Research ArticleHIV

HIV-1 Concentrations in Human Breast Milk Before and After Weaning

Science Translational Medicine  17 Apr 2013:
Vol. 5, Issue 181, pp. 181ra51
DOI: 10.1126/scitranslmed.3005113

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Knowing When to Wean

Breast-feeding is essential for infant survival and well-being in the low-resource settings in sub-Saharan Africa most affected by the HIV-1 epidemic. This necessitates breast-feeding by HIV-1–infected mothers despite the 10 to 15% risk of transmitting the infection to the infant via breast milk. Concentrations of HIV-1 in breast milk influence whether the breast-fed infant will acquire infection. Kuhn and colleagues conducted a clinical trial among 958 women in Lusaka, Zambia, to evaluate the safety and efficacy of exclusive breast-feeding followed by abrupt weaning at 4 months as a strategy to prevent postnatal HIV-1 transmission and promote healthy child survival. Women were randomized to wean abruptly at 4 months or to continue breast-feeding for a duration of their own choosing and were followed with their infants from delivery to 24 months postpartum. Infants were tested at regular intervals to determine their HIV-1 status, and concentrations of HIV-1 RNA and DNA were measured in breast milk at 4 and 4.5 months. Two weeks after weaning (4.5 months), HIV-1 concentrations in breast milk were substantially higher than if breast-feeding continued. Among those continuing to breast-feed at 4.5 months, HIV-1 concentrations in milk were lowest if breast-feeding was exclusive. The boost in milk HIV-1 concentrations during weaning counteracted any advantage of shortening the duration of breast-feeding on overall postnatal HIV-1 transmission risks. Breast milk is produced in response to infant suckling. The new data demonstrate that changes in the frequency of suckling as occurs with nonexclusive breast-feeding and at the time of weaning also influence HIV-1 concentrations in breast milk. The results support continuation and possible intensification of maternal antiretroviral drug treatment over the full duration of time when any breast milk exposures are likely to occur after planned weaning.