Caring for HIV-positive mothers after childbirth is critical, particularly when discussing the health of both the mother and the infant. HIV, if not managed appropriately, can pose significant risks, including transmission during breastfeeding. Therefore, it is essential to establish comprehensive care that addresses breastfeeding practices and overall health considerations.

HIV Transmission Risks During Breastfeeding

The risk of HIV transmission from mother to child through breastfeeding is influenced by several factors, including the mother's viral load, adherence to antiretroviral therapy (ART), infant prophylaxis, and the feeding method (exclusive breastfeeding vs. mixed feeding) during the first six months.

• Mothers Without Viral Suppression

The risk of transmission is higher for mothers who are not virally suppressed or who are not on ART during the third trimester and at delivery. Breastfeeding is not recommended in such cases. If a mother chooses to breastfeed despite these risks, healthcare providers should counsel her on harm-reduction strategies, including strict adherence to ART and infant prophylaxis.

• Mothers with Viral Suppression

For mothers on ART with an undetectable viral load at delivery, the risk of transmitting HIV through breast milk is less than 1%. To minimize this risk, the following practices should be implemented:

-          Monitor maternal HIV viral load every one to two months while breastfeeding.

-          Guide proper breast care and managing issues like overproduction and engorgement.

-          Address any signs of nipple damage, yeast infections, or mastitis promptly.

-          Advise exclusive breastfeeding for the first six months, as mixed feeding increases the risk of HIV transmission.

-          Encourage slow weaning over two to four weeks to reduce risks associated with rapid weaning.

Special Circumstances

Certain conditions may necessitate stopping breastfeeding, such as cracked or bleeding nipples, mastitis, or if the mother has a newly detectable viral load. In these cases, it may be advised to pump and flash heat breast milk to eliminate HIV before feeding or to use formula as an alternative.

Infant Prophylaxis

All infants born to HIV-positive mothers should receive antiretroviral post-exposure prophylaxis to lower the risk of HIV transmission. Ideally, the infant prophylaxis should be initiated within the first six to twelve hours of birth. The specific regimen depends on the mother's viral load and the infant's feeding method.

• For Formula-Fed Infants

-          Infants born to mothers with suppressed viral loads (<50 copies/mL) have a low risk of HIV infection. For these infants, two weeks of zidovudine is typically given if the mother has maintained suppressed viral loads.

-          If the mother has acute HIV or had unsuppressed viral levels during pregnancy, the infant should receive combination ART prophylaxis to mitigate transmission risk.

For breastfeeding mothers with HIV, the approach to infant ART prophylaxis depends on the viral load of the mother and adherence to ART:

• Mothers with Viral Suppression: If the mother is virally suppressed on ART, the necessity of continuing infant ART prophylaxis is debated. Some guidelines suggest extending zidovudine prophylaxis to six weeks, while others recommend shorter durations. A study showed no significant difference in HIV infection rates at six months between infants who continued prophylaxis for six months versus those who stopped at six weeks.
• Mothers Not Virally Suppressed: Breastfeeding is not advised for these mothers due to high transmission risks. If breastfeeding is chosen, infants should receive antiviral prophylaxis, ideally starting with a three-drug regimen for six weeks, followed by daily nevirapine until weaning. Studies indicate that ongoing prophylaxis reduces postnatal transmission risk.

Other considerations

• Monitoring for HIV acquisition occurs every three months during breastfeeding and for several months post-weaning. If an infant tests positive for HIV, they should receive immediate antiretroviral treatment.
• For infants with mothers of unknown HIV status, rapid testing is crucial, and appropriate prophylaxis should be initiated if the results are positive. If the mother is confirmed HIV-negative, breastfeeding can commence without precautions.
• Postpartum Management - All HIV-positive women should continue ART postpartum to prevent disease progression and transmission. However, adherence can be challenging; studies show only about 53% maintain adequate adherence post-birth. Therefore, support and counselling are essential. Additionally, ART regimens may need adjustment based on pregnancy-related factors.
• Family planning discussions are recommended for all mothers, with postpartum contraception offered.

In summary, managing the health and breastfeeding practices of HIV-positive mothers is crucial to minimize the risk of transmission to their infants while ensuring both mother and child receive appropriate care and support.

-This article is authored by Dr. Hira Mardi, Consultant – Obstetrics and Gynaecology, Manipal Hospital Varthur Road.