Breast feeding in HIV: assessing risks in a London clinic

In the UK, national guidelines recommend that all HIV‐positive women should refrain from breastfeeding for prevention of mother to child transmission (PMTCT). However, the World Health Organisation recommends that HIV positive mothers from low income countries should exclusively breastfeed until six months and continue until twelve months with anti‐retroviral therapy (ART) for mother and/or child. In our clinic, a high proportion of HIV positive women are from Africa and mixed messages regarding breast feeding may occur. The decision to not breast feed is sensitive and difficult, particularly where bottle feeding may be associated with HIV. A 2010 BHIVA position statement suggests that in exceptional circumstances breastfeeding may be supported with intense monitoring if the mother has an undetectable viral load. However, there is currently not sufficient evidence regarding transmission or ART toxicity. After a clinic disclosure of breastfeeding at four months post‐delivery, we examined our current practice to investigate how monitoring may need to change if breastfeeding were supported in certain circumstances. A review of notes was undertaken to consider ART and viral load in the post natal‐period to assess potential risks of breastfeeding in our cohort. All HIV‐positive pregnant women who delivered during 2009–10 were eligible. 41 women were identified as having a live delivery of which 30 (73.2%) identified as Black African. 18 (44.0%) were new diagnoses in pregnancy. In total, 28 (68.2%) were on ART, or ART was indicated for the mother, and 13 for PMTCT only (table 1).BL‐median (IQR) W12‐median (IQR) pDistance at 6MWT (m) 658 (605–691) 715 (IQR 690–830) <0.0001 DEXA spine (z‐score) −1.15 (−1.7/−0.7) −1.05 (−1.4/−0.3) 0.002 DEXA spine (z‐score)(TDF‐treated pts) −1.4 (−1.7/−0.7) −1.3 (−1.55/−0.5) 0.002 DEXA femoral neck (z‐score)(walk only) −0.8 (−1.4/−0.2) −0.5 (−1.2/−0.2) 0.047 DEXA femoral ward (z‐score)(walk only) −1 (−1.9/−0.6) −0.75 (−1.4/−0.2) 0.004 BMI 25.7 (24.6–26.3) 24.9 (21.4−26) 0.0016 Waist circumference (cm) 93 (87−100) 92 (85.5−98.5) 0.029 LDL cholesterol (mg/dL) 126 (113−154.5) 116 (96–137.5) 0.0003A viral load greater than 100 was found in 4 (9.8%) at delivery. All of the babies delivered were HIV negative. The mean time to post‐delivery viral load was 65.4 days (range 24–584). Of those who were meant to be undetectable on ART, 6/28 (21.4%) had a viral load >100 copies/ml. 12(92.3%) of those who took ART for PMTCT were detectable at post‐delivery viral load. Our clinic review suggests that if breast feeding is to be supported in certain circumstances: i) increased frequency of monitoring will be necessary for those on ART; ii) those on ART for PMTCT only would need to continue ART in the post natal period with such monitoring.