Maternal HIV-AIDS. Maternal HIV infection

The Human Immunodeficiency Virus (HIV) is a retrovirus that destroys lymphocytes and other cells responsible for the immune (defensive) system of people, making infections and other immune diseases possible.  Acquired Immune Deficiency Syndrome (AIDS) is the final stage of HIV infection, in which the body's immune system is severely damaged by the virus. Not all people with HIV develop AIDS.
HIV is transmitted through bodily fluids:

• In sexual intercourse 
• Through blood: Sharing needles for drug use, transfusions and other contact with blood from an infected person.
• From mother to child during pregnancy, childbirth or breastfeeding (BF).

Before the advent of Combination Anti-Retroviral Treatment (cART), the risk of Mother-to-Child Transmission (MTCT) of HIV through BF was 5 to 42% ^{(White 2014)}. Prevention involves avoiding BF in regions or (developed) countries where the use of formula milk is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). Otherwise, BF in mothers with HIV is preferable because of the higher morbidity and mortality resulting from feeding with BF substitutes. ^{(García 2015)}

The efficacy of cART proven in experiences with breastfeeding mothers in Nigeria and Zambia with IMT ≈ 0 ^{(Ngoma 2015, Okafor2014)}, similar to that obtained (< 2%) when BF is avoided ^{(Lolekha 2017)}, makes that since 2010 WHO has sufficient evidence to recommend as an option to maintain BF in mothers with HIV, provided it is ensured:
    - Lifelong cART follow-up and continuity (Option B+).
    - Monthly viral load controls (< 50 copies/ml).
    - BF pumping and warming in special cases

Since 2016, WHO breastfeeding recommendations for HIV mothers who wish to breastfeed are the same as for non-HIV mothers (exclusive breastfeeding 6 months and then partial breastfeeding two or more years) as long as they take cART and continue viral load controls. Exclusive or non-exclusive breastfeeding and its duration do not influence IMR. Health authorities will provide cART and controls, and, depending on the country's possibilities will decide whether to discourage BF as a preventive measure. ^{(WHO 2016)}

Given the effectiveness of cART, that reduces viral load to undetectable or less than 40 copies/mL and prevents transmission, the campaign slogan Undetectable = Untransmissible (U =U) has been imposed as a paradigm in sexual transmission. ^{(Rodger 2019 and 2016, The Lancet HIV 2017)}

But there are doubts whether U = U is valid for transmission through LM ^{(Kahlert 2018, Waitt 2018)}, as cART suppresses HIV RNA from milk, but not the virus (DNA) associated with CD4+ T cells present in LM ^{(Prendergast 2019, Van de Perre 2012)}. However, it is known that with HIV-DNA in vaginal secretions and zero viral load, there is no horizontal transmission. ^{(Nelson 2020, Prazuck 2013)}

Systematic reviews did not identify any cases of MTCT of HIV through BF in a defined "optimal scenario" ^{(Kahlert 2018)} setting: pregnant woman who has adherence to taking her cART, regular clinical care, and HIV viral load of <50 copies RNA/ml during pregnancy and breastfeeding). The general recommendation in developed countries to criminalize or outlaw BF in mothers with HIV may no longer be warranted; a shared decision-making process and support for mothers with HIV who choose to breastfeed, ensuring cART uptake and viral load checks is advocated. ^{(Symington 2022, Wagner 2020, Agwu 2020, Tuthill2019, Kahlert 2018)}

If the viral load is not suppressed, pumping and pasteurization of own milk or pasteurized donor milk (bank milk) or commercial infant formula is recommended until negative viral load is achieved. ^{(Panel 2024, WHO 2021)}

Several developed countries (Switzerland, Germany, Great Britain, United States, Italy), still recommending avoidance of BF as the most effective measure to prevent MTCT of HIV, have changed their guidelines to support HIV-positive people who choose to breastfeed, receive cART and have a sustained undetectable viral load. ^{(HHS Panel 2023, Gilleece 2019, Kahlert 2018)}

In these countries, dozens of HIV-positive mothers (25 in Switzerland, 44 in the United States, 28 in Canada. 30 in Germany, 13 in Italy, ) have breastfed and HIV detection in infants has been negative months after the end of breastfeeding. ^{(Crisinel 2023, Levison 2023, Weiss 2022, Prestileo 2022)}

Policies that maximize the rate of diagnosis of HIV-infected persons and prophylaxis in serodiscordant cases (HIV seronegative mother with HIV partner) are needed to decrease the cases of MTCT that occur when the mother is infected during infancy. ^{(Anderson 2020, Tan 2017, WHO 2017 & 2014)}

The most commonly used combination of ART is the association of two nucleoside analogue reverse transcriptase inhibitors (NRTIs) with a ritonavir-boosted protease inhibitor (PI/r) or an integrase inhibitor (II): 2 NRTIs + 1 PI/r or 1 II. ^{(HSJD-HC 2023, Nelson 2014)}

During pregnancy and postpartum, cART regimens that include dolutegravir (especially in association with emtricitabine and tenofovir alafenamide) seem safer and more effective in controlling viral load than those that do not ^{(Chinula 2023)}, and can even be associated only with lamivudine. ^{(Rohr 2024)}

ARTs are excreted in very low amounts in BF, with a relative dose of less than 10%, and are very well tolerated by infants  ^{(Aebi-Popp 2022, Kapito 2021, Mugwanya 2017 & 2016, Palombi 2016)}. Concern may be raised about the possible development of resistance if HIV infection occurs in the infant. ^{(Aebi-Popp 2022)}

See below the information of these related products:

• Abacavir (ABC) (Safe product and/or breastfeeding is the best option.)
• Amprenavir (Fairly safe. Mild or unlikely adverse effects. Compatible under certain circumstances. Follow-up recommended. Read Commentary.)
• Atazanavir Sulfate (ATV) (Fairly safe. Mild or unlikely adverse effects. Compatible under certain circumstances. Follow-up recommended. Read Commentary.)
• Darunavir (DRV) (Safe product and/or breastfeeding is the best option.)
• Dolutegravir (DTG), Dolutegravir Sodium (Safe product and/or breastfeeding is the best option.)
• Efavirenz (EFV) (Safe product and/or breastfeeding is the best option.)
• Emtricitabine (FTC) (Safe product and/or breastfeeding is the best option.)
• Lamivudine (3TC) (Safe product and/or breastfeeding is the best option.)
• Lopinavir / Ritonavir (LPV /r) (Safe product and/or breastfeeding is the best option.)
• Nevirapine (NVP) (Fairly safe. Mild or unlikely adverse effects. Compatible under certain circumstances. Follow-up recommended. Read Commentary.)
• Raltegravir (RAL) (Safe product and/or breastfeeding is the best option.)
• Tenofovir (TAF / TDF) (Safe product and/or breastfeeding is the best option.)
• Zidovudine (ZDV / AZT) (Safe product and/or breastfeeding is the best option.)