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Dr. Turck:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and joining me today to discuss his presentation at the 2023 ANAC Conference that focused on the new recommendations for infant feeding for patients with HIV is Dr. William Short. Dr. Short is an Associate Professor of Medicine and Infectious Disease at the University of Pennsylvania in Philadelphia. Dr. Short, thanks for joining me today.

Dr. Short:
Well, thank you for having me. It’s a pleasure to be here.

Dr. Turck:
So to get us started, Dr. Short, what are the current recommendations for patients with HIV when it comes to feeding infants?

Dr. Short:
So in January of 2023, there was an update to the guidelines. Just to give you a little historical perspective, prior to that there had been a really clear recommendation that breastfeeding was not the preferred method of infant feeding due to the risk of transmission. So the major change that came about in January of 2023 was to now support parental choice through shared decision-making and that it did not take into account a specific infant feeding mode. It was really about a choice, and that really was the key difference that came out of the guideline update.

Dr. Turck:
As a follow-up to that, are there different recommendations for mothers who are on antiretroviral therapy during pregnancy versus those who are not?

Dr. Short:
Sure. So the way I approach it—and I think it’s good to start here because I think this is a topic that is probably not familiar to many individuals or providers—when I see someone who is of childbearing potential, I often first ask, “Are you interested in having a child?” I think that’s one of the first things. But more specifically, when I look at talking about infant feeding or breast or chest feeding, I think it’s important to one, be very clear what the guidelines recommend, and number two—and I think this is really the point that really stands out the most having provided this counseling for many individuals—the key is to let individuals know that achieving and maintaining viral suppression with antiretroviral therapy—so someone’s taking their antiretroviral therapy, they’re fully suppressed, and you do that through pregnancy and the postpartum period—it decreases your risk of transmission through breastfeeding to less than 1 percent, but it is not zero.

Dr. Turck:
And how does the risk of HIV transmission through breastfeeding compare to other modes of transmission to infants?

Dr. Short:
So most of it is when you think about perinatal HIV transmission, we typically think of that as occurring at one of many time points, right? So it can occur during the pregnancy, it can occur at delivery, and then it can also occur postpartum. And postpartum is usually through breast or chest feeding, so we just covered that. But I think when you look throughout the pregnancy, the majority of transmission tends to occur at delivery; about 2/3 occurs at delivery. Having said that, with moderate antiretroviral therapy, if someone is taking antiretrovirals and is fully suppressed from the time of conception all the way through pregnancy, they basically have a zero risk of transmission. This is new data that we have. But if someone comes in and they start antiretroviral therapy, they get suppressed, we say also that it’s a less than 1 percent chance.

And really, the number of cases of perinatal HIV transmission in the United States have really hit an all-time low. Our latest data is out to 2019. I know the CDC does have some that take into account after the COVID-19 pandemic, and the rates are still low at less than 1 percent. And when you take into account those individual transmissions, there are really a lot of serious factors that go into play like not taking any retrovirals, not having HIV testing, or if there’s an acute seroconversion during their pregnancy.

Dr. Turck:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. William Short about the new infant feeding recommendations for patients with HIV.

So given everything we’ve discussed so far, Dr. Short, what role does maternal viral load suppression play in the new recommendations, and how is it monitored?

Dr. Short:
So viral load suppression is critical to this whole process. When you look at someone who has sustained undetectable viral load and they say they want to breast or chest feed, I think it’s important that we support them in that. If you have someone who has a detectable viral load, you really should talk to them about what are the risks of that transmission because their viral load is higher, but really, viral load is critical. And right now during the postpartum period with infant feeding, there really are no clear guidelines on how often viral loads should be monitored, and this is something that among many individual sites and providers is very varied. It’s a heterogeneous sort of mix of what people are doing. We tend to follow viral loads monthly in someone who has decided to breast or chest feed, and that is something that we’ve been doing. And then if there’s any increase in detectability or there’s an increase in the viral load, again, it’s a conversation we have with that individual person who is doing the feeding.

Dr. Turck:
Now prioritizing mental health and education are both incredibly important when it comes to making informed decisions, so what are the recommendations for counseling patients with HIV about feeding their infants?

Dr. Short:
There’s a couple different counseling points that are really critical when you go through the guidance document. One thing we’ve done at Penn, and this is in collaboration with Children’s Hospital of Philadelphia who we work as a group to provide care, so it’s really three different disciplines. It’s an HIV provider, which is myself, the obstetrical or high-risk maternal-fetal medicine provider for OB, and then the pediatric providers. So the three of us work together in collaboration to provide this specialty care, and we have come up with a document that really addresses that question you just asked about, and it’s really a series of bullets that we go down. We’ve actually taken this to our Community Advisory Board and had them review it, and they really liked it, but it’s more of a checklist. So it’s just what you said. We want to make sure when we’re talking to someone, we hit all those points.

So one of the points right out of it is I understand that infant feeding with properly prepared formula or pasteurized donor human milk from a milk bank eliminates the risk of HIV transmission to the infant, and we want to make sure we provide that counseling. And then the next one really follows through what I mentioned about if you have viral suppression on antiretroviral, it reduces your risk to less than 1 percent but not zero. So we do that. And other counseling points we talk about is that providers may do more testing on the infant. The infant may get different medications. You’re going to work on how to transition to formula feeding and really keeping open lines of communication, and all that is really built in this document. And like I said, between the three different groups of providers, we really go through that to make sure we hit all the key points, which I think is essential.

Dr. Turck:
And before we close, Dr. Short, are there any additional thoughts you want to leave with our audience today?

Dr. Short:
So I think one of the points we didn’t talk about is I ask you to look at an individual who comes to you with this request because there have been many cases of providers where they are adamant and absolute that this should not occur. And what happens when you set that expectation and the patient wants to breast or chest feed, they’re going to do it, and then what’s going to happen is they’re going to do it out of care, not taking antiretrovirals where the risk is higher, so I think it’s very important to sort of have these ongoing conversations and really to figure out, what was the motivation? What is the motivation to actually do this? Why do you want to do it? And for many people, once I mention that it’s not zero risk, they automatically say, “Oh, I’m not going to do that.” So, you know, there’s a misconception that “Oh, people are not really concerned about it.” They are. And believe me when I say that the majority of people I talk to back away. But there are some other individuals who have a really strong reason why they want to breast or chest feed, and I think you need to get that.

And my final point is that—and it was really clear in the guidelines, and I think it’s important—engaging Child Protective Services or similar agencies is not an appropriate response to an infant feeding choice of an individual with HIV. All that does is worsen stigma. I’ve seen patients where it happens, and you ruin a very potential wonderful experience for this person, so I ask you to please get yourself educated and updated on this topic. It’s changing, it’s not going away, and you need to be ready when someone presents to you and asks you for the service.

Dr. Turck:
Well, the health and well-being of mothers with HIV and their growing infants is such an important topic. And I want to thank my guest, Dr. William Short, for sharing his valuable insights from his presentation at the 2023 ANAC Conference.

Dr. Short, it was a pleasure speaking with you.

Dr. Short:
No, thank you so much. It was a pleasure to be here.

Dr. Turck:
For ReachMD, I’m Dr. Charles Turck. To access this and other episodes in this series, visit Clinician’s Roundtable on ReachMD.com where you can Be Part of the Knowledge. Thanks for listening.