeding intervention support associated with access to anti-retroviral therapy for women yet requiring treatment for themselves reduces the practice of mixed feeding and slashes the early mother-to-child HIV transmission rate to 4.3% in breastfeeding populations.
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Abstract
Mother-to-child transmission of hepatitis B virus (HBV) is among the most important causes of chronic HBV infection and is the commonest mode of transmission worldwide. Currently, the presence of HBsAg, HBeAg and HBV DNA in breast milk is confirmed. Several studies have reported that breastfeeding carries no additional risk that might lead to vertical transmission. Beyond some limitations, the surveys have not demonstrated any differences in HBV transmission rate regarding feeding practices in early childhood. Promotion of breastfeeding is substantial, especially for low-income individuals and regions with uncertain, unfeasible, and unsafe water supplies. Lactoferrin, minimal inflammation or activation within the infant gut during exclusive breastfeeding, and nonspecific biological molecules in the milk are identified as major factors of breast-milk defense. This review discusses preemptive antiviral therapy during pregnancy and lactation. Long-term follow up of breast-milk HBV concentrations and correlation with serum viral load; nucleos(t)ide analogue concentrations in breast milk in HBV-positive mothers in the setting of chronic HBV infection; safety of antiviral therapy during pregnancy and lactation; and the difference in viral load in the milk in exclusive or non-exclusive breastfeeding are still open questions. The paper reviews the current data and outlines the course of further investigation into this often underestimated issue.
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Kuhn L. Milk mysteries: Why are women who exclusively breast-feed less likely to transmit HIV during breast-feeding? Clin Infect Dis 2010; 50:770-2. [PMID: 20121425 DOI: 10.1086/650536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, Department of Epidemiology, Columbia University, New York, New York 10032, USA.
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Maru S, Datong P, Selleng D, Mang E, Inyang B, Ajene A, Guyit R, Charurat M, Abimiku A. Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria. AIDS Care 2010; 21:1114-23. [PMID: 20024770 DOI: 10.1080/09540120802705842] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Mixed feeding confers excess risk of mother-to-child transmission (MTCT) of HIV compared with exclusive breastfeeding and exclusive formula feeding. We undertook a qualitative and quantitative cross-sectional survey to identify the social determinants of mixed feeding among a subset of the 469 HIV-infected women enrolled in a MTCT prevention program in Jos, Nigeria. Formula was provided free-of-cost. Of the 91 participants, 68 (75%) exclusively formula fed, 7 (8%) exclusively breastfed, and 16 (18%) practiced mixed feeding. Of the mixed feeding women, seven primarily formula fed and nine primarily breastfed. Women who primarily formula fed described family pressure as the reason for mixed feeding, while women who primarily breastfed reported insufficient breast milk. In a multivariate analysis, lack of partner support of the feeding decision predicted mixed feeding behavior (OR: 4.2; 95% CI: 1.2-14.9; p=0.03). Disclosure of HIV status was significantly correlated (p<0.001) with partner support. HIV prevention interventions aimed at reducing mixed feeding should encourage supportive partner relationships that facilitate disclosure of HIV status. Attention should also be made to the differing pressures faced by women attempting to exclusively breast feed and exclusively formula feed.
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Affiliation(s)
- Sheela Maru
- Yale University School of Medicine, New Haven, CT, USA
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Kuhn L, Sinkala M, Thea DM, Kankasa C, Aldrovandi GM. HIV prevention is not enough: child survival in the context of prevention of mother to child HIV transmission. J Int AIDS Soc 2009; 12:36. [PMID: 20015345 PMCID: PMC2796993 DOI: 10.1186/1758-2652-12-36] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 12/11/2009] [Indexed: 11/10/2022] Open
Abstract
Clinical and epidemiologic research has identified increasingly effective interventions to reduce mother to child HIV transmission in resource-limited settings These scientific breakthroughs have been implemented in some programmes, although much remains to be done to improve coverage and quality of these programmes. But prevention of HIV transmission is not enough. It is necessary also to consider ways to improve maternal health and protect child survival. A win-win approach is to ensure that all pregnant and lactating women with CD4 counts of <350 cells/mm3 have access to antiretroviral therapy. On its own, this approach will substantially improve maternal health and markedly reduce mother to child HIV transmission during pregnancy and delivery and through breastfeeding. This approach can be combined with additional interventions for women with higher CD4 counts, either extended prophylaxis to infants or extended regimens of antiretroviral drugs to women, to reduce transmission even further. Attempts to encourage women to abstain from all breastfeeding or to shorten the optimal duration of breastfeeding have led to increases in mortality among both uninfected and infected children. A better approach is to support breastfeeding while strengthening programmes to provide antiretroviral therapy for pregnant and lactating women who need it and offering antiretroviral drug interventions through the duration of breastfeeding. This will lead to reduced HIV transmission and will protect the health of women without compromising the health and well-being of infants and young children.
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Affiliation(s)
- Louise Kuhn
- Gertrude H, Sergievsky Center, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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Abstract
New studies of breastfeeding have discovered or confirmed the benefits to mother and child. They reinforce an emphasis on exclusive breastfeeding - no other food or fluids - during the first 6 months. Studies include findings from across the world, in well-resourced and poorly resourced settings. They also emphasize longer duration of breastfeeding, into the second year of life, and gradual rather than abrupt weaning. For HIV-infected mothers, the dangers of non-exclusive feeding in the first half year of life have been well documented in recent publications. Other studies open up the possibilities for antiretroviral treatment to accompany breastfeeding, whether given to the mother, or child, or both. To be effective, implementation of any recommendations must consider individual, family, and community resources.
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Minnie KS, van der Walt SJC, Klopper HC. A systematic review of counselling for HIV testing of pregnant women. J Clin Nurs 2009; 18:1827-41. [DOI: 10.1111/j.1365-2702.2009.02805.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW In developing countries where replacement feeding is generally not feasible or safe, hundreds of thousands of infants acquire HIV infection during breastfeeding. Data from recently completed studies provide insight into the safety and hazards of different feeding approaches as well as the use of antiretroviral therapy to prevent postnatal transmission. RECENT FINDINGS Several studies confirm that the benefits of avoiding or shortening breastfeeding are offset by adverse outcomes in those infants who escape infection. Reductions in HIV transmission achieved with either formula feeding or early weaning are counterbalanced by increases in uninfected child mortality resulting in no net benefit for HIV-free survival. However, exclusive breastfeeding is associated with a significant decrease in HIV transmission risk. Antiretroviral treatment during breastfeeding to the mother or her infant appears to reduce the risk of postnatal transmission. Studies evaluating daily nevirapine to the breastfeeding infant suggest protection during the period of treatment. Similarly, infants born to breastfeeding women receiving antiretroviral therapy are at lower risk of acquiring HIV. SUMMARY While awaiting further studies defining optimal approaches to preventing HIV transmission during breastfeeding, promoting exclusive breastfeeding and assuring antiretroviral treatment for women with advanced HIV disease will likely prevent the majority of needless maternal and infant deaths.
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25
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Tournoud M, Ecochard R, Kuhn L, Coutsoudis A. Diversity of risk of mother-to-child HIV-1 transmission according to feeding practices, CD4 cell count, and haemoglobin concentration in a South African cohort. Trop Med Int Health 2008; 13:310-8. [DOI: 10.1111/j.1365-3156.2008.02004.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Petrovic K, Maimbolwa M, Johansson E. Primiparous mothers' knowledge about mother-to-child transmission of HIV in Lusaka, Zambia. Midwifery 2007; 25:e1-e10. [PMID: 18164791 DOI: 10.1016/j.midw.2007.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 06/08/2007] [Accepted: 08/20/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE to learn what primiparous mothers in Lusaka, Zambia know about human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), mother-to-child transmission (MTCT) of HIV, and breast feeding. DESIGN qualitative interviews analysed by thematic manifest content analysis. SETTING postnatal wards at Lusaka University Teaching Hospital. PARTICIPANTS 14 primiparous mothers were interviewed. FINDINGS 1 year after implementation of the prevention of MTCT programme in Zambia, the majority of the women interviewed lacked basic knowledge about MTCT. They did not know that HIV is present in breast milk and that it is a source of transmission. Few mothers had been informed about breast feeding, correct attachment and ways of avoiding breast infection. The mothers seemed to be uncertain about what HIV actually is, and they preferred to talk about MTCT and safe breast feeding rather than HIV/AIDS in general, which was the main reason for their participation in the study. According to the mothers, the most effective way of preventing transmission of HIV to the unborn baby was a single dose of nevirapine. Many believed that treatment is equal to cure and gives the baby full protection. The overall feeling of mothers was that they had not received information and support from the antenatal clinics and postnatal wards. The more traditional women preferred not to discuss these issues with their friends, their husbands or their families, which may make it more difficult to spread information and encourage couples to make decisions about their and their baby's future. CONCLUSION these findings suggest that primiparous mothers and their families need more education about MTCT of HIV. The mothers also need basic education about breast feeding and how to avoid breast injuries. The main reason for mothers' poor knowledge may be that health workers do not have the necessary information. There seems to be a need for training in breast-feeding and baby-feeding counselling in the context of HIV in order to promote exclusive and safe breast feeding. As such, further research about health workers' knowledge and methods of teaching is required.
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Affiliation(s)
- Karin Petrovic
- International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
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Kuhn L, Sinkala M, Kankasa C, Semrau K, Kasonde P, Scott N, Mwiya M, Vwalika C, Walter J, Tsai WY, Aldrovandi GM, Thea DM. High uptake of exclusive breastfeeding and reduced early post-natal HIV transmission. PLoS One 2007; 2:e1363. [PMID: 18159246 PMCID: PMC2137948 DOI: 10.1371/journal.pone.0001363] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 10/23/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Empirical data showing the clear benefits of exclusive breastfeeding (EBF) for HIV prevention are needed to encourage implementation of lactation support programs for HIV-infected women in low resource settings among whom replacement feeding is unsafe. We conducted a prospective, observational study in Lusaka, Zambia, to test the hypothesis that EBF is associated with a lower risk of postnatal HIV transmission than non-EBF. METHODS AND RESULTS As part of a randomized trial of early weaning, 958 HIV-infected women and their infants were recruited and all were encouraged to breastfeed exclusively to 4 months. Single-dose nevirapine was provided to prevent transmission. Regular samples were collected from infants to 24 months of age and tested by PCR. Detailed measurements of actual feeding behaviors were collected to examine, in an observational analysis, associations between feeding practices and postnatal HIV transmission. Uptake of EBF was high with 84% of women reporting only EBF cumulatively to 4 months. Post-natal HIV transmission before 4 months was significantly lower (p = 0.004) among EBF (0.040 95% CI: 0.024-0.055) than non-EBF infants (0.102 95% CI: 0.047-0.157); time-dependent Relative Hazard (RH) of transmission due to non-EBF = 3.48 (95% CI: 1.71-7.08). There were no significant differences in the severity of disease between EBF and non-EBF mothers and the association remained significant (RH = 2.68 95% CI: 1.28-5.62) after adjusting for maternal CD4 count, plasma viral load, syphilis screening results and low birth weight. CONCLUSIONS Non-EBF more than doubles the risk of early postnatal HIV transmission. Programs to support EBF should be expanded universally in low resource settings. EBF is an affordable, feasible, acceptable, safe and sustainable practice that also reduces HIV transmission providing HIV-infected women with a means to protect their children's lives. TRIAL REGISTRATION ClinicalTrials.gov NCT00310726.
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Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
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Kourtis AP, Jamieson DJ, de Vincenzi I, Taylor A, Thigpen MC, Dao H, Farley T, Fowler MG. Prevention of human immunodeficiency virus-1 transmission to the infant through breastfeeding: new developments. Am J Obstet Gynecol 2007; 197:S113-22. [PMID: 17825642 DOI: 10.1016/j.ajog.2007.03.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 02/12/2007] [Accepted: 03/01/2007] [Indexed: 11/22/2022]
Abstract
Breastfeeding accounts for up to half of all infant human immunodeficiency virus (HIV) infections worldwide and carries an estimated transmission risk of about 15% when continued into the second year of life. Because replacement feeding is not safely available, culturally acceptable, or affordable in many parts of the world and because breastfeeding provides protection against other causes of infant mortality, approaches that reduce breastfeeding mother-to child transmission of HIV are being explored. These include exclusive breastfeeding for the infant's first few months of life followed by rapid weaning, treatments of expressed milk to inactivate the virus, and antiretroviral prophylaxis taken by the infant or mother during breastfeeding, which are strategies currently being tested in clinical trials. Passive (antibodies) and active (vaccine) immunoprophylaxis will also soon begin to be tested. This paper focuses on current and planned research on strategies to prevent breastfeeding transmission of HIV.
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Affiliation(s)
- Athena P Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Abstract
Breastfeeding, particularly for the first 6 months of life, is unquestionably the ideal way to feed most infants. However, the human immunodeficiency virus (HIV) pandemic has caused debate and confusion about the best way for HIV-positive mothers to feed their children. This review provides recent key findings and opinions around making breastfeeding safer for HIV-positive women, and argues for preservation of breastfeeding, as opposed to complete avoidance of breastfeeding for all HIV-positive women.
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Affiliation(s)
- H M Coovadia
- Centre for HIV/AIDS Networking, University of KwaZulu-Natal, Durban, South Africa.
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Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 2007; 369:1107-16. [PMID: 17398310 DOI: 10.1016/s0140-6736(07)60283-9] [Citation(s) in RCA: 426] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Exclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding. METHODS 2722 HIV-infected and uninfected pregnant women attending antenatal clinics in KwaZulu Natal, South Africa (seven rural, one semiurban, and one urban), were enrolled into a non-randomised intervention cohort study. Infant feeding data were obtained every week from mothers, and blood samples from infants were taken monthly at clinics to establish HIV infection status. Kaplan-Meier analyses conditional on exclusive breastfeeding were used to estimate transmission risks at 6 weeks and 22 weeks of age, and Cox's proportional hazard was used to quantify associations with maternal and infant factors. FINDINGS 1132 of 1372 (83%) infants born to HIV-infected mothers initiated exclusive breastfeeding from birth. Of 1276 infants with complete feeding data, median duration of cumulative exclusive breastfeeding was 159 days (first quartile [Q1] to third quartile [Q3], 122-174 days). 14.1% (95% CI 12.0-16.4) of exclusively breastfed infants were infected with HIV-1 by age 6 weeks and 19.5% (17.0-22.4) by 6 months; risk was significantly associated with maternal CD4-cell counts below 200 cells per muL (adjusted hazard ratio [HR] 3.79; 2.35-6.12) and birthweight less than 2500 g (1.81, 1.07-3.06). Kaplan-Meier estimated risk of acquisition of infection at 6 months of age was 4.04% (2.29-5.76). Breastfed infants who also received solids were significantly more likely to acquire infection than were exclusively breastfed children (HR 10.87, 1.51-78.00, p=0.018), as were infants who at 12 weeks received both breastmilk and formula milk (1.82, 0.98-3.36, p=0.057). Cumulative 3-month mortality in exclusively breastfed infants was 6.1% (4.74-7.92) versus 15.1% (7.63-28.73) in infants given replacement feeds (HR 2.06, 1.00-4.27, p=0.051). INTERPRETATION The association between mixed breastfeeding and increased HIV transmission risk, together with evidence that exclusive breastfeeding can be successfully supported in HIV-infected women, warrant revision of the present UNICEF, WHO, and UNAIDS infant feeding guidelines.
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Affiliation(s)
- Hoosen M Coovadia
- Centre for HIV/AIDS Networking, University of KwaZulu-Natal, South Africa
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31
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Hartmann SU, Berlin CM, Howett MK. Alternative modified infant-feeding practices to prevent postnatal transmission of human immunodeficiency virus type 1 through breast milk: past, present, and future. J Hum Lact 2006; 22:75-88; quiz 89-93. [PMID: 16467289 DOI: 10.1177/0890334405280650] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preventing mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) through breastfeeding is important to reduce the number of infected children. Research on making breastfeeding safer is a high priority. The authors reviewed the attempts to develop alternative methods, other than antiretroviral (ARV) therapy of mothers and/or babies, to decontaminate breast milk of infectious HIV-1 (free and associated with lymphocytes). They also review how these methods affect milk constituents, as well as their current and prospective status. A PubMed search for English publications on methods to prevent MTCT through breast milk was completed. Methods that have been tested, other than systemicuse or ARV or immunoprophylaxis, to reduce or prevent MTCT of HIV-1 through breast milk were broadly classified into 5 groups: (1) modified feeding practices, (2) heat treatment of milk, (3) lipolysis, (4) antimicrobial treatment of the breastfeeding mother, and (5) microbicidal treatment of infected milk. Their advantages and disadvantages are discussed, as well as future directions in the prevention of MTCT through breastfeeding.
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Affiliation(s)
- Sandra Urdaneta Hartmann
- Department of Microbiology and Immunology, Pennsylvania State University, College of Medicine, USA
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Thea DM, Vwalika C, Kasonde P, Kankasa C, Sinkala M, Semrau K, Shutes E, Ayash C, Tsai WY, Aldrovandi G, Kuhn L. Issues in the design of a clinical trial with a behavioral intervention--the Zambia exclusive breast-feeding study. ACTA ACUST UNITED AC 2004; 25:353-65. [PMID: 15296810 DOI: 10.1016/j.cct.2004.06.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2004] [Accepted: 06/04/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE We present the rationale and design of the Zambian Exclusive Breast-feeding Study (ZEBS), a randomized trial evaluating the efficacy of short-duration exclusive breast-feeding (EBF) as a strategy to reduce postnatal human immunodeficiency virus (HIV) transmission while preserving the other health benefits of this important mode of infant feeding. METHODS One thousand two hundred HIV-positive pregnant women were recruited in Lusaka, Zambia, and followed with their infants for 24 months. In addition to Nevirapine (NVP), all women received intensive and frequent clinic- and home-based counseling to support exclusive breast-feeding. When the infant was 1 week of age, half of the women were randomly assigned to a group encouraged to abruptly (<24 h) cease all breast-feeding at 4 months. The primary outcome of the experimental (randomized) comparison is HIV-free survival at 24 months. The design is also observational and will compare HIV transmission rates between those who do and do not adhere to the counseling intervention promoting exclusive breast-feeding. CONCLUSION Our study aims to quantify the benefit-risk ratio of early cessation of exclusive breast-feeding to interrupt mother-to-child transmission of HIV with an intensive behavioral intervention and has both observational and experimental analytic approaches. Our study design assesses efficacy and also has a prominent applied component that if the intervention is effective, it will permit rapid and sustainable adoption within low-resource communities.
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Affiliation(s)
- Donald M Thea
- Center for International Health and Development, Boston University School of Public Health, 710 Albany Street, 715, Boston, MA 02118, USA.
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Ross JS, Labbok MH. Modeling the effects of different infant feeding strategies on infant survival and mother-to-child transmission of HIV. Am J Public Health 2004; 94:1174-80. [PMID: 15226139 PMCID: PMC1448417 DOI: 10.2105/ajph.94.7.1174] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We investigated how, under various conditions, the risk of mother-to-child transmission of HIV through breastfeeding compares with the risk of death from artificial feeding. METHODS We developed a spreadsheet simulation model to predict HIV-free survival during 7 age intervals from 0 to 24 months for 5 different infant feeding scenarios in resource-poor settings. RESULTS Compared with artificial feeding, breastfeeding during the first 6 months by HIV-positive mothers increases HIV-free survival by 32 per 1000 live births. After 6 months, as the age-specific mortality rate and risk of death caused by replacement feeding both decline, replacement feeding appears to be safer. CONCLUSIONS Under conditions common in countries with high HIV prevalence, replacement feeding by HIV-infected mothers should not be generally encouraged until after the infant is approximately 6 months old.
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Affiliation(s)
- Jay S Ross
- Academy for Educational Development, Washington, DC, USA.
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Poggensee G, Schulze K, Moneta I, Mbezi P, Baryomunsi C, Harms G. Infant feeding practices in western Tanzania and Uganda: implications for infant feeding recommendations for HIV-infected mothers. Trop Med Int Health 2004; 9:477-85. [PMID: 15078266 DOI: 10.1111/j.1365-3156.2004.01214.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Current infant feeding guidelines of UNICEF/UNAIDS/WHO for HIV-infected women recommend the avoidance of breastfeeding or to breastfeed exclusively. In the context of a prevention of HIV mother-to-child transmission programme we assessed the feeding practices in peripheral areas of Tanzania and Uganda. A total of 237 mothers in south-western Tanzania and 424 mothers in western Uganda attending urban and rural antenatal care services as well as village women were interviewed with regard to duration of breastfeeding, time of introduction of additional nutrients and type of solid and liquid nutrients. The average reported duration of breastfeeding was 24 months in Tanzania but 18 months in Uganda (P < 0.001). Solid nutrients were added on average at month 6 in both areas while liquids were given significantly earlier in Tanzania (month 4) than in Uganda (month 5; P < 0.001). A total of 19% and 48% of the study participants, respectively, stated to breastfeed their infants exclusively at the age of 4 months in Tanzania and Uganda. Age between 26 and 35 years, urban residence and ethnic group were the risk factors for earlier introduction of nutrients in Uganda. In Tanzania, solid maize porridge was the most frequent (94%) and often single nutrient given during breastfeeding, while in Uganda combinations of nutrients such as bananas, millet and beans were used. Milk was the most frequently added fluid in Uganda whereas in Tanzania various liquids such as liquid maize porridge, milk, juice or water were used. Feeding practices differed considerably in the two countries. According to the interviewees, exclusive breastfeeding was rarely practiced in Tanzania. Our findings underline the necessity to promote exclusive breastfeeding if infant feeding recommendations are to be realized and emphasize the need to assess the local situation in order to ensure that locally appropriate information and recommendations are given to the target groups.
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Affiliation(s)
- Gabriele Poggensee
- German Agency for Technical Co-operation, PMTCT-Project, Berlin, Germany.
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Shetty AK, Coovadia HM, Mirochnick MM, Maldonado Y, Mofenson LM, Eshleman SH, Fleming T, Emel L, George K, Katzenstein DA, Wells J, Maponga CC, Mwatha A, Jones SA, Abdool Karim SS, Bassett MT. Safety and trough concentrations of nevirapine prophylaxis given daily, twice weekly, or weekly in breast-feeding infants from birth to 6 months. J Acquir Immune Defic Syndr 2004; 34:482-90. [PMID: 14657758 DOI: 10.1097/00126334-200312150-00006] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the success of antiretroviral prophylaxis in reducing mother-to-child HIV-1 transmission, postpartum transmission through breast milk remains a problem. Antiretroviral administration to the infant during the period of breast-feeding could protect against postnatal transmission. An open-label phase 1/2 study was designed to assess the safety and trough concentrations of nevirapine (NVP) given once weekly (OW), twice weekly (TW), or once daily (OD) to HIV-exposed breast-feeding infants for 24 weeks. Following maternal dosing with 200 mg NVP orally at onset of labor, breast-feeding infants were randomized within 48 hours of birth to 1 of 3 regimens: arm 1, NVP given OW (4 mg/kg from birth to 14 days, upward arrow to 8 mg/kg from 15 days to 24 weeks), arm 2, NVP given TW (4 mg/kg from birth to 14 days, upward arrow to 8 mg/kg from 15 days to 24 weeks), and arm 3, NVP given OD (2 mg/kg from birth to 14 days, upward arrow to 4 mg/kg from 15 days to 24 weeks). Trough NVP concentrations and clinical and laboratory abnormalities were monitored. Of the 75 infants randomized (26 to OW, 25 to TW, and 24 to OD dosing), 63 completed the 32-week follow-up visit. No severe skin, hepatic, or renal toxicity related to NVP was observed. Neutropenia occurred in 8 infants. Trough NVP levels were lower than the therapeutic target (100 ng/mL) in 48 of 75 (64.0%) samples from infants in the OW arm, 3 of 65 (4.6%) samples in the TW arm, and 0 of 72 samples in the OD arm. Median (range) trough NVP concentrations were 64 ng/mL (range: <25-1519 ng/mL) with OW dosing; 459 (range: <25-1386 ng/mL) with TW dosing; and 1348 (range: 108-4843 ng/ml) with OD dosing. Our data indicate that NVP prophylaxis for 6 months was safe and well tolerated in infants. OD NVP dosing resulted in all infants with trough concentration greater than the therapeutic target and maintenance of high drug concentrations. A phase 3 study is planned to assess the efficacy of OD infant NVP regimen to prevent breast-feeding HIV-1 transmission.
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Affiliation(s)
- Avinash K Shetty
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Kourtis AP, Butera S, Ibegbu C, Belec L, Duerr A. Breast milk and HIV-1: vector of transmission or vehicle of protection? THE LANCET. INFECTIOUS DISEASES 2003; 3:786-93. [PMID: 14652204 DOI: 10.1016/s1473-3099(03)00832-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Transmission of HIV-1 to the infant through breastfeeding is a major cause of new paediatric HIV-1 infections worldwide. Although extended breastfeeding accounts for approximately 40% of infant HIV infections worldwide, most breastfed infants remain uninfected, despite prolonged and repeated exposure to HIV-1. Mechanisms associated with transmission of HIV-1 through breastfeeding and factors related to protection from such transmission remain poorly understood. Here we focus on the cellular origin of HIV in breast milk and on immune factors within the milk that may offer protection from transmission of HIV infection. The presence of innate immunity and induction of adaptive immunity against HIV is explored: in particular, specific antibodies, cellular responses, and their significance. The role of mucosal immune activation and epithelial integrity in HIV transmission is also addressed. We are of the opinion that advances in laboratory methods that study specific aspects of immunity will help open new areas of understanding of HIV transmission through breastfeeding and mechanisms of protection, and contribute to the development of novel prevention strategies.
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Suryavanshi N, Jonnalagadda S, Erande AS, Sastry J, Pisal H, Bharucha KE, Shrotri A, Bulakh PM, Phadke MA, Bollinger RC, Shankar AV. Infant feeding practices of HIV-positive mothers in India. J Nutr 2003; 133:1326-31. [PMID: 12730418 DOI: 10.1093/jn/133.5.1326] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Exclusive breast-feeding is widely accepted and advocated in India; however, clinicians are now faced with advising women infected with human immunodeficiency virus (HIV) about the risks and benefits of other infant feeding options. This study assessed factors that influence the infant feeding decisions of HIV-infected mothers in Pune, India. From December 2000 to April 2002, HIV-positive (HIV(+)) pregnant women (n = 101) from a government hospital antenatal clinic were interviewed prepartum about infant feeding intention, feeding practice immediately postpartum and feeding after a minimum of 2 wk postpartum. Of the HIV(+) sample, the last 39 were interviewed more intensively to examine factors affecting feeding decision making. We found that an equal number of HIV(+) women intended to breast-feed (44%) or give top milk (44%) (diluted animal milk). Women who chose to top feed were also more likely to disclose their HIV status to family members. Mixed feeding occurred frequently in our sample (29%); however, for the majority of those (74%), it lasted only 3 d postpartum. The hospital counselor had an important role in assisting women in their intended feeding choice as well as actual practice. The time immediately after delivery was noted as critical for recounseling about infant feeding and further support of the woman's decision, thus lowering the risk of mixed feeding. Lack of funds, poor hygienic conditions and risk of social repercussions were more commonly noted as reasons to breast-feed. Top milk, the alternative for breast-milk used in this population, however, must be investigated further to assess its nutritional value and safety before it can be endorsed widely for infants of HIV(+) women.
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Kuhn L, Peterson I. Options for prevention of HIV transmission from mother to child, with a focus on developing countries. Paediatr Drugs 2002; 4:191-203. [PMID: 11909011 DOI: 10.2165/00128072-200204030-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Use of antiretroviral drugs among HIV-infected pregnant women in many developed countries has significantly reduced rates of mother-to-child HIV transmission, demonstrating that this route of transmission is amenable to intervention. Prevention of transmission in developing countries has proved to be more difficult, although recent advances in short-course antiretroviral drug interventions have made it an immediate possibility, rather than a distant hope as it was seen to be in the recent past. Non-antiretroviral drug interventions, including washing of the birth canal with antiseptic solution and micronutrient supplementation, have not been found to be effective at interrupting mother-to-child HIV transmission, but may have other benefits for maternal and child health. An important issue for developing countries is prevention of postnatal HIV transmission through breast feeding. In most developing countries, formula feeding is not a reasonable option, given the higher rates of mortality from diarrheal and respiratory disease associated with avoidance of all breast feeding. A promising new line of research has recently been broached with the findings from a study in South Africa, which demonstrated that exclusive breast feeding is associated with a significant reduction in postnatal transmission of HIV.
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Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians & Surgeons, Columbia University, and Department of Epidemiology, Joseph L. Mailman School of Public Health, New York 10032, USA.
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Gaillard P, Piwoz E, Farley TM. Collection of standardized information on infant feeding in the context of mother-to-child transmission of HIV. Stat Med 2001; 20:3525-37. [PMID: 11746335 DOI: 10.1002/sim.1092] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Complete avoidance of breast-feeding is the surest way to avoid mother-to-child transmission (MTCT) of HIV through breast-feeding, but replacement feeding exposes infants, especially those born in developing countries, to the risk of other infectious diseases with consequent increase in morbidity and mortality. One study has suggested that exclusive breast-feeding during the first months of life carries a lower risk of HIV transmission than when other foods are given in addition to breast milk. Other studies have provided limited data on the risks of HIV transmission according to different patterns of breast-feeding, but studies have used different definitions of breast-feeding patterns and have analysed their data with adjustment on different risk factors. This hampers our ability to understand the mechanisms underlying HIV transmission through breast milk and the risks associated with different infant feeding practices. Consequently it is difficult to determine the best interventions to reduce the risk of transmission and the development of optimal policies. In collaboration with research teams involved with infant feeding research, the World Health Organization has developed a tool to assist studies on MTCTto collect information in a standardized manner, using common definitions and terms. The purpose is to facilitate comparisons between studies and the quantification of the risks of transmission according to various feeding patterns, after adjusting for potential confounding variables. The tool includes a core questionnaire to record infant feeding practices and other key information on the mother's and the infant's health. It also provides guidance on methods of analysis and presentation of the complex data on infant feeding. The tool can be used in prospective research studies on MTCT prevention, as well as providing the framework to assess infant feeding patterns in intervention programmes, such as those providing intensive counselling to mothers on infant feeding. The tool will facilitate the compilation of information from these studies which will ultimately provide scientific basis for updating guidelines and policies on infant feeding by mothers infected with HIV.
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Affiliation(s)
- P Gaillard
- World Health Organization, Department of HIV/AIDS (Prevention), Geneva, Switzerland
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