Why all HIV+ Women on Antiretroviral Therapy Should

Breastfeed in both Low and High Resource Settings

Natella Rakhmanina, MD, PhD Professor of Pediatrics

The George Washington UniversityDirector, Special Immunology Program

Children's National Health SystemSenior Technical Advisor

Elizabeth Glaser Pediatric AIDS Foundation

HIV and Women WorkshopSeattle, 2017

Facing Lynne……is toughSamuel J. Heyman Service to America Medals honoring outstanding federal employees for service to their communities and for making a

difference

But Being Russian Helps….

Breastfeeding in the Resource Rich Settings

• 81.1% started to breastfeed in 2013 in the USA and 51.8% were breastfeeding at 6 months (2016 Breastfeeding Report Card, CDC)

• 83% initiated breastfeeding in the UK in 2010, exclusive breastfeeding at six months was 34% (UNICEF, UK, 2012)

• 89% off mother in Canada breastfed in 2011–2012, with 26% breastfeeding exclusively for six months (Statistics Canada)

Essential Women’s Right

Maternal Benefits of Breastfeeding

• Improved postpartum recovery• Decreased postpartum depression • Improved long term bone health• Decreased maternal cardiovascular

diseases• Diminished risk of cancer (breast and

ovarian)

AAP Policy Statement, 2012

Rights of the Child

Per Convention on the Rights of the Child, children have a right to the best start in life

with the best chance for health including higher intelligence, better growth,

protection against immediate and chronic diseases

Benefits of Breastfeeding for Children

• Decreased allergic diseases• Improved neurodevelopmental outcomes• Reduced obesity and other factors related to

heart disease • Reduced early childhood infections and

gastrointestinal disease (IBD, celiac disease)• Reduced diabetes rates and childhood

cancers• Improved outcomes in prematurity and LBW

AAP Policy Statement, 2012

Prenatal HIV Exposure and Prematurity

Uthman et al.Lancet HIV. 2017 Jan;4(1):e21-e30

See for yourself……

This is good…….. But this is better………

PROMISE Results

Among HIV-infected women who do not meet criteria for initiation of HAART for their own health, what is the optimal intervention to prevent transmission of HIV to infants during breastfeeding?

R

2,431 mother-infant pairs

Maternal ART during

breastfeeding

Infant daily NVP during

breastfeeding

n=1,220 n=1,211

PROMISE Postpartum Component: Maternal ART vs Infant NVP for Preventing PP MTCT

Taha T et al. IAS 2016 Durban S Africa, Abs. LBPE013

13 sites Africa, 1 site IndiaEnrolled June 2011-October 2014

Medianduration

BF15 mos

Infant: Median GA: 39 wkMedian BW: 2.9 kg

Mother: Median CD4: 68697% WHO Stage IMedian age: 26 yr

At 6 months of age, estimate 0.3%

(95% CI, 0.1-0.6)

At 9 months of age, estimate 0.5%

(95% CI, 0.2-0.8)

At 12 months of age, estimate 0.6%(95% CI, 0.4-1.1)

PROMISE Postpartum Component: Maternal ART vs Infant NVP for Preventing PP MTCT

Taha T et al. IAS 2016 Durban S Africa, Abs. LBPE013

No statistically significant difference in probability of MTCT of HIV by study arm (in both primary and sensitivity analyses).

Infant 12-month survival rate was extremely high (98.9%)

and did not differ significantly by study arm

PROMISE Postpartum Component: Maternal ART vs Infant NVP for Preventing PP MTCT

Taha T et al. IAS 2016 Durban S Africa, Abs. LBPE013

Infant Survival

NIH Statement, July 2016

“Maternal antiretroviral therapy safely minimizes the threat of HIV transmission

through breast milk while preserving the health advantages of breastfeeding, as the high infant

survival in this study underscores.”Anthony Fauci

Number of Children 0-14 Years Living with HIV Globally, 1990-2015: 2015 vs 2016 Estimates, UNAIDS 2016

Revision SPECTRUM model based on 2016 review of available data: PMTCT with ART more effective than prior estimates Median age children starting ART older than prior estimates Lead to mortality in children higher than prior estimates Result: ↓ children LWH than previous due to ↓ incidence & ↑ mortality

1.8 M

2.6 M

WHO, 2009

Number of Children 0-14 Years Newly Infected with HIV Globally, 1990-2015: 2015 vs 2016 Estimates, UNAIDS 2016

Revision SPECTRUM model based on 2016 review of data: MTCT with incident infection estimates lower than earlier PMTCT with ART more effective than prior estimates Results in fewer children than prior estimates due to ↓

incidence

160,000

220,000

27% lower

WHO, 2009

Compared to Low Resource Settings, we have:

• Less pressure for mixed feeding methods • Ample maternal VL monitoring and

repeat infant testing • Better and easier to take maternal ART

regimens with multiple choices • Better monitoring of short and long-term

toxicity

We get it….

In high resource settings PreP comes first

How to do it right?

“For to be free is not merely to cast off one's chains, but to live in a way that respects and enhances the freedom of

others” Nelson Mandela

How to do it right?• Initiating counseling before pregnancy and early

in pregnancy • Providing education on breastfeeding and

expectations for mother/child• Discussing all available options including donor

breast milk (wet nurse, banked breast milk)• Supporting mother in her decision and helping

hers and infant ART adherence • Repeating HIV testing in mother and the child

Seattle votes!

Seattle votes!

BAN or NO BAN?

• WHO recommends breastfeeding - NO BAN!• USA does not recommend breastfeeding- BAN!• Canada does not recommend breastfeeding -

BAN!• UK does not recommend, but understands –

BREXIT!• Europe – it depends…..• Your answer????