HIV This Week

Kantarci S, Koulinska IN, Aboud S, Fawzi WW, Villamor E. Subclinical Mastitis, Cell-Associated HIV-1 Shedding in Breast Milk, and Breast-Feeding Transmission of HIV-1. J Acquir Immune Defic Syndr. 2007; 46(5):651-654.

Mastitis has been identified as a risk factor for mother-to-child transmission of HIV-1 through breast-feeding. It is unclear whether this association is mediated by increased cell-free virus versus cell-associated virus HIV shedding in breast milk. Kantarci and colleagues examined the risk of mother-to-child transmission associated with subclinical mastitis and the relation between mastitis and cell-free virus or cell-associated virus shedding in breast milk. Fifty-nine women who transmitted HIV through breast-feeding (cases) were individually matched to 59 non-transmitting controls nested in a cohort from Tanzania. For each case, the authors selected a milk specimen obtained before the infant's first positive test to quantify sodium and potassium and measure cell-free virus and cell-associated virus concentrations. Controls were matched on the child's age at the time of sample collection. Women with a breast milk sodium/potassium ratio suggestive of mastitis (>1.0) had an 11-fold greater odds of transmission (95% confidence interval [CI]: 1.2 to 98.1), compared to women with a sodium/potassium ratio </=0.6, after adjusting for maternal CD4 cell count and vitamin A supplementation. Although mastitis was positively related to both cell-free virus and cell-associated virus shedding in breast milk, only the association with the latter was strong and statistically significant. In conclusion, increased cell-associated HIV-1 shedding in breast milk could mediate the association between mastitis and mother-to-child transmission.

Editors’ note: Simpler methods to diagnose sub-clinical mastitis, studies to determine when it is safe to resume breast-feeding from the affected breast, and the results of current trials underway assessing the prevention efficacy of antiretroviral treatment provided to HIV-positive lactating women and/or their breastfeeding infants are needed for informed policy guidance.

In April 2007, UNAIDS released Securing the future-advocating for children, a call for the global community to recognize that "children still remain largely absent from national and international political responses to the AIDS pandemic". Most efforts to date to protect children from HIV have focused on prevention of mother-to-child transmission programs. Though expanding prevention of mother-to-child transmission programs, particularly in sub-Saharan Africa, are crucial, even widespread prevention of mother-to-child transmission programs would still be grossly inadequate for achieving the goal of protecting children from HIV. The global community needs to fundamentally reframe its approach to HIV prevention to fully address the health of families; otherwise the future for at-risk children is likely to remain bleak. After identifying challenges with current approaches, Heymann and colleagues review recent research that provides insights into ways prevention programs may be adapted to better protect families and children from the devastating consequences of HIV. Only by protecting families from HIV will we be able to achieve the goal of an HIV-free generation.

Editors’ note: HIV prevention among partners is key to preventing children becoming infected or being orphaned due to HIV. Couples have a joint incentive to remain HIV-free, to identify HIV infection in either partner early to prevent onward transmission and access treatment, and to make fertility plans together.