{"id":856,"date":"2013-06-18T15:30:20","date_gmt":"2013-06-18T15:30:20","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=856"},"modified":"2013-06-17T21:34:07","modified_gmt":"2013-06-17T21:34:07","slug":"hiv-mothers-without-art-when-and-how-should-they-wean","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2013\/06\/18\/hiv-mothers-without-art-when-and-how-should-they-wean\/","title":{"rendered":"HIV+ mothers without ART:  when and how should they wean?"},"content":{"rendered":"<p>Without antiretrovirals, breastfeeding contributes 28% to the risk of mother-to-child HIV transmission (MTCT) (<a href=\"http:\/\/sti.bmj.com\/content\/88\/Suppl_2\/i44.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63\">http:\/\/sti.bmj.com\/content\/88\/Suppl_2\/i44.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63<\/a>).\u00a0 Antiretroviral drugs make achieving he WHO goal of near elimination of MTCT imaginable (<a href=\"http:\/\/sti.bmj.com\/content\/87\/3\/261.full\">http:\/\/sti.bmj.com\/content\/87\/3\/261.full<\/a>; <a href=\"http:\/\/sti.bmj.com\/content\/86\/Suppl_2\/ii48.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63\">http:\/\/sti.bmj.com\/content\/86\/Suppl_2\/ii48.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63<\/a>).\u00a0 But, in the meantime, what advice should be given to HIV+ mothers in those low-resource settings where antiretrovirals are still not available?<\/p>\n<p>In this context, the health benefits of breastfeeding may yet override the risks of MTCT, as indicated by recent WHO guidance (<a href=\"http:\/\/depts.washington.edu\/ghivaids\/reslimited\/case5\/discussion.html#ref\">http:\/\/depts.washington.edu\/ghivaids\/reslimited\/case5\/discussion.html#ref<\/a>).\u00a0 But when and how should infants be weaned in order to minimize the inevitable risk?\u00a0 To give the best advice, we need to know more about how MTCT takes place.\u00a0 A recent study (Louise Kuhn et al.) seeks to fill gaps in our knowledge by examining the relation between weaning and HIV concentration in breast milk (<a href=\"http:\/\/stm.sciencemag.org\/content\/5\/181\/181ra51.abstract?sid=c20e20f7-1f36-474d-99dc-ac2c265d505f\">http:\/\/stm.sciencemag.org\/content\/5\/181\/181ra51.abstract?sid=c20e20f7-1f36-474d-99dc-ac2c265d505f<\/a>).<\/p>\n<p>958 Zambian mothers and their infants were randomized to wean abruptly (4 months) or continue breastfeeding, and HIV concentrations were measured at 4 and 4.5 months.\u00a0 Two weeks after weaning HIV-1 concentrations in the milk of the abrupt weaners \u2013 median RNA, 2780 copies\/ml. ; DNA, 14 copies\/ml. \u2013 were observed to be dramatically higher than for non-abrupt weaners \u2013 median RNA, &lt;50 copies\/ml.;\u00a0 DNA, &lt;1 copy\/ml..\u00a0 Furthermore, HIV concentrations were higher even where breast-feeding was non-exclusive (median RNA 293 copies\/ml.; DNA, 2 copies\/ml.).<\/p>\n<p>It would appear from this that the risks of MTCT are not evenly distributed over the period during which the child is breastfed, but spike quite abruptly at the time when weaning takes place.\u00a0 The physiological explanation of this phenomenon remains unclear; the authors propose as most likely the opening of the paracellular tight junctions of the mammary gland, which is known to occur during weaning.\u00a0 The fact that other studies have reported no association between non-exclusive breast-feeding and HIV-1 concentrations may, in the authors\u2019 view, be attributable to their failure to focus on the short interval of time following disruption of full breast-feeding.<\/p>\n<p>The validity of these findings, if confirmed by further studies, lends weight to the existing WHO recommendation for mothers to reduce breast-feeding frequency gradually over the weeks leading up to the last planned breast milk feed (<a href=\"http:\/\/www.avert.org\/pmtct-guidelines.htm\">http:\/\/www.avert.org\/pmtct-guidelines.htm<\/a>).\u00a0 Evidently, abrupt weaning following exclusive breast-feeding, if genuinely achieved, would eliminate the PMCT risk through breast milk (though weaning abruptly is associated with maternal morbidity). \u00a0The problem, however, is that even minimal deviation from abrupt weaning presents the most acute risk of PMTC.<\/p>\n<p>So, gradual weaning seems advisable, accompanied, as the authors suggest, by the expression and discarding of breast milk to relieve engorgement. \u00a0Where antiretrovirals are being offered for the child\u2019s health, HIV-1 infected women should continue the antiretrovirals they used through lactation <i>over the full duration of time when any breast milk exposures occur<\/i>. \u00a0Existing WHO guidelines regarding ART regimes for these mothers stipulate that drugs should be continued until one week after breastfeeding is finished (<a href=\"http:\/\/www.avert.org\/pmtct-guidelines.htm\">http:\/\/www.avert.org\/pmtct-guidelines.htm<\/a>).\u00a0 The authors point out that in the light of their findings, the \u201cone or two-week period\u201d that \u201chas been considered adequate\u201d may be too short.\u00a0 At all events the existing WHO guidelines seem inadequate, given the complexity of the practical issues surrounding weaning, and the acuteness of PMTC risk concentrated at this stage.<\/p>\n<p>This study focuses on the issue of weaning as it presents itself for breast-feeding mothers without ART.\u00a0 The authors point to the urgent need for further research of the dynamics of PMCT through breast-milk when ART is being given.\u00a0 They also urge the importance of pursuing the same investigation in relation to the weaning of the older infant \u2013 given the WHO guidelines have now shifted to encourage weaning at a later stage (post 12 months).\u00a0 Further clarification through research in this area seems urgently needed.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Without antiretrovirals, breastfeeding contributes 28% to the risk of mother-to-child HIV transmission (MTCT) (http:\/\/sti.bmj.com\/content\/88\/Suppl_2\/i44.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63).\u00a0 Antiretroviral drugs make achieving he WHO goal of near elimination of MTCT imaginable (http:\/\/sti.bmj.com\/content\/87\/3\/261.full; http:\/\/sti.bmj.com\/content\/86\/Suppl_2\/ii48.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63).\u00a0 But, in the meantime, what advice should be given to HIV+ mothers in those low-resource settings where antiretrovirals are still not available? In this context, the [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2013\/06\/18\/hiv-mothers-without-art-when-and-how-should-they-wean\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2042,2012,2791],"tags":[],"class_list":["post-856","post","type-post","status-publish","format-standard","hentry","category-hiv-care","category-hiv-infection","category-mother-to-child-hiv-transmission"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>HIV+ mothers without ART: when and how should they wean? - Sexually Transmitted Infections<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/sti\/2013\/06\/18\/hiv-mothers-without-art-when-and-how-should-they-wean\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"HIV+ mothers without ART: when and how should they wean? - Sexually Transmitted Infections\" \/>\n<meta property=\"og:description\" content=\"Without antiretrovirals, breastfeeding contributes 28% to the risk of mother-to-child HIV transmission (MTCT) (http:\/\/sti.bmj.com\/content\/88\/Suppl_2\/i44.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63).\u00a0 Antiretroviral drugs make achieving he WHO goal of near elimination of MTCT imaginable (http:\/\/sti.bmj.com\/content\/87\/3\/261.full; http:\/\/sti.bmj.com\/content\/86\/Suppl_2\/ii48.abstract?sid=fcfaeecc-767f-4db8-b644-77db5aa8db63).\u00a0 But, in the meantime, what advice should be given to HIV+ mothers in those low-resource settings where antiretrovirals are still not available? 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