瑞士醫生表示:當無法檢測到病毒載量時是否提供母乳哺喂,應該向

 

瑞士醫生表示:當無法檢測到病毒載量時是否提供母乳哺喂,應該向感染愛滋病毒之女性傳達其真正的不確定性風險

Keith Alcorn,資料來源:aidsmap news2018823日,財團法人台灣紅絲帶基金會編譯

 

一群瑞士醫生在審查現有證據後得出結論:高收入環境中的愛滋病毒感染婦女,在接受有效的抗反轉錄病毒治療且達到無法檢測到病毒載量時,於充分討論母乳哺喂的風險和益處的基礎上,自己所做出的決定應該得到支持,而不是不鼓勵母乳哺喂。

 

他們的意見 - 以及對證據的討論 - 發表在開放搜尋之期刊“瑞士醫學周刊”上。

他們認為,如果沒有證據顯示當女性在無法檢測到病毒載量時確實透過母乳哺喂而造成傳播,那麼醫務人員有責任提供愛滋病毒感染者有關母乳哺喂的潛在風險和益處等公正信息,並於女性無論做出何種抉擇時均予以支持。

 

在資源有限的環境中,世界衛生組織建議感染愛滋病毒的婦女應該接受抗反轉錄病毒療法和母乳哺喂12-24個月。該指南反映了在資源有限的環境中母乳哺喂在對抗嬰兒死亡率上的保護作用。

 

在高收入環境中,除了少數之例外,國家的治療指南持續阻止正在服用抗反轉錄病毒療法之愛滋病毒感染母親的母乳哺喂。最近在針對相關科學文獻的回顧後,突顯了此尚未解答的科學問題。

但是,一群瑞士醫生現在已經加入英國的同行中,一起共同質疑是否應該完全勸阻母乳喂養。

 

該小組包括一些主要醫院的兒科醫生和婦產科專家,這些醫院為瑞士國內愛滋病毒的感染者提供照護,他們針對自2009年以來已發表的科學文獻進行了審查,以確定透過母乳喂養而傳播愛滋病毒的任何報告的病例。該等母親的病毒載量低於50拷貝/ ml,且持續存留在醫療照護中並完全順從於抗反轉錄病毒治療。他們將此描述為“最佳情景”,並指出在2012年至2016年間在瑞士愛滋病病毒世代中的分娩孕婦分析中,有95.9%的母親在分娩時已經完全抑制其病毒載量,顯示此方案可被廣泛適用。

 

先前對科學文獻的評估著重於對傳播病例上的關注但對於完全病毒抑制的證據上並沒有那麼嚴格要求,因此其中母親是否具有完全抑制的病毒載量則難以確定。一項關於母乳哺喂期間母親抗反轉錄病毒治療或嬰兒預防性治療的隨機研究(PROMISE研究)發現,分娩後6個月的傳播風險約為0.3%,分娩後12個月的傳播風險約為0.7%。

 

但瑞士審查的作者指出,在PROMISE研究的整個調查期間沒有關於病毒載量抑制的證據,這意味著無法確定在本研究期間發生的任何傳播是否發生在「最佳狀態」的條件下。在這種情境下,他們沒有在任何其他文件上發現登載著透過母乳哺喂傳播愛滋病毒的案例。

 

審查的作者說,這留下了臨床上均衡的一種情況 - 真正的科學之不確定性 - 因此醫生應該與愛滋病毒感染者就嬰兒餵養上於做出決定時進行共同之決策。

審查作者建議,在討論了婦女對哺餵上的偏好後,醫療團隊應在討論嬰兒哺餵時向婦女傳達下面所詳列的各點。同時並應告知婦女,無論她們做出了何種決定,都仍將會得到醫療團隊的支持。

 

母乳哺喂 - 潛在的風險

目前在母乳哺喂上並沒有相當於PARTNER這種針對性行為傳播的正式性研究,去評估當病毒載量

  被完全抑制時透過母乳喂養傳播的風險。

迄今為止缺乏傳播上之證據,故不允許我們排除傳播的可能性。

透過細胞有關之病毒傳播的可能性無法排除,對這種可能性目前知之甚少。

目前缺乏有關嬰兒在母乳中攝入的抗反轉錄病毒藥物潛在毒性的信息。

由於睡眠中斷和情緒障礙可能影響這一期間的服藥的順從性,因此在產後期間,服藥的順從性的

  支持尤為重要。

乳腺炎可能會增加傳播風險。

混合餵養(母乳加上任何其他液體,如配方奶粉或固體)可能會增加傳播的風險,因此建議在頭四

  個月進行純母乳喂養。

 

母乳哺喂 - 潛在的好處

母乳哺喂對嬰兒有很多益處,大多數歐洲國家對於HIV陰性母親建議母乳喂養。

母乳哺喂是一種簡單、輕鬆、免費為嬰兒提供營養的方式,。

母乳哺喂透過降低產後憂鬱的風險使母親受益。

母乳哺喂特別是對於年輕女性,可能會降低未來罹患乳腺癌的風險。

母乳喂哺養可降低母親罹患第2型糖尿病的風險,並有助於控制血糖。

 

瑞士的文獻回顧審查與英國愛滋病協會最近的治療指引採取了類似的方法,該協會強調了母親良好參與於醫療照護中和每月病毒載量的檢測,以及在母乳喂養期間嬰兒HIV DNA檢測的重要性。

英國受滋病協會的指引建議,在女性選擇母乳哺喂的情況下,應鼓勵她們在盡可能短的期間內這樣做,最好不要超過六個月。

 

 

Breastfeeding with undetectable viral load: genuine uncertainty on risk should be communicated to women with HIV, say Swiss doctors

Keith Alcorn, Published: 23 August 2018, aidsmap news

 

Women with HIV on effective antiretroviral treatment in higher-income settings who have undetectable viral load should be supported to make their own decisions about breastfeeding based on a full discussion of the risks and benefits, rather than being discouraged from breastfeeding, a group of Swiss doctors has concluded after reviewing the available evidence.

Their opinion – and discussion of the evidence – is published in the open-access journal Swiss Medical Weekly.

They argue that in the absence of evidence that transmission does occur through breastfeeding when a woman has an undetectable viral load, the onus is on healthcare workers to provide unbiased information about the potential risks and benefits of breastfeeding to women living with HIV, and to support women in whatever choice they make.

In resource-limited settings the World Health Organization recommends that women living with HIV should take antiretroviral therapy and breastfeed for 12-24 months. This guidance reflects the protective effect of breastfeeding against infant mortality in resource-limited settings.

In higher-income settings national guidelines continue to discourage breastfeeding by mothers with HIV who are taking antiretroviral therapy, with few exceptions. A recent review of the scientific literature highlighted unanswered scientific questions.

But a group of Swiss doctors has now joined their British counterparts in questioning whether breastfeeding should be discouraged entirely.

The group, which includes paediatricians and specialists in obstetrics and gynaecology from some of the main hospitals providing care to people living with HIV in Switzerland, carried out a review of the scientific literature published since 2009 to identify any reported cases of HIV transmission through breastfeeding when the mother had a viral load below 50 copies/ml, was in continuous care and was fully adherent to antiretroviral treatment. They describe this as the 'optimal scenario', and point out that in an analysis of pregnant women who gave birth between 2012 and 2016 in the Swiss HIV Cohort, 95.9% of mothers already had a fully suppressed viral load at the time of delivery, indicating that this scenario is likely to be widely applicable.

Previous reviews of the scientific literature have been less strict regarding evidence of full viral suppression and have drawn attention to cases of transmission where it is difficult to be certain if the mother had a fully suppressed viral load. A randomised study of antiretroviral therapy or infant prophylaxis during breastfeeding (the PROMISE study) found that the risk of transmission was approximately 0.3% six months after delivery and 0.7% 12 months after delivery.

But the authors of the Swiss review point out that there is no evidence available on viral load suppression throughout the follow-up period in the PROMISE study, meaning that it is not possible to determine whether any transmission that took place during this study occurred in the conditions of the 'optimal scenario'. They did not identify any other documented cases of HIV transmission through breastfeeding in this scenario.

The review authors say that this leaves a situation of clinical equipoise – genuine scientific uncertainty – and that doctors should engage in shared decision-making with women living with HIV about infant feeding decisions.

The review authors suggest that the following points should be communicated to women when infant feeding is discussed, after discussing the woman’s preferences regarding feeding. Women should be informed that whatever decision they make, they will be supported by their healthcare team.

Breastfeeding – potential risks

§  There is no formal study, equivalent to the PARTNER study of sexual transmission, which has evaluated the risk of transmission through breastfeeding when viral load is fully suppressed.

§  The lack of evidence of transmission to date does not allow us to rule out the possibility of transmission.

§  The possibility of transmission through cell-associated virus cannot be ruled out; not enough is known about this possibility.

§  There is a lack of information about potential toxicities of antiretroviral drugs taken in by the infant in breast milk.

§  Adherence support is especially important in the postpartum period owing to the sleep disruption and mood disorders that may affect adherence during this period.

§  Mastitis might increase the risk of transmission.

§  Mixed feeding (breast milk plus any other liquids, such as formula, or solids) may increase the risk of transmission so exclusive breastfeeding for the first four months is recommended in Switzerland.

Breastfeeding – potential benefits

§  Breastfeeding has numerous benefits to the infant and is recommended in most European countries for HIV-negative mothers.

§  Breastfeeding is a simple, easy and free way of providing nutrition to the infant.

§  Breastfeeding benefits the mother by reducing the risk of postpartum depression.

§  Breastfeeding may reduce the future risk of breast cancer, especially for younger women.

§  Breastfeeding reduces the risk of type 2 diabetes for mothers and helps control blood sugar.

The Swiss review takes a similar approach to recent guidance from the British HIV Association, which emphasises the importance of good engagement in care and monthly viral load testing for mothers and HIV DNA testing for infants during the breastfeeding period.

The British HIV Association guidance recommends that, where women choose to breastfeed, they should be encouraged to do so for as short a time as possible, ideally no more than six months.

Reference

Kahlert C et al. Is breastfeeding an equipoise option in effectively treated HIV-infected mothers in a high-income setting? Swiss Medical Weekly, 148:w14648, 2018.