MILAN — Current guidelines recommend that women with HIV avoid breast-feeding, but some do so without advising their physician and without monitoring for the safety of their baby.
However, when a woman has an undetectable viral load, the risk is minimal, according to some specialists.
“What we need now is a protocol,” Mona Loutfy, MD, from the University of Toronto, said here at the 16th European AIDS Conference.
That just might be on the way. During a lively debate at the conference, Women Against Viruses in Europe (WAVE) — a subgroup of the European AIDS Clinical Society (EACS) — committed to creating formal breast-feeding guidelines.
“This is probably the first group to come together as an organization to put together a recommendation on how to support women,” Dr Loutfy told Medscape Medical News.
The WAVE subgroup plans to work with pediatricians and other clinicians to share effective practices, and to determine whether the field is at the point that it can acknowledge that women are likely breast-feeding without the consent or knowledge of their physicians.
I was shocked.
The groundwork for the debate was set when updated clinical guidelines were released by EACS. In addition to updating vaccine recommendations and adding information about comorbidities, the guidelines recommend against breast-feeding. But in case a woman insists on breast-feeding, “we recommend follow-up with increased clinical virological monitoring of both the mother and the infant.”
Even with the strong air of discouragement, this statement is “a breakthrough,” said Dr Loutfy. Three years ago, “no one would have even talked about this.”
What has changed is the thinking about transmission risk in people with suppressed viral loads. In the past few years, some high-profile studies have shown that immediate treatment that results in a suppressed viral load for at least 6 months protects against transmission.
The randomized controlled HPTN 052 trial (N Eng J Med. 2011;365:493-505), the prospective PARTNER cohort (JAMA. 2016;316:171-181), and the Opposites Attract Trial — presented at the International AIDS Society 2017 Conference — all showed that in people with fully suppressed viral loads, there were no transmissions of HIV between partners, whether they were straight or gay, and whether or not they used condoms.
That research, followed by the public information campaign known as Undetectable = Untransmittable, or U=U, has pushed the conversation from strict abstinence or sex only with condoms to the possibility of natural conception between straight serodiscordant couples, as reported by Medscape Medical News.
It has “completely changed the way I practice,” said Dr Loutfy.
Before, it was just like, no breastfeeding. Now it’s a conversation.
She recalled a community meeting that she, HIV physicians, women living with HIV, and other healthcare professionals attended a few years ago. A midwife asked: “Are we going to have this conversation [an insistence on strict bottle-feeding] like we always do? Or are we going to actually acknowledge that women are breast-feeding already and not telling us?”
Dr Loutfy said she was sure that was not true, but woman after woman broke the news to her: they had been breast-feeding. They’d just been doing it in secret, with no support and no viral load monitoring for their infant.
“I was shocked,” she said. “Before, it was just like, no breastfeeding. Now it’s a conversation.”
Switzerland to the Front
Switzerland has been at the front of this conversation for nearly a decade. Before HPTN 052, the Swiss AIDS Federation published a statement saying that if a person with HIV has an undetectable viral load for 6 months, no other sexually transmitted infections, and a monogamous relationship, he or she can have sex without a condom.
That drew counterstatements — insisting on continued condom use — from the World Health Organization and health policy organizations from individual countries.
Now, Switzerland is poised to be one of the first countries in Europe to support breast-feeding by women with undetectable viral loads, albeit accompanied by monthly viral load tests for mothers and weekly tests for infants.
The goal is not universal breast-feeding, said Karoline Aebi-Popp, MD, from the University of Bern in Switzerland. The goal is patient-centered informed consent, where women and their clinicians talk openly about the pros and cons of breast-feeding on an individual basis and discuss the risks and benefits to the mother and child.
“Following that discussion, some may elect to breast-feed,” said Karina Butler O’Connell, MD, from University College Dublin, a pediatrician who advocated for the child in the debate. “But others may change their minds.”
It’s a conversation physicians are already having among themselves, as reported by Medscape Medical News.
“If the woman is undetectable through the whole pregnancy and she insists on breast-feeding, we would support her,” said Dr Aebi-Popp. “The worst thing is if they do it and they don’t tell us.”
Dr Aebi-Popp said she will be collecting data from all the Swiss women who do decide to breast-feed for future research.
Different Ways to Monitor
During the debate, panel members did not agree what monitoring should entail or which clinicians should be involved. Pediatricians, who recently came out against women with HIV breast-feeding in the United States, “are always going to be thinking of the child and say, no.” So physicians must work to build bridges to that specialty, said Dr Aebi-Popp.
Justyna Kowalska, MD, from the Medical University of Warsaw in Poland, said she would never support breast-feeding without the help of a lactation consultant and input from the woman’s obstetrician. A woman might get support from her infectious disease clinician, only to have her obstetrician discourage her from breast-feeding, she told Medscape Medical News.
“It’s a process that requires a lot of people to get on board and understand,” she said.
In addition, physicians grapple with how exactly to monitor viral load.
As mentioned, in Switzerland, the protocol is monthly plasma viral load testing for the mother and weekly testing for the infant. In Germany, the regimen includes monthly breast-milk and plasma viral load testing and an antiretroviral pharmacokinetics test of the infant whenever blood is drawn for routine tests, said Annette Haberl, MD, from Frankfurt University in Germany, who worked with a woman who breast-fed exclusively about 6 years ago. In Canada, Dr Loutfy reported, there is no access to pharmacokinetic tests, but blood tests are conducted.
“Is that good? Is that bad? I don’t know,” said Dr Haberl.
It is a question that will take time to answer with evidence, said Dr Kowalska. The next step will be meeting with individual specialists and women living with HIV to hammer out protocols.
“It won’t come forward in the next year or the year after,” she said, “but it’s a start.”
Dr Loutfy, Dr Aebi-Popp, Dr Haberl, and Dr Kowalska have disclosed no relevant financial relationships.
16th European AIDS Conference. Abstract PS8/2. Presented October 27, 2017.
Follow Medscape on Twitter @Medscape and Heather Boerner @HeatherBoerner
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