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HIV and Pregnancy

Kecie Pitts, MD, Matthew Zeitler, MD, and Michael Baca-Atlas, MD
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Almost 2 million adolescents and adults in the US are living with HIV. Many of these are women of childbearing age. How do we manage our pregnant patients who are HIV positive, especially if we have limited access to specialists? Hippo’s own Drs. Matt Zeitler and Michael Baca-Atlas discuss HIV and pregnancy with HIV fellow Dr. Lakecia Pitts.

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Spencer J. -

Given that the use of formula itself is not risk-free, and that breastfeeding can be an integral and important part of mothering , is there a role for informed consent regarding breastfeeding among women living with HIV?

Is there a way to mitigate risk, e.g. continuing prophylaxis for the baby? Or limiting breastfeeding to the period of exclusive breastfeeding, and discontinuing when complementary foods are introduced?

I wonder if there is a risk of mothers breastfeeding while not informing their doctor/baby's doctor, similar to the way families may "secretly" bed share - or worse, fall asleep with baby in an even less safe environment like a recliner - if a absolute "don't bed share" message is given. In that case, education regarding the risks can help families make better informed and safer decisions.

I found this article comparing HAART in mother or prophylactic treatment of the infant; both strategies were highly effective at preventing transmission (0.6% transmission rate):
Prevention of HIV-1 Transmission Through Breastfeeding: Efficacy and Safety of Maternal Antiretroviral Therapy Versus Infant Nevirapine Prophylaxis for Duration of Breastfeeding in HIV-1-Infected Women With High CD4 Cell Count (IMPAACT PROMISE): A Randomized, Open-Label, Clinical Trial (J Acquir Immune Defic Syndr 2018;77:383–392)
"Seven of 1219 (0.57%) and 7 of 1211 (0.58%) analyzed infants in the mART and iNVP arms, respectively, were
HIV-infected"

Spencer Joslin, MD
Family & Adolescent Medicine, former breastfeeding peer counselor

Neda F., MD -

Hi Spencer! Kecie and Matt put together the following thoughts for you. I hope they're helpful!

"Thank you for such a thoughtful, patient-centered question. Data is evolving around HIV transmission to infants through breastfeeding. There is data that suggests there is minimal risk of transmitting HIV through breastfeeding in women on ART who are virally suppressed (HPTN 046, IMPAACT PROMISE, Tanzania study). On the contrary, in the Mma Bana Study there were 2 cases of HIV transmission via breastfeeding among 500 women with mom’s whose viral load was undetectable (<50 copies/mL), suggesting that viral suppression does not eliminate the risk of HIV transmission through breastfeeding. However, these studies have occurred in low resource settings where there is no safe alternative to breastfeeding which limits our ability to generalize the results to practice in the US.
The results of the IMPAACT PROMISE study are promising in that (1) we have additional info that supports maternal ART as means of decreasing HIV transmission to infants and (2) prolonged infant “PrEP” beyond the current recommended 6 weeks may provide ongoing protection for infants who may continue to be at increased risk of HIV transmission beyond the initial neonatal period, particularly if they are breastfed. Both potentially allow for risk reduction while supporting and respecting the mom’s decision to breastfeed. Unfortunately, it is difficult to ascertain the impacts of selection bias, presence of confounders, small sample size, etc on the results of this study.
Regarding prolonged infant PrEP, a couple of things to consider is (1) this practical in the real world considering things like daily administration, cost, disclosure risks, culture and psychosocial barriers, access to providers skilled to manage this in primary care, etc, (2) the potential for resistance in the setting of missed doses if transmission occurs (which impacts treatment options), and (3) nevirapine is not without risks and includes side effects such as rash (ie SJS), liver toxicity, and severe hypersensitivity reaction that can cause multi organ system damage.
With the data we have, there are no current mitigation strategies that eliminate the risk of HIV transmission nor are without risks themselves. As you said, these risks are delicately balanced against those associated with not breastfeeding. With safe and accessible formula options in the US, we emphasize the AAP, ACOG, and CDC guidelines that suggest formula feeding. However, we ultimately empower our moms living with HIV by seeking to understand their perspective and feelings around breastfeeding, informing them of risks and ways to mitigate those risks if they decide to breastfeed, and establish a plan that supports and respects their decision. The DHHS perinatal guidelines (hyperlinked text) have several strategies for risk reduction measures for mothers and families who choose to breastfeed. "

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Hippo Primary Care Written Summary May 2021 296 KB - PDF

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