Tag Archives | HIV

New HIV and Breastfeeding Resource from the World Alliance for Breastfeeding Action (WABA)

By Pamela Morrison, IBCLC

Photo by  DFID - UK Department for International Development via Flickr Creative Commons

Photo by DFID – UK Department for International Development via Flickr Creative Commons

Have you gained the impression that maternal infection with the Human Immunodeficiency Virus (HIV) automatically rules out breastfeeding? Or that formula-feeding by HIV-positive mothers, whenever possible, is always recommended? If you have had access to different global World Health Organization (WHO) HIV and infant feeding recommendations over the years, do you find them confusing? If the answer to any one of these questions is Yes, then you are not alone.

Based on the huge amount of research conducted since the 1985 discovery that HIV could be transmitted in mothers’ milk, global guidance about breastfeeding in the context of HIV has been changing every few years. One of the spillover effects has been that IBCLCs and others who work with mothers and babies have frequently been exposed to outdated and/or myth-information.

However, IBCLCs can now feel more confident than ever before in supporting HIV-positive clients who express a desire to breastfeed. With certain safe-guards, including maternal adherence to antiretroviral (ARV) regimens which are mandatory in developed countries, the risk of transmission of HIV through breastfeeding can be reduced to virtually zero.

Originally conceived as a joint ILCA-WABA collaborative project, with a gestation period of over seven years, WABA marked World AIDS Day this December with the easy delivery of a new Comprehensive Resource entitled “Understanding International Policy on HIV and Breastfeeding” which can be downloaded HERE.

Intended for use by policy-makers, national breastfeeding committees, breastfeeding advocates, women’s health activists and others working for public health in the community, the Resource sets out why breastfeeding in the context of HIV has never been as safe as it is today. Recent research shows that HIV-positive mothers who receive effective ARVs, protecting their own health sufficiently to result in a near-normal life-span, can also expect that the risk of transmission of HIV to their babies during pregnancy, birth, and throughout the recommended period of breastfeeding, can be close to zero. As a consequence, today’s HIV-positive mothers are enabled to avoid both the stigma and the risks of formula-feeding because current HIV and infant feeding guidance is once again more closely aligned to WHO recommendations for their uninfected counterparts, in place over the last decade: exclusive breastfeeding for 6 months and continued breastfeeding with the introduction of age-appropriate complementary feeding for up to 2 years or beyond.

Building on current research, the 2010 global HIV and infant feeding guidelines and ARV recommendations for prevention of transmission of vertical HIV show that, for the first time, there is enough evidence to recommend ARVs while breastfeeding. Where ARVs are available, it is recommended that HIV-positive mothers breastfeed until their babies are 12 months of age. Furthermore, updated WHO programmatic advice issued earlier this year for ARVs for pregnant women and prevention of HIV infection in their infants has gone a long way towards clarifying many previously perceived ambiguities. Rather than different ARV regimens being decided on the basis of an individual HIV-positive mother’s disease progression, a clear recommendation is now made for provision of ARVs to all HIV positive pregnant women from the time that they are first diagnosed with HIV and continued for life.

With proper treatment, an infected mother’s viral load becomes undetectable, not only protecting her own health and survival, but also reducing to virtually zero the risk of her baby acquiring HIV through her breastmilk.

Thus, current guidance has enabled countries as diverse as South Africa and the United Kingdom to develop national recommendations which once again effectively support breastfeeding for all babies. The up-to-date guidelines simultaneously free health workers from having to tailor infant feeding advice to the HIV-status of their clients and lift from HIV-positive mothers the stigma attached to previous advice about formula-feeding. Most importantly, current guidance ensures the greatest likelihood of HIV-free survival for babies exposed to the virus.

Fully referenced throughout, the Resource’s six sections clarify many past misconceptions by helping to explain how they came about. They track the impact of HIV on women and their infants, review past and current research on transmission of the virus through breastfeeding, trace the evolution of past guidance, outline current policy and counselling recommendations and list easily accessed informational and training materials.

The Resource clarifies how, in a situation of competing infant feeding risks, breastfeeding can now be safely promoted and supported. It is hoped that this tool will enable all who work with HIV-positive mothers to confidently endorse current HIV and breastfeeding recommendations so that each individual child’s chance to survive and thrive can be maximized.

We hope that this document impacts practice and helps to support mothers with HIV all over the world. Please download your own copy of “Understanding International Policy on HIV and Breastfeeding” HERE

pmorrisonPamela Morrison’s interest in HIV and breastfeeding arose from having worked as a private practice IBCLC in a country where HIV-prevalence amongst pregnant women reached 25%, yet breastfeeding was both the cultural norm and a cornerstone of child survival. While in Zimbabwe, Pamela also worked as a BFHI Facilitator and Assessor, as well as serving on the Zimbabwe National Multi-sectoral Breastfeeding Committee and the national BFHI Task Force. She has also served on the World Alliance for Breastfeeding Action (WABA) Task Forces for Children’s Nutrition Rights, and for HIV and Infant Feeding, and the ILCA Ethics & Code Committee. After moving to England in 2005, she was employed until 2009 as a Consultant to WABA. She is currently the ILCA media representative on HIV, and continues to do volunteer work for WABA.

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The Power of Milk Donation at Milk Matters in Cape Town, South Africa

By Louise Goosen, RN, RM, IBCLC

Put a group of enthusiastic “Lactavists” in a room, give them a challenge and WOW, there is no holding back!

The story of Milk Matters Milk Bank in South Africa started 10 years ago at Mowbray Maternity Hospital in Cape Town where two of the  founding members were employed part time as lactation consultants. With the support of our colleagues, we collected 20 liters of milk only to discover, to our horror, that no one was interested in using our precious bootie … not surprising when the HIV rate in the country was over 25%.

Soon, our modern day hero, Dr Allan Horn, a neonatologist from Groote Schuur Hospital, heard about our precious milk. He was eager to use our pasteurised milk as he believed it could make a difference to the unacceptably high mortality and morbidity rates of the micro-premature babies in his unit. He was right and soon two other hospitals were requesting donor milk.

Those were small beginnings. We have since registered as a Public Benefit and Non Profit Organisation, improved our donor and milk screening techniques, developed posters, pamphlets and promo videos, sent regular articles to magazines and newspapers, developed a website, and established a presence on Facebook and Twitter. This has enabled us to dramatically increase the Milk Matters donor base. Subsequently, our processing rate has grown from one liter per week to almost six liters a day and it is still not enough. We supply donor milk to four large neonatal intensive care units on a daily basis and 24 other hospitals when the need arises.

Although we started “giving our milk away” at no charge, this had to change and we are now forced to charge a processing fee in an attempt to recover some of our costs. Our sustainability would not have been possible if it were not for the founder members who still offer their services voluntarily.

There is plenty still to be done. In a developing country where the exclusive breastfeeding rate at 6 months is a mere 8%, we could never rest on our laurels. The need to increase our breastfeeding rates as a nation is paramount. Donor breastmilk must never be viewed as a replacement for mother’s own milk, but it does fill the gap when ill health prevails or when mothers need the time to build up their own supply.

Encouraging all mothers to consider the impact of human milk is critical. Crippling, outdated information that “forbade” HIV+ mothers to breastfeed has changed and HIV+ mothers are now actively encouraged to breastfeed while they and their babies have access to antiretroviral (ARV) drug treatment. Twelve months ago, our National Department of Health called on each and every one of us to reinstitute breastfeeding as the norm in our communities. What’s more the Department is encouraging the establishment of donor milk banks throughout the country. Milk Matters has already helped in the setting up of 5 other milk banks and more are in the developmental stages. Our latest invite is from further afield, Malawi, a fellow African country to the north of us.

Milk Matters continues to reach out as the approximately 50 babies that we are feeding every day or 1,500 babies that we are feeding every month isn’t enough. Many more need access to their own mothers’ milk and that is where our true mission lies.

Please visit us on the web at www.milkmatters.org or on Twitter at www.twitter.com/milkmatters.

Louise Goosen’s full time career in breastfeeding started in 1986 when she also ran birth preparation classes for 7 years. She qualified as an IBCLC in 2003. She has been a member of the South African Breast Feeding Association for the last 30 years and been chairperson for over 10 years. Since its inception in 2002, she has been an active member of the South African Kangaroo Mothercare Foundation (KMC). After ten years at Mowbray Maternity Hospital as the resident IBCLC and BFHI co-coordinator, trainer and assessor, she has taken up the voluntary position as chairperson of the breastmilk bank, Milk Matters. She is also still involved with breastfeeding and KMC training for medical, physiotherapy, dietetic and nursing students.

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Are Oligosaccharides a Key to Reducing HIV in Breastfed Babies?

One of the most fascinating mysteries of our time is the low rate of mother-to-infant transmission of HIV via the milk of an infected mother. In the absence of antiretroviral drug therapy (ART), 10-15% of babies born to infected mothers acquire the virus from breastmilk; when both mother and infant are treated with ART, this incidence can be reduced to 2% or less.

Several components of human milk have been shown to offer protection to those more than 85% of babies who don’t get HIV after repeated exposures. Immunoglobulins, like IgA, IgG, and IgM provide specific immune response to certain pathogens; lactoferrin accomplishes various tasks, to include killing bacteria and preventing  surviving bacteria from multiplying. In a study released earlier this year, researchers at Duke University in North Carolina reported that HIV-specific B-cells found in the colostrum of infected mothers actually neutralize the virus. An international team of researchers based in California, New York, Boston, and Zambia, in a study released on August 15 by the American Journal of Clinical Nutrition (Bode, et al., 2012) identifies yet another protective component: human milk oligosaccharides.

Oligosaccharides are plentiful in breastmilk, and there are over 130 of them (Smith, 2008). They are made from chains of simple sugars, and they do a few things that make them superheroes in the fight against pathogens – any invading virus or bacteria. Oligosaccharides are PREbiotics, which act like food for good bacteria in the baby’s gut. Prebiotics feed and promote the proliferation of PRObiotics, which crowd out pathogens. Another important, protective function of oligosaccharides is that they prevent pathogens from attaching to the gut lining. They do this either by attaching to the part of the bacteria or virus that would attach to the baby’s gut, or by themselves attaching to the gut epithelium and, in essence, occupying all of the “docks” where pathogens might seek to put down a mooring. Oligosaccharides are most plentiful in the earliest days, weeks, and months of breastfeeding, decreasing in number and volume as the baby gets older. Oligosaccharides are undigestible, which allows them to populate the baby’s intestine; the large volume of oligosaccharides is part of what causes a newborn to stool often, perhaps every time he breastfeeds.

This mechanism is also protective against HIV and other viruses, because the frequency of the bowel being emptied doesn’t give pathogens time to “set up shop” and get down to the business of infecting the baby. This is one possible explanation for why the protective effect of breastfeeding against HIV may wane as the baby gets older. Of the 12.1% of infants who acquired HIV through their mother’s breastmilk, 68.2% of those transmissions occurred after 6 months (Iliff et al., 2005). The addition of complementary foods may also cause or allow for breaches in the infant’s gut integrity; it is through these breaches that HIV can be acquired. The findings reported by Bode, et al. are exciting. We already knew that oligosaccharides play a significant role in keeping babies healthy and free from infection, but recognizing that, in high enough concentrations, they actually protect infants from a pathogen that is present in the milk is remarkable. In nations where the risk of infant death from gastrointestinal or respiratory infections is higher than the risk of transmission of HIV from an infected mother to her baby, understanding why and how a mother’s own milk gives her infant his best chance for survival can provide important teaching points for public health workers, especially when cautioning against mixed feeding of these vulnerable infants. Additionally, these innate protective factors in human milk offer insight into how a vaccine against HIV might be developed for use in adults at risk of acquiring the virus.

References:

Bode, L., Kuhn, L., Kim, H., Hsiao, L., Nissan, C., Sinkala, M., Kankasa, C., et al. (2012). Human milk oligosaccharide concentration and risk of postnatal transmission of HIV through breastfeeding. American Journal of Clinical Nutrition (ePub ahead of print). doi: 10.3945/ ajcn.112.039503

Friedman, J., Alam, S. M., Shen, X., Xia, S. M., Stewart, S., Anasti, K., Pollara, J., et al. (2012). Isolation of HIV-1-neutralizing mucosal monoclonal antibodies from human colostrum. PLoS One 7(5). doi: 10.1371/journal.pone.0037648

Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J., Moulton, L. H., et al. (2005). Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 19(7), 699-708.

Smith, L. (2008). Biochemistry of human milk. In R. Mannel, P. J. Martens, & M. Walker (Eds.), Core Curriculum for Lactation Consultant Practice (pp. 269-284). Sudbury, MA: Jones & Bartlett.

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana recently retired after serving as a clarinetist on active military (Army) duty in the West Point Band since 1995.

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