Dr. Mona Loutfy: HIV transmission and breastfeeding in Canada

Dr. Mona Loutfy: HIV transmission and breastfeeding in Canada

February 14, 2020 0 By Jose Scott


I’m Mona Loutfy, I am an infectious
disease specialist and professor at Women’s College Hospital and
the University of Toronto. The current Canadian
infant feeding guidelines in the context of HIV
are pretty straightforward. Two organizations or groups have come
out with recommendations or statements. One is Health Canada, the second one is the
Canadian Pediatric AIDS Research Group. And both of them recommend no
breastfeeding and they recommend exclusive formula feeding. CPARG’s
statement, which was actually very helpful, does say that
if a woman does plan to breastfeed, it’s not instant
recommendation that a child protection agency gets called, but to work with the
woman and support the woman. The challenges with the current Canadian
guidelines on infant feeding is that they’re in contrast to international
guidelines. In August 2016 the WHO came out with new infant feeding guidelines
that supports women living with HIV to breastfeed. Now, they mainly focus on
women that come from low- and mid-income countries, but many women living with HIV
in Canada actually are originally from those countries. So they’re unclear, or
there’s confusion, about what they should do. Should they follow the Canadian
guidelines? Should they follow the WHO guidelines? And some women want to
breastfeed. The other big challenge is that there’s a real question whether
there’s transmission of HIV through breast milk when the mother living with
HIV is on antiretroviral therapy with a fully suppressed viral load. We’ll never
completely know that answer. It’s probably very, very low chance, negligible,
but we’ll never know. But there’s this battle between
pediatric infectious disease specialists, adult infectious disease specialists, the
community. Maybe ‘battle’ is not the right term, but a heated discussion about
what the best thing is to do for the child, for the mother, for the family.
Whether it is exclusive formula feeding or exclusive breastfeeding. The challenges
for care providers regarding infant feeding in the context of HIV is that
the guidelines are contrasting, women want to breastfeed, pediatric infectious
disease specialists don’t want women to breastfeed, and as an adult infectious
disease specialist I feel a bit caught
in the middle. We know that, from two studies,
HPTN 052 and the PARTNER study, that if a person living with HIV takes
their antiretrovirals and is fully adherent with a fully suppressed viral
load, they do not transmit HIV sexually in studies. That’s incredible.
We also know that if a woman is on antiretroviral therapy before she gets
pregnant and takes antiretroviral therapy during her entire pregnancy, the chance
of the baby becoming infected is zero! Also incredible. So I ask you, why doesn’t
that translate also to breastfeeding? I think it likely does. The problem is
we’re probably never going to get the study in breastfeeding. We’re never going
to get an HPTN 052 study in breastfeeding and HIV. So there’s always
going to be this debate, this controversy, and I’m not sure what to do about it. It takes a long time to counsel a woman
now. At least we’re doing counselling now. Ten years ago, when I started in the field
I used to just do, “No breastfeeding!” “Complete formula-feeding!”
But now it takes much longer. There’s much more to discuss, more choices,
which is actually a good thing. Discussing that some guidelines say it’s
okay to breastfeed and that we don’t know what the transmission is, but that
it’s very, very low. So it can take up to 30 minutes, 45 minutes, one hour, and this
is a long period of time for a physician. I think what service providers need to
know about infant feeding and HIV is that it should really be a shared care
decision-making process. The first thing is they should discuss breastfeeding,
infant feeding with the expectant mother, parents living with HIV. What that means
is to start with a compassionate discussion about, what do you feel, and
how are you feeling about breastfeeding and HIV? Do you want to breastfeed, do you
not want to breastfeed? There are options. Formula is an excellent option. It’s been
highly developed, it does provide very good nutrients now. Teaching that a
person can bond with a baby even while providing a bottle and that actually
that opportunity can be shared amongst different people. So
predominantly in Canada, probably 95, 98-percent-plus will formula feed, and
that’s great. But what if somebody does want to breastfeed? I think a care
provider should know the data. It’s relatively complicated, so they can’t
just go, okay go and breastfeed. What’s being done in Toronto if a woman wants
to breastfeed: I see her as an adult infectious disease specialist, the
pediatric infectious disease specialist sees her, we often will get a social
worker, a midwife involved to support her, the baby after being born is being given
triple antiretroviral therapy, the mother is being seen every month for adherence
checking and viral load taking, the baby is being seen by pediatric infectious
diseases once a week or twice – or every two weeks for also viral load
checking. It’s relatively intensive. So one of the things I want service
providers to know is to not just say go and breastfeed. The woman has to be
followed, supported and it’s relatively complex. But I want service providers in
Canada to know that it is maybe an option now.