Update on postnatal prophylaxis with antiretrovirals and controversies in breastfeeding in children of HIV mothers

Abstract

The adoption of prophylaxis measures has reduced Vertical Transmission (TV) to less than 1% in Spain in the children of women with HIV (MVIH) New cases of infection are usually due to failures in the implementation of TV prevention measures during pregnancy. Although plasma viral load (CVp) close to delivery is the most important risk factor in VT, there are other factors to consider, such as prematurity, type of delivery, time of rupture of the water... and maternal clinical situation, including primary infection during pregnancy. These factors are minimized if undetectable pCV (< 50 copies/ml) is reached before delivery after antiretroviral treatment (ART) during pregnancy. In addition, postnatal prophylaxis with antiretrovirals (ARV) as monotherapy or combination therapy has been shown to be effective in reducing HIV VT in combination with previous measures and as the only measure in the case of newborns of an HIV-infected mother who did not receive antepartum/intrapartum prophylaxis measures. In recent years, the use of triple therapy in high-risk cases of TV has increased. Postnatal prophylaxis should be started as soon as possible, and it is recommended to start in the first 4-6 hours of life. In low-risk newborns, prophylaxis has been simplified to 2-4 weeks of oral AZT (zidovudine). As for the feeding of these newborns born to MVIH, exclusive artificial breastfeeding is currently the only form of feeding that does not involve risk of transmission and is the recommended feeding method in our environment.
The real risk of mother-to-child transmission of HIV associated with breastfeeding in the context of universal ART, adherence to treatment, and undetectable plasma viral load (pCV) is unknown. It is below 1%, but it is not zero. Currently, breastfeeding could be considered non-contraindication only if all of the following conditions are met: history of adherence to excellent ART; viral suppression for as long as possible, and at least the third trimester of pregnancy; commitment to postpartum bonding and the possibility of breastfeeding support and/or previous breastfeeding experience; availability of accessible lactation consultants to respond to unforeseen situations; close analytical control with monthly qvP in the mother until the end of the lactation period and a viral load recommended 2 months after the end of breastfeeding.