Mastitis, HIV and breastfeeding

[Prince]

Hi

In a country where the national health authorities have decided that health services will primarily counsel and support mothers know to be HIV-infected to breastfeed and receive antiretrovirals, if the mother develops mastitis....
1. then is it suggested that the mother does not breastfeed from that breast and just express in the meantime?
2. If this is the case, is this because the risk of passing HIV on to the infant increases during a bout of mastitis because the HIV load increases but also the intercellular spaces between lactocytes increase?
3. Is she able to provide the EBM to her baby once it has been heat treated? If so, how exactly must it be heat treated?

Thanks!

[admin]

Prince:

I am not sure I am capable of answering this question, as I am not totally versed in the risks of breastfeeding following HIV infection. We do know, however, that the use of antiretrovirals, does reduce both the level of HIV virus in milk, and its transmission overall to the infant.

In a case of mastitis, it is logical that due to damage of the alveolar cellular system, that any HIV present in the plasma would more likely penetrate into the damaged breast. Thus, it is quite likely that the damaged tissue would indeed permit the entry of virus into this milk at higher levels than in the non-damaged breast.

Lastly, if she can indeed heat treat the milk, it would most certainly reduce the viability of HIV in milk if it is done properly. As for how to heat the milk, I defer to others who might know more about this, but the article below suggests that bringing it to a boil over a fire, kills all the viral particles.

Below is the flash heating method used in the first article.

Tom Hale Ph.D.

-------------Flash Heating Method ------------------------------

The flash-heat method has been described elsewhere.17 Briefly, 50 mL of expressed breast milk in an uncovered sterile 16-oz (455-mL) commercial glass food jar was placed in 450 mL of water in a Hart brand 1-qt aluminum pan (Hendler and Hart, Cape Town, South Africa) purchased locally. Water and milk were heated together over a single-burner butane stove, used to imitate the intense heat of a fire, until the water reached 100°C and was at a rolling boil. The breast milk was immediately removed from the water and allowed to cool to 37°C. Temperature data were collected at 15-second intervals using thermometer probes (Cole-Palmer Digi-Sense DuaLogR Thermocouple Thermometers, Vernon Hills, IL). Flash- heating typically reached temperatures greater than 56°C for 6 minutes 15 seconds and peaked at 72.9°C. Flash-heated and unheated breast milk samples were then divided into 1.5-mL aliquots and immediately stored at 280°C. Samples were shipped frozen on dry ice to the California Department of Health Services Viral and Rickettsial Disease Laboratory for viral analysis.

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J Acquir Immune Defic Syndr. 2007 Jul 1;45(3):318-23.
Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries.
Israel-Ballard K, Donovan R, Chantry C, Coutsoudis A, Sheppard H, Sibeko L, Abrams B.
Source
Division of Epidemiology, School of Public Health, University of California, Berkeley, CA 94720-7360, USA. ballardk@berkeley.edu
Abstract

BACKGROUND:
Up to 40% of all mother-to-child transmission of HIV occurs by means of breast-feeding; yet, in developing countries, infant formula may not be a safe option. The World Health Organization recommends heat-treated breast milk as an infant-feeding alternative. We investigated the ability of a simple method, flash-heat, to inactivate HIV in breast milk from HIV-positive mothers.
METHODS:
Ninety-eight breast milk samples, collected from 84 HIV-positive mothers in a periurban settlement in South Africa, were aliquoted to unheated control and flash-heating. Reverse transcriptase (RT) assays (lower detection limit of 400 HIV copies/mL) were performed to differentiate active versus inactivated cell-free HIV in unheated and flash-heated samples.

RESULTS:
We found detectable HIV in breast milk samples from 31&#37; (26 of 84) of mothers. After adjusting for covariates, multivariate logistic regression showed a statistically significant negative association between detectable virus in breast milk and maternal CD4+ T-lymphocyte count (P=0.045) and volume of breast milk expressed (P=0.01) and a positive association with use of multivitamins (P=0.03). All flash-heated samples showed undetectable levels of cell-free HIV-1 as detected by the RT assay (P<0.00001).

CONCLUSIONS:
Flash-heat can inactivate HIV in naturally infected breast milk from HIV-positive women. Field studies are urgently needed to determine the feasibility of in-home flash-heating breast milk to improve infant health while reducing postnatal transmission of HIV in developing countries.
PMID: 17514015 [PubMed - indexed for MEDLINE]

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J Acquir Immune Defic Syndr. 2000 Aug 1;24(4):325-9.
Effects of lipolysis or heat treatment on HIV-1 provirus in breast milk.
Chantry CJ, Morrison P, Panchula J, Rivera C, Hillyer G, Zorilla C, Diaz C.
Source
Department of Pediatrics, University of California Davis, Sacramento, California, USA. caroline.chantry@ucdmc.ucdavis.edu
Abstract
BACKGROUND:
Transmission of HIV-1 infection through breastfeeding is associated with integrated DNA (provirus) in milk cells. Reduction of HIV-1 DNA in milk may lessen infectivity.
PURPOSE:
To investigate efficacy of two methods available in developing countries to reduce HIV-1 proviral DNA in breast milk.

METHODS:
Methods simulated field conditions; milk was heated by bringing it to a boil, for instance, over a cooking fire, and lipolysis was done at room temperature. Four HIV-positive pregnant women were recruited for this pilot study, instructed to feed formula exclusively, and to stimulate milk production using pumping. Milk was collected twice weekly for 3 weeks and analyzed qualitatively for HIV-1 proviral DNA by polymerase chain reaction at three stages: 1) fresh, 2) after standing for 6 hours, and 3) after having been brought to the boiling point.

RESULTS:
Seventeen samples from 4 mothers were analyzed. Fifteen of 17 fresh samples (88%) had measurable HIV-1 proviral DNA despite all mothers' having had low or undetectable plasma viral loads. Lipolysis (standing at room temperature) for 6 hours did not destroy proviral DNA: 6 of 7 samples (86%) tested positive for DNA after lipolysis. No samples of milk (n = 8) brought to a boil were positive for HIV-1 proviral DNA (p <.0001).

CONCLUSIONS:
This preliminary evidence suggests that inherent lipolytic activity of fresh breast milk is inadequate for destruction of HIV-1; bringing breast milk to a boil may result in decreased HIV-1 infectivity; and breast milk cell-associated HIV-1 may not reflect plasma viral load. Nutritional value or possible bacterial contamination of milk treated in this manner was not assessed.

PMID: 11015148 [PubMed - indexed for MEDLINE]

[Prince]

Thank you very much!