A Study of Breastfeeding and HIV.

Clinical Problem: Advising the HIV-1 exposed or infected woman regarding the possibility of the HIV-1 virus being passed through breastmilk to her infant.

This is of critical concern to mothers and their infants in this country and abroad. Women must be made aware of the risk of infection to their infants from affected human milk, their own or someone else's. They must also have the benefits of continued breastfeeding in the face of HIV portrayed accurately.

Research done in the area of breastfeeding and HIV has shown that the HIV-1 virus is present in the breastmilk of HIV-1 infected mothers. "Proviral HIV-1 DNA has been detected via the polymerase chain reaction (PCR) in 22 of 31 breastmilk samples of HIV-1 positive women" (Palasanthiran et al., 1993, 443).

In addition, a link has been established with the timing of the mother's post-natal seroconversion and the breastfeeding child's seroconversion closely thereafter.

Dunn et al. (1992) states that "mothers who acquire HIV-1 postnatally can transmit the infection through breastfeeding; our summary analysis indicates a 29% risk of transmission under these circumstances" (587). Additionally they found that "infants may be at especially high risk of acquiring infection during the viraemia [presence of virus in the blood] that is commonly observed in primary HIV infection; this view is supported by the finding that children acquired infection shortly after their mothers" (587).

Even so, studies themselves show flawed and circumstantial evidence of transmission by this route. Riordan (1993) states that "although the potential for HIV-1 transmission through breastfeeding exists, the proportion of transmission attributable to breastfeeding is not established" (3). This is due to the inability to know exactly when the mother was exposed to HIV-1 and then when she seroconverted. Should it have been prior to birth and she was asymptomatic she may have been in the window period of conversion unknowingly during the pregnancy. This means that the transmission of the HIV-1 was likely passed prenatally and does not necessarily implicate nursing.

It has been documented that prenatal transmission of the HIV-1 virus can occur. "The vast majority of seropositive women who give birth to HIV infected infants are themselves asymptomatic. Moreover, the majority of infants who are born to seropositive mothers are uninfected. Indeed, the current rates of maternal-fetal transmission average about 25 to 30 percent" (Pizzo and Butler, 1991, 652).

It is also important to know that the presence of viruses other than the HIV-1 virus commonly appear in human milk. Some of these viruses pass through breastmilk and act beneficially to protect the infant, others do not. "Cytomegalovirus is readily transmitted through breastmilk. For healthy fullterm neonates, this exposure results in antibodies that give the baby a lifelong resistance without the baby becoming ill. Likewise, the rubella virus can be passed through maternal milk lymphocytes to the infant without the baby who acquires rubella in this manner becoming ill" (Riordan, 1993, 3).

When counseling the HIV exposed or infected breastfeeding mother, it is important to know that the HIV-1 virus is an enveloped virus and research has shown that the antiviral properties of lipids in human milk may inactivate the HIV-1 virus.

The gastrointestinal tract of the infant has been studied to determine if the mucosal lining is the transmission site for the HIV virus. Pizzo and Butler (1991) suggest "that the gastrointestinal tract may be the focus for the entry of HIV during vertical transmission and underscores the importance of increasing our knowledge of mucosal immunity" (653).

Experiments conducted at Johns Hopkins Children's Center in Baltimore by Robert Yolken have been aimed at confirming the infection fighting properties of antibodies in human milk, "yet when they were separated from breastmilk and rotoviruses were incubated in what was left, contrary to expectations, the viruses did not multiply" (Raloff, 390).

Yolken's team identified mucins as the second class of infection-fighting proteins in breastmilk. They also found a much smaller protein in breastmilk that inhibits the replication of rotoviruses--and apparently by the same mechanism: a binding of the virus to sialic acid, a sugar.

Yolken suggests that the newborn probably does not have intestinal mucins, so most of its mucin-derived protection would come from breastmilk. Babies probably make their own mucins as they develop. It is important to note that cow's milk does contain mucins but in lower concentrations than in human milk. The benefits of mucins are not likely to be found in formulas made from cow's milk because most of the milk's protein is filtered out during manufacturing (Raloff, 1992).

Encouraging news comes from studies done by researchers in which fifty-five Haitian infants born to seropositive mothers converted back to being seronegative while breastfeeding and remained clinically well (Arnold, 1993; Riordan 1993). Arnold (1993) also cites a study by Tozzi et al. (1990), which "looked at Italian infants born to HIV-1 positive mothers and found that the breastfed ones had a slower progression to AIDS from birth and that their survival after diagnosis was better than those infants who were bottlefed. The question thus becomes, are there intrinsic factors in human milk that are preventing or inhibiting HIV infection?" (47).

Despite the protective properties found in human milk, through research, the World Health Organization (WHO), UNICEF, the Centers for Disease Control (CDC), and the American Academy of Pediatrics Task Force on Pediatric AIDS (AAP), have released similar recommendations stating that in the United States and other countries where safe nutrition other than breastfeeding is available, HIV infected mothers should be advised against breastfeeding their infants to avoid that possible route of HIV infection.

This has led Hu et al. (1992) to conclude that "recommendations for one group of women will undoubtedly affect other groups. For example, if recommendations that HIV seropositive women should not breastfeed are made, uninfected women may also be discouraged from breastfeeding" (1510). This misinterpretation leads to a vulnerable posture among professional proponents of breastfeeding. Cries for more controlled and larger studies are requested, though followthrough continues to be elusive due to the nature of transmission and the difficulty with pinpointing the moment of infection.

The influence of organizations such as WHO is profound and often results in women from developing nations choosing to bottlefeed where they have little access to the pure water supply needed for success. They also do not generally have the resources to purchase artificial feeding products or the refrigeration necessary for storage. For these reasons breastfeeding is continuing to be encouraged in the developing world, including to those mothers who are HIV exposed or infected. Here the health promoting benefits of mother's milk outweigh the risks of mortality associated with bottlefeeding and HIV transmission. This disparity leads to a double standard.

Human milk needs to be valued as a natural resource and choices that promote its pollution need to be avoided. Even as the protection of pure water supplies is promoted there must be a personal and global commitment to protect this most basic of food supplies, the protection of which governments cannot effectively dictate or legislate.

Additionally, lack of complete information by governments, schools, and health facilities about sexual activity, with or without condoms, does not serve the population who make their choices about sexuality responsibly. It does serve to maintain high risk behaviors and all the related complications of increasing HIV/AIDS and STD transmission, undesired pregnancy, and high teen pregnancy rates.

To make responsible choices, accurate information regarding the effectiveness of condoms in the prevention of transmission of the AIDS and HIV viruses, as well as other sexually transmitted diseases, and their effectiveness in pregnancy prevention needs to be truthful. Note the following:

   We must recognize that there are differences between pregnancy prevention
   and disease prevention. HIV is 1/25 the width of sperm (Goldsmith, 1987,
   2262) and "can pass easily through even the smallest gaps in condoms."
   Researchers studying surgical gloves made out of latex, the same material
   in condoms, found "channels of 5 microns that penetrated the entire
   thickness of the glove" (Arnold, S. et al., 1988). HIV measures .1 microns
   (Dirubbo, 1987, 1306).

   At the National Conference on HIV in Washington, D.C., November 15-18,
   1991, 800 of those in attendance, primarily researchers in the field, were
   asked if they would trust a condom to protect them during intercourse with
   a known HIV infected person. Not one of the raised a hand (Crenshaw, 1991).

In conclusion, the body of research and knowledge to date needs to be taken into account when advising the HIV exposed or infected breastfeeding mother. There are no simplistic answers, though some would follow a formula based primarily on in which country the mother resides. This mother needs support to make an informed decision based on her knowledge of alternatives. The professional lactation consultant, nurse, or other health care provider who keeps current with the professional literature in this area will be an excellent resource to counsel with this woman and her family.

This mother needs to be made aware of the WHO recommendations, she needs to be reassured that her seropositive condition does not restrict her from holding, touching, and kissing her baby. And finally, this mother needs referral to a support network for mothers and children with HIV/AIDS.

References:

Arnold, Lois D. W. 1993. "HIV and breastmilk: what it means for milk Banks." Journal of Human Lactation, 9(1), 47-48.

Arnold, Susan G. 1988. "Latex gloves not enough to exclude viruses." Nature, 8(335), 19. In Focus on the family article. In defense of a little virginity. 1992.

Crenshaw, T. November 1991. From remarks made at the National Conference on HIV, Washington, D.C. In Focus on the family article. In defense of a little virginity. 1992.

Dirubbo, Nancy E. 1987. "The condom barrier." American Journal of Nursing, (10)1306. In Focus on the family article. In defense of a little virginity. 1992.

Dunn, D T., M. L. Newell, A. E. Ades, and C. S. Peckham. 1992. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. The Lancet, 340(8819), 585-589.

Goldsmith, Marcia F. 1987. Sex in the age of AIDS calls for common sense and condom sense. Journal of the American Medical Association, 257(5), 2262. In Focus on the family article. In defense of a little virginity. 1992.

Hu, Dale J., W. L. Heyward, R. H. Byers Jr., B. M. Nkowane, M. Benjamin, M. J. Oxtoby, S. E. Holck, and D. L. Heymann. 1992. HIV infection and

breastfeeding: policy implications through a decision analysis model. AIDS, 6(12), 1505-1513.

Kabara, J. J. 1980. Lipids as host-resistance factors of human milk. Nutrition Review, (38), 65-73. In Orloff et al., see below.

Orloff, S. L., J. C. Wallingford, and J. S. McDougal. 1993. Inactivation of human immunodeficiency virus type 1 in human milk: effects of intrinsic factors in human milk and of pasteurization. Journal of Human Lactation, 9(1), 13-15.

Palasanthiran, P., J. B. Ziegler, G. J. Stewart, M. Stuckey, J. A. Armstrong, D. A. Cooper, R. Penny, and J. Gold. 1993. Breast-feeding during primary maternal human immunodeficiency virus infection and risk of transmission from mother to infant. The Journal of Infectious Diseases, 167(2), 441-444.

Pizzo, Philip A., and K. M. Butler. 1991. "In the vertical transmission of HIV, timing may be everything." The New England Journal of Medicine, 325(9), 652-653.

Raloff, J. 1992. "Breast milk: can it slime away disease?" Science News, 142 (23), 390.

Riordan, Jan. 1993. AIDS and breastfeeding: the ultimate paradox. Journal of Human Lactation, 9(1), 3-4.

Sarkar, N. H. 1973. "Effect of human milk on the mouse mammary tumor virus." Cancer Research, (33) 626-629. In Orloff, et al., see above.

Thormar, H., C. E. Issacs, H. R. Brown, and M. R. Barshatsky. 1987. "Inactivation of enveloped viruses and killing of cells by fatty acids and monoglycerrides." Antimicrobial Agents in Chemotherapy, (31) 27-31.

Tozzi, A., E Pezzoti, and D. Greco. 1990. "Does breast-feeding delay progression to AIDS in HIV-infected children?" AIDS, (4), 1293-1294. In Arnold, see above.

Welsch, J. K., M. Arsenakis, and R. J. Coelen. 1979. "Effect of antiviral lipids, heat and freezing on the activity of viruses in Human Milk. Journal of Infectious Diseases, (140), 322-328. In Orloff, et al., see above.

Yolken, R. H. and D. S. Newburg. 1992. "Anti-HIV components of human milk." In Raloff, see above.

--Mary Braaten Miner has been a CE for over 16 years. Her certifications and experiences are numerous, including ALACE certification, but her real joy comes from sharing her services with the women of the Dominican Republic and Haiti, which she has been doing since 1993.3