BREASTFEEDING IN HIV POSITIVE MOTHERS

 Is breastfeeding contraindicated in HIV + mothers ?

- We know that the virus can pass thru the breast milk. Although we know the benefit of
breast feeding , Mothers worry about transmitting the HIV to the child .
- So it is important that she and her family be guided accordingly by the HCW by providing her
with the correct and accurate information on the benefits and risks of breastfeeding by an
HIV + mother .
- In one of the landmark trials done in Africa in 1999 , Lancet reported a cohort of HIV +
mother and breastfed infants at a minimum of 3 months . Babies exclusively breastfed had
a lower risk of HIV infection compared to those with mixed feeding . Postulates were :
1. that the formula milk may have damaged the intestinal lining and provided an entry for
the virus
2. antibodies from mother were transferred from mother thru breast milk

- In 2005 Zvitambo cohort compared postnasal transmission between mixed , exclusively

breastfed . It showed that those given mixed feeding had higher transmission of HIV virus
- In 2007 Coovadia et al followed babies with early introduction of solid foods and
breastfeeding and noted that they were more likely to acquire HIV infection like the infants
who received mixed feeding with breast milk and formula milk more than exclusively
breastfed children. In formula fed infants there was likely a higher risk of dying at 15.1%. (HR
2.06)
- AFASS CRITERIA- introduced in 2007
1. Acceptable
2. Feasible
3. Affordable
4. Sustainable
5. Safe

- 2008-2009 : Becquet Cohorts studied the breastfeeding duration as a major determinant

of postnatal HIV transmission. It showed that postnatal transmission (PT) did not differ
between exclusively and predominantly breastfed children BUT the negative effects of
mixed breastfeeding with esp with early introduction of SOLIDS on postnatal transmission
were confirmed .

- 2017- the burden of illness:

1. Estimated 36.9 M PLHIV mostly in Low to Middle Income Countries
2. There was a 50% decline from 320,000 HIV inf in 2010 to 160,000 new HIV infection
among under 5 children in 2021
3. Since the start of PMTCT programmes , 1.5 M HIV deaths and 2.9M HIV infections have
been averted among pregnant women and children
-In 2019 Transmission of HIV thru breastfeeding showed :
1. rate of shedding is 20-60% HIVRNA &/or DNA
2. Mode of excretion in breastmilk is from both cell-free and cell-associated virus
3. Transmission rate without ART use per month of breastfeeding is only 0.74 % /month (not the
predominant mode of transmission postnatally as it contributes only 1/3)
4. Risk factors for breastfeeding transmission is affected by
a. HIV RNA viral load in blood or breast milk
b. duration of breastfeeding
c. addition of a replacement feeding early (< 6 months of life )”mixed feeding “
d. severity of maternal immunodeficiency; absence of antiHIV IgM or sigA in breastmilk
e. Absence of HIV-specific cytotoxic T cells in breast milk
f. mastitis and other inflammatory process in the breast / breast milk

5.Public health effect of breastfeeding transmission : approx. 100.000 new pediatric infections
attributed to breastfeeding annually; frequent and severe dse if infant ART is not initiated early.

6.LMICs , breastfeeding with maternal ART; Infant post-exposure prophylaxis (recommended by WHO
for 6 weeks or longer if risk of MTCT is high but pre-exposure prophylaxis was not recommended by
WHO. Past; in high income settings, formula feeding is recommended. Pasteurization of breastmilk is not
included in the WHO guidelines; Potential passive immunoprophylaxis (under evaluation)

7.With effective maternal suppression, absolute transmission risk , even during extended periods is <1%
in trial settings ; If mother acquires HIV during breastfeeding , risk of postnatal transmission is
extremely high (30%) particularly among young infants .

8.A combination of high maternal HIV viral load and Immature intestinal integrity can increase
susceptibility to transmission

PHILIPPINE HIV/AIDS DATA

1. ONLY 26% of pregnant women LHIV are receiving effective ARVs for PMTCT (excluding single
dose Nevirapine )
2. Estimated number of new HIV inf 0-19 yrs old 3000
3. Children receiving ART 0-14 yrs old 120
4. Estimated number of new HIV inf (adolescents and young people 15-24 yrs old 7800
5. No data was available for young people 15-24 yrs old tested for HIV in the last 12 months and
received the result of last test (female) (male )
ELIMINATION OF MOTHER TO CHILD TRANSMISSION is now the VISION

- IF POPULATION IS PREDOMINANTLY BREASTFEEDING & THERE IS LESS 5% HIV CASES , IT IS

CONSIDERED AS ELIMINATION
- FOR NON BREASTFEEDING POPULATION , LESS 2% is considered elimination of HIV infection
- WHO REQUIRES that HIV & Syphilis EMTCT processes , indicators are achieved within a
context of human rights , gender equality and community engagements.

EMTCT OF HIV BY 2030

1. Advocate for greater political and financial commitment

2. Target high risk populations such as adolescent girls and young women
3. Implement novel service delivery models such as community treatment groups
4. Performing regular viral load monitoring during pregnancy and postpartum to ensure
suppression before delivery and during breastfeeding &
5. Harnessing technology in monitoring and evaluation and HIV diagnostics

PRIMARY CARE FLOWCHARTS FOR UHC

ELECTIVE CS in HIV should be done only if indicated

LIVING WITH HIV WHILE PREGNANT … WHAT SHOULD WE DO ?
1. If your planning to get pregnant and you have HIV , talk to your doctor . You should be
maintained on ART
2. Is it safe to exercise ? YES , 20 -30 minutes daily except for high impact sports and
those that exposes you to high temp , high altitude, scuba , skydiving
3. Recommend walking , swimming , stationary bike , yoga & pilates , low impact aerobics,
strength training
4. Exercise is unsafe in preterm labor , vaginal bleeding , ROM, cerclage , HTN , severe
anemia , uncontrolled Dm , advanced HIV , cachectic
5. s/s
6. Need to take vitamins like nonHIV preg and continue 3 months postpartum, Eat a
balanced diet
7. There are studies showing improvement in CD4 count with vitamin B+C+E
8. Avoid undercooked foods, avoid nuts with high concentration of saturated fatty acids,
coffee is allowed not more than 2 cups a day

SCREENING FOR HIV IN PREGNANCY

 PREVENTION OF MOTHER TO CHILD TRANSMISSION (EMTCT) OF HIV

CASCADE OF PMTCT SERVICES
1 Antenatal Testing : HIV Counseling & testing
2 Antiretroviral Therapy
3 Safe labor and delivery techniques
4 Safer infant feeding
5 Early Infant Diagnosis
6 Final Diagnosis for HIV exposed infants, through linkage of both
mother & child to appropriate care and treatment

 Antenatal Screening
- Recommended a sa standard of care for all sexually active women
- Routine component of preconception and antenatal care
- Provider – initiated HIV Testing & Counselling
- 2 APPROACHES :
a. OPT-IN approach – inform patient everything she needs to know
b. OPT-OUT approach- Inform patient HIV test will be done as part of routine
prenatal laboratory tests.
- Mandatory testing is UNLAWFUL (RA 8504); DOH A.O. 2016-0035 “ guidelines on
the PROVISION OF Quality antenatal care in all birthing centers and health facilities
providing maternity care services. This will prevent Stigmatization , reduces cost of
tests and deals with potential geographic shifts in epidemiology.
 CDC STI GUIDELINES 2021, ACOG RECOMMENDATION
1. All pregnant women should be tested for HIV during the 1st prenatal visit
2. Repeat testing at 3rd trimester (< 36 weeks ) for High risk women

 HIV PISOG HANDBOOK, 2020

- All pregnant women should be tested for HIV during the 1st prenatal visit (OPT_OUT
APPROACH)
- Repeat testing at 3rd trimester (ideally between 34-36 weeks ) to pregnant women
with an initial Negative HIV test but at increased risk for acquiring HIV

 HIV TESTING
- RAPID HIV TESTING should be done during Labor & delivery for any woman with
undocumented HIV status using the OPT-OUT APProach. If not tested during labor
& Delivery , an EXPEDITED TESTING must be done immediately postpartum
- It has a high negative predictive value (100%),High sensitivity & Specificity
(approaching 100%) and a Positive predictive value (44-100%).
CURRENT HIV DIAGNOSTIC TESTING ALGORITHM for ADULTS AND
INFANTS > 18 MONTHS OLD

Screening test – rapid

or EIA
 PROPOSED ALGORITHM OF rHIVda CONFIRMATORY TESTING

T0 – reactive

Perform rHIVda T1 Non-reactive Repeat test after 2 – 6

weeks

REACTIVE

Perform rHIVda T2 Non-reactive Record as inconclusive

Repeat rHIVda after 2-6 weeks

Send sample to SLH-NRL- SACCL
REACTIVE

Perform rHIVda T3 Nonreactive Record as inconclusive

Repeat rHIVda after 2-6 weeks

REACTIVE
Send sample to SLH-NRL-SACCL

Release result as
HIV positive

 The ffg tests are used inrHIVda Confirmatory testin for NRL-SLH/SACCL:
1. T1-Sysmex HISCL HIV Ag+Ab Assay kit
2. T2- Vidas HIV Duo Ultra or SD HIV-1/2 3.0 or Alere Determine HIV ½
3. T3-Geenius HIV ½ Confirmatory Assay kit
 HIV SCREENING ON PRENATAL VISIT

Prenatal counseling on 1st visit at OB-OPD and inclusion of HIV

testing in screening tests explained . Use OPT-OUT approach

Pregnant woman referred to HACT counselor prior to testing

If positive , send for confirmatory test

HIV positive on Confirmatory testing

Referred to HACT for ART

Mode of delivery Infant feeding :

- Counseling on the benefits
Depends on the following
of breastfeeding and risk of
transmission
- Mother fills up AFASS
VAGINAL DELIVERY may be done CESARIAN SECTION if : assessment form and
if assessment explained
- Less than 4 weeks - Family included in
- On ART for at least 4 ART counselling
weeks - Viral load is unknown - Waiver signed on choice of
- With viral load of less or is greater than feeding
than 1000 copies/ml 1000 copies per ml
- No obstetric indication - Elective CS @ 38
for cesarian delivery weeks BEC MAY
SUDDENLY go into
labor if 39 weeks

USE MODIFIED EINC ON CATCHING BABY by

Pediatrician
“ DURING PRENATAL CARE , EXCLUSIVE BREASTFEEDING IS RECOMMENDED
FOR HIV-INFECTED MOTHERS FOR THE 1ST 6 MONTHS OF LIFE UNLESS
REPLACEMENT FEEDING IS ACCEPTABLE , FEASIBLE, AFFORDABLE,
SUSTAINABLE AND SAFE FOR THEM AND THEIR INFANTS BEFORE THAT TIME “

ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC) PRACTICES MODIFIED FOR

HIV EXPOSED INFANTS

EINC HIV MODIFIED EINC

Immediate and thorough drying Properly timed cord clamping of at least 1-3
minutes
Early skin to skin contact Immediate bathing followed by thorough drying
to remove maternal blood and fluids
Properly time clamping and cutting of the cord Immediate skin to skin contact
after 1-3 minutes
Latching-on is recommended if breastfeeding has
Nonseparation of the newborn from the mother been chosen as the infant feeding option
for early breastfeeding initiation and rooming in

 WHO EARLY _____ NEWBORN CARE with first embrace guidelines, 2014
 UNINTERRUPTED SKIN TO SKIN CONTACT
SAFETY INFANT FEEDING OPTIONS
- HCW should help the woman identify the safest feeding option for
her infant and allow her to make an informed choice given her
health and socioeconomic conditions
- No ARV : 9-16 % risk of maternal to child transmission
- With ARV – 1-2 % risk of maternal to child transmission
- Mothers should be counselled on dangers of mixed feeding
- Other options
1. Wet nursing from screened surrogate mother
2. Donated milk from screened donor
3. Milk bank
4. Commercial infant formula (last and discouraged)

PRENATAL VISITS OF AN HIV- INFECTED PREGNANT WOMAN

1. In general, management and general principles of ART and HIV
management do not differ between pregnant people with perinatally
acquired HIV and those with non-perinatally acquired HIV (sexually
acquired)
2. Optimal ART regimens should be selected based on resistance
testing, ART treatment hx and pill burden
3. Consultation with experts in HIV and pregnancy is recommended
when the presence of extensive drug resistance warrants use of ART
for which there is limited experience in pregnancy
CONDUCT OF PRENATAL CARE
1st visit Refer to HIV specialist

Prenatal labs : CBC , ABO typing, Urine

CS, Screen for : HepaB, anti-HBs,
Syphilis , Tuberculosis, Rubella IgG

HIV lab exam HIV RNA viral load, CD4 count , serum
ALT , Creatinine

Fetal monitoring Baseline UTZ , congenital scan @ 20

weeks AOG, regular biometry @ 28
weeks and monthly or more frequently as
needed

HIV meds If on ARV: CONTINUE

If not yet on ARV : start ARV ASAP and
continue for life

Vaccination Flu shot at anytime,

Hepatitis B vacc if negative for antibody
(catch up vaccination )
TDaP @ 27-36 weeks
COVID 19 vaccine up to 1 booster

Partner screening May be offered screening for HIV, other

STD

Counselling on breastfeeding/ Full breastfeeding actively offered ;

contraception Postpartum contraception

Vitamin supplementation Given by HCP

SAFE LABOR AND DELIVERY TECHNIQUES
 Optimally managed HIV positive pregnant women with endometritis and
chorioamnionitis may be allowed vaginal delivery
 Drugs used in postpartum hemorrhage should be used with caution due to
possible drug interaction with ARVs like Protease inhibitors, Integrase inhibitors,
methylergometrine aleate and other ergometrine

INFANTS BORN TO HIV MOTHERS SHALL BE GIVEN ARV PROPHYLAXIS AT

BIRTH WHEN HIV EXPOSURE IS RECOGNIZED AT BIRTH

SCENARIO INFANT ARV DURATION

PROPHYLAXIS
Infants of mothers who are Daily Nevirapine 6 weeks
receiving ARV for at least 4
weeks and are
breastfeeding
6 weeks
Infants of mothers Daily Nevirapine
receiving ARV for at least 4
weeks and are on
replacement feeding

Infants born to mothers Start treatment at birth 6 weeks

with HIV who are at HIGH
RISK of acquiring HIV
(breastfed or formula milk)

Infants who are at HIGH Start treatment at birth 12 weeks

RISK of acquiring HIV
including those 1st
identified as exposed to
HIV during postpartum
period (breastfed or
formula milk)