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Abioye AI, Sudfeld CR, Noor RA, Ulenga N, Sando D, Fawzi WW. Anemia and Iron Supplementation in Relation to Viral Load and Mortality among 70,442 People Living with Human Immunodeficiency Virus in Tanzania. J Nutr 2024; 154:1927-1935. [PMID: 38615735 PMCID: PMC11217031 DOI: 10.1016/j.tjnut.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/02/2024] [Accepted: 04/10/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Anemia may be associated with poor clinical outcomes among people living with human immunodeficiency virus (HIV) (PLHIV) despite highly active antiretroviral therapy (HAART). There are concerns that iron supplementation may be unsafe to prevent and treat anemia among PLHIV. OBJECTIVE The objective of the study was to evaluate the associations of anemia and iron supplementation with mortality and viral load among PLHIV in Tanzania. METHODS We analyzed data from a cohort of 70,442 nonpregnant adult PLHIV in Tanzania conducted between 2015 and 2019. Regression models evaluated the relationships between anemia severity and iron supplement use with mortality and unsuppressed HIV-1 viral load among all participants and stratified by whether participants were initiating or continuing HAART. RESULTS Anemia was associated with an increased risk of mortality and unsuppressed viral load for participants who initiated or continued HAART. Iron supplement use was associated with reduced mortality risk but also had a greater risk of an unsuppressed viral load among participants continuing HAART. There was no association of iron supplement use with mortality, and unsuppressed viral load among PLHIV that were initiating HAART. There was a stronger negative association between iron supplement use and the risk of having an unsuppressed viral load among participants with stage III/IV disease compared with stage I/II disease. CONCLUSIONS Anemia is associated with increased risk of mortality and unsuppressed viral load, but the benefits and safety of iron supplements appear to differ for those initiating compared with continuing ART as well as by HIV disease severity.
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Affiliation(s)
- Ajibola Ibraheem Abioye
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States.
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Ramadhani Abdallah Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Andersen CT, Duggan CP, Manji K, Seage GR, Spiegelman D, Perumal N, Ulenga N, Fawzi WW. Iron supplementation and paediatric HIV disease progression: a cohort study among children receiving routine HIV care in Dar es Salaam, Tanzania. Int J Epidemiol 2022; 51:1533-1543. [PMID: 35167662 PMCID: PMC9557856 DOI: 10.1093/ije/dyac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 01/30/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anaemia is common among HIV-infected children and iron supplementation is prescribed routinely for the prevention and management of anaemia among children. Limited evidence suggests iron supplementation may have adverse effects among HIV-infected populations. We aimed to estimate the effect of iron supplement use on mortality, disease progression and haematological outcomes among HIV-infected children in Dar es Salaam, Tanzania. METHODS A prospective cohort study was conducted among HIV-infected children (aged 0-14 years) receiving antiretroviral treatment or supportive care between October 2004 and September 2014. Clinical data were recorded on morbidity and vital status, haematological status and prescriptions at each clinical visit. Cox proportional hazards models adjusted for time-varying covariates were used to estimate the association of time-varying iron supplementation on the hazard rate of mortality, HIV disease stage progression, tuberculosis incidence and anaemia and microcytosis persistence. RESULTS In all, 4229 children were observed during 149 260 clinic visits for a mean follow-up of 2.9 years. After adjustment for time-varying clinical covariates, time-varying iron supplementation was associated with a 2.87 times higher hazard rate of mortality (95% CI: 1.70, 4.87) and a 1.48 times higher hazard rate of HIV disease stage progression (95% CI: 1.10, 1.98). Iron supplementation was also associated with a lower rate of anaemia persistence (HR = 0.47; 95% CI: 0.37, 0.61). No differences in the association between iron supplementation and clinical outcomes were observed by antiretroviral therapy or anaemia status. CONCLUSIONS Iron supplementation may increase the risk of HIV disease stage progression and mortality among HIV-infected children, while reducing the risk of anaemia.
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Affiliation(s)
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - George R Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Departments of Social and Behavioral Sciences, Biostatistics, and Epidemiology of Microbial Diseases, Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Abioye AI, Andersen CT, Sudfeld CR, Fawzi WW. Anemia, Iron Status, and HIV: A Systematic Review of the Evidence. Adv Nutr 2020; 11:1334-1363. [PMID: 32383731 PMCID: PMC7490171 DOI: 10.1093/advances/nmaa037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
People living with HIV (PLWHIV) are at high risk of anemia due to inadequate iron intake, HIV and opportunistic infections, and inflammation, and as a side effect of antiretroviral therapy. Though iron supplementation can reduce iron deficiency anemia (IDA) in the general population, its role in anemia and in the health of PLWHIV is unclear due to concerns that iron supplementation may increase HIV replication and risk of opportunistic infections. We systematically reviewed the evidence on indicators of iron status, iron intake, and clinical outcomes among adults and children with HIV. The evidence suggests that anemia is associated with an increased risk of all-cause mortality and incident tuberculosis among HIV-infected individuals, regardless of anemia type, and the magnitude of the risk is greater with more severe anemia. High serum ferritin is associated with adverse clinical outcomes, although it is unclear if this is due to high iron or inflammation from disease progression. One large observational study found an increased risk of all-cause mortality among HIV-infected adults if they received iron supplementation. Published randomized controlled trials of iron supplementation among PLWHIV tend to have small sample sizes and have been inconclusive in terms of effectiveness and safety. Large randomized trials exploring approaches to safely and effectively provide iron supplementation to PLWHIV are warranted.
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Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Schaub R, Badiou S, Viljoen J, Dujols P, Bolloré K, Van de Perre P, Newell ML, Bland R, Nagot N, Tuaillon E. The immune response to sub-clinical mastitis is impaired in HIV-infected women. J Transl Med 2018; 16:296. [PMID: 30359283 PMCID: PMC6202806 DOI: 10.1186/s12967-018-1667-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/17/2018] [Indexed: 11/23/2022] Open
Abstract
Background Subclinical mastitis (SCM) is relatively common in lactating women and may be associated with HIV shedding in breast milk. The potential association between HIV infection and breast milk immunologic factors and immune response to SCM needs to be addressed. Methods In this cross-sectional study, SCM (Na/K ratio > 1) was tested in 165 mature breast milk samples collected from 40 HIV-infected women who didn’t transmit HIV to their child by breastfeeding and 43 HIV-uninfected women enrolled in an interventional cohort in South-Africa (Vertical Transmission Study). The level of 33 immune markers related to Th1/Th2 related response, inflammation and bacterial exposure were compared in ART-naive HIV-infected versus HIV-uninfected women. The associations between HIV infection and SCM on the concentration of immune factors were tested separately by Wilcoxon rank-sum test and corrected for false discovery rate. To control for potential confounder effects and take into account the clustering of breast milk samples from a single woman, multivariate mixed linear models adjusted on child age at the time of sampling were performed for each immune factor. Results Subclinical mastitis was detected in 15 (37.5%) HIV-infected women and 10 (23.3%) HIV-uninfected women. In the absence of SCM, the breast milk levels of IP-10 and MIG were higher and IL1-RA lower in HIV-infected women than in HIV-uninfected women (respectively p < 0.001, p = 0.001, p = 0.045). In HIV-uninfected women, SCM was characterized by a robust immune response with higher concentrations of a broad panel of Th1 and inflammatory related immune markers than in samples without SCM. By contrast, in HIV-infected women a limited number of immune markers were increased and lower increases were observed in samples with SCM than without SCM. Conclusion HIV infection in ART-naïve women was associated with elevated breast milk levels of IP-10 and MIG, which areTh1-related cytokines induced by IFN-γ. During SCM, a lower and narrower immune response was observed in HIV-infected than HIV-uninfected women, suggesting that HIV infection affects the capacity of the mammary gland to respond to SCM. Electronic supplementary material The online version of this article (10.1186/s12967-018-1667-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roxane Schaub
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France. .,Département d'Information Médicale, CHU de Montpellier, Montpellier, France. .,CIC AG/Inserm 1424, Centre Hospitalier de Cayenne, Av. des flamboyants, BP 6006, 97 306, Cayenne CEDEX, French Guiana, France.
| | - Stéphanie Badiou
- Département de Biochimie, CHU de Montpellier, Montpellier, France
| | - Johannes Viljoen
- Department of Medical Virology, University of Pretoria and NHLS, Pretoria, South Africa
| | - Pierre Dujols
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France.,Département d'Information Médicale, CHU de Montpellier, Montpellier, France
| | - Karine Bolloré
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France.,Département de Bactériologie-Virologie, CHU de Montpellier, Montpellier, France
| | - Marie-Louise Newell
- Institute for Developmental Science, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ruth Bland
- Africa Centre for Health and Population studies, University of KwaZulu-Natal, Durban, South Africa.,School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Royal Hospital for Children, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France.,Département d'Information Médicale, CHU de Montpellier, Montpellier, France
| | - Edouard Tuaillon
- Pathogenesis and Control of Chronic Infections, INSERM, EFS, Université Montpellier 1, Montpellier, France.,Département de Bactériologie-Virologie, CHU de Montpellier, Montpellier, France
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Nevirapine, sodium concentration and HIV-1 RNA in breast milk and plasma among HIV-infected women receiving short-course antiretroviral prophylaxis. PLoS One 2015; 10:e0121111. [PMID: 25812161 PMCID: PMC4374672 DOI: 10.1371/journal.pone.0121111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 02/10/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction Risk factors for breast milk transmission of HIV-1 from mother to child include high plasma and breast milk viral load, low maternal CD4 count and breast pathology such as mastitis. Objective To determine the impact of nevirapine and subclinical mastitis on HIV-1 RNA in maternal plasma and breast milk after intrapartum single-dose nevirapine combined with either 1-week tail of Combivir (zidovudine/lamivudine) or single-dose Truvada (tenofovir/emtricitabine). Methods Maternal plasma and bilateral breast milk samples were collected between April 2008 and April 2011 at 1, 4 and 6 weeks postpartum from HIV-infected Tanzanian women. Moreover, plasma samples were collected at delivery from mother and infant. Results HIV-1 RNA was quantified in 1,212 breast milk samples from 273 women. At delivery, 96% of the women and 99% of the infants had detectable nevirapine in plasma with a median (interquartile range, IQR) of 1.5 μg/mL (0.75–2.20 μg/mL) and 1.04 μg/mL (0.39–1.71 μg/mL), respectively (P < 0.001). At 1 week postpartum, 93% and 98% of the women had detectable nevirapine in plasma and breast milk, with a median (IQR) of 0.13 μg/mL (0.13–0.39 μg/mL) and 0.22 μg/mL (0.13–0.34 μg/mL), respectively. Maternal plasma and breast milk HIV-1 RNA correlated at all visits (R = 0.48, R = 0.7, R = 0.59; all P = 0.01). Subclinical mastitis was detected in 67% of the women at some time during 6 weeks, and in 38% of the breast milk samples. Breast milk samples with subclinical mastitis had significantly higher HIV-1 RNA at 1, 4 and 6 weeks (all P < 0.05). Conclusion After short-course antiretroviral prophylaxis, nevirapine was detectable in most infant cord blood samples and the concentration in maternal plasma and breast milk was high through week 1 accompanied by suppressed HIV-1 RNA in plasma and breast milk.
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Wood LF, Chahroudi A, Chen HL, Jaspan HB, Sodora DL. The oral mucosa immune environment and oral transmission of HIV/SIV. Immunol Rev 2014; 254:34-53. [PMID: 23772613 DOI: 10.1111/imr.12078] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The global spread of human immunodeficiency virus (HIV) is dependent on the ability of this virus to efficiently cross from one host to the next by traversing a mucosal membrane. Unraveling how mucosal exposure of HIV results in systemic infection is critical for the development of effective therapeutic strategies. This review focuses on understanding the immune events associated with the oral route of transmission (via breastfeeding or sexual oral intercourse), which occurs across the oral and/or gastrointestinal mucosa. Studies in both humans and simian immunodeficiency virus (SIV) monkey models have identified viral changes and immune events associated with oral HIV/SIV exposure. This review covers our current knowledge of HIV oral transmission in both infants and adults, the use of SIV models in understanding early immune events, oral immune factors that modulate HIV/SIV susceptibility (including mucosal inflammation), and interventions that may impact oral HIV transmission rates. Understanding the factors that influence oral HIV transmission will provide the foundation for developing immune therapeutic and vaccine strategies that can protect both infants and adults from oral HIV transmission.
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Affiliation(s)
- Lianna F Wood
- Seattle Biomedical Research Institute, Seattle, WA, USA
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King CC, Ellington SR, Kourtis AP. The role of co-infections in mother-to-child transmission of HIV. Curr HIV Res 2013; 11:10-23. [PMID: 23305198 PMCID: PMC4411038 DOI: 10.2174/1570162x11311010003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/11/2012] [Accepted: 12/14/2012] [Indexed: 01/27/2023]
Abstract
In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.
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Affiliation(s)
- Caroline C King
- Division of Reproductive Health, NCCDPHP, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-K34, Atlanta, GA 30341, USA.
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Virologic determinants of breast milk transmission of HIV-1. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 743:69-80. [PMID: 22454342 DOI: 10.1007/978-1-4614-2251-8_5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Non-antiretroviral Approaches to Prevention of Breast Milk Transmission of HIV-1: Exclusive Breastfeeding, Early Weaning, Treatment of Expressed Breast Milk. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 743:197-204. [DOI: 10.1007/978-1-4614-2251-8_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Slyker JA, Chung MH, Lehman DA, Kiarie J, Kinuthia J, Holte S, Tapia K, Njiri F, Overbaugh J, John-Stewart G. Incidence and correlates of HIV-1 RNA detection in the breast milk of women receiving HAART for the prevention of HIV-1 transmission. PLoS One 2012; 7:e29777. [PMID: 22253778 PMCID: PMC3256181 DOI: 10.1371/journal.pone.0029777] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/03/2011] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The incidence and correlates of breast milk HIV-1 RNA detection were determined in intensively sampled women receiving highly active antiretroviral therapy (HAART) for the prevention of mother-to-child HIV-1 transmission. METHODS Women initiated HAART at 34 weeks of pregnancy. Breast milk was collected every 2-5 days during 1 month postpartum for measurements of cell-associated HIV DNA and cell-free HIV RNA. Plasma and breast milk were also collected at 2 weeks, 1, 3 and 6 months for concurrent HIV-1 RNA and DNA measurements. Regression was used to identify cofactors for breast milk HIV-1 RNA detection. RESULTS Of 259 breast milk specimens from 25 women receiving HAART, 34 had detectable HIV-1 RNA (13%, incidence 1.4 episodes/100 person-days 95% CI = 0.97-1.9). Fourteen of 25 (56%) women had detectable breast milk HIV-1 RNA [mean 2.5 log(10) copies/ml (range 2.0-3.9)] at least once. HIV-1 DNA was consistently detected in breast milk cells despite HAART, and increased slowly over time, at a rate of approximately 1 copy/10(6) cells per day (p = 0.02). Baseline CD4, plasma viral load, HAART duration, and frequency of breast problems were similar in women with and without detectable breast milk HIV-1 RNA. Women with detectable breast milk HIV-1 RNA were more likely to be primiparous than women without (36% vs 0%, p = 0.05). Plasma HIV-1 RNA detection (OR = 9.0, 95%CI = 1.8-44) and plasma HIV-1 RNA levels (OR = 12, 95% CI = 2.5-56) were strongly associated with concurrent detection of breast milk HIV-1 RNA. However, no association was found between breast milk HIV-1 DNA level and concurrent breast milk HIV-1 RNA detection (OR = 0.96, 95%CI = 0.54-1.7). CONCLUSIONS The majority of women on HAART had episodic detection of breast milk HIV-1 RNA. Breast milk HIV-1 RNA detection was associated with systemic viral burden rather than breast milk HIV-1 DNA.
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Affiliation(s)
- Jennifer A Slyker
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.
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Breastfeeding and Transmission of HIV-1: Epidemiology and Global Magnitude. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 743:3-25. [DOI: 10.1007/978-1-4614-2251-8_1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Bulterys M, Ellington S, Kourtis AP. HIV-1 and breastfeeding: biology of transmission and advances in prevention. Clin Perinatol 2010; 37:807-24, ix-x. [PMID: 21078452 DOI: 10.1016/j.clp.2010.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Breastfeeding accounts for about 40% of mother-to-child transmission of HIV-1 worldwide and carries an estimated risk of transmission of 0.9% per month after the first month of breastfeeding. It is recommended that HIV-1-infected women completely avoid breastfeeding in settings where safe feeding alternatives exist. However, as replacement feeding is not safely available in many parts of the world, and because breastfeeding provides optimal nutrition and protection against other infant infections, there is intense ongoing research to make breastfeeding safe for HIV-1-infected mothers in resource-limited settings. More research is needed to determine the optimal duration of breastfeeding, optimal weaning practices, and which individual antiretroviral prophylactic regimen is best for HIV-1-infected mothers and their infants in a particular setting.
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Affiliation(s)
- Marc Bulterys
- Division of HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA
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Response to Segat et al. ‘Are DEFB1 gene polymorphisms associated with HIV-1 infection and virus replication?’. AIDS 2009. [DOI: 10.1097/qad.0b013e328327726a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
The increasing success of prevention of mother-to-child HIV transmission programmes means that in Africa, very large numbers of HIV-exposed, uninfected (HIV-EU) children are being born. Any health problems that these children may have will thus be of enormous public health importance, but to date have been largely neglected. There is some evidence that HIV-EU African children are at increased risk of mortality, morbidity and slower early growth than their HIV-unexposed counterparts. A likely major cause of this impaired health is less exposure to breast milk as mothers are either less able to breastfeed or stop breastfeeding early to protect their infant from HIV infection. Other contributing factors are parental illness or death resulting in reduced care of the children, increased exposure to other infections and possibly exposure to antiretroviral drugs. A broad approach for psychosocial support of HIV-affected families is needed to improve health of HIV-EU children. High quality programmatic research is needed to determine how to deliver such care.
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Makasa M, Kasonka L, Chisenga M, Sinkala M, Chintu C, Tomkins A, Filteau S. Early growth of infants of HIV-infected and uninfected Zambian women. Trop Med Int Health 2007; 12:594-602. [PMID: 17445127 DOI: 10.1111/j.1365-3156.2007.01836.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Parental HIV infection may affect even those exposed children who remain uninfected. We investigated early growth, an indicator of overall health, of infants born to Zambian mothers recruited for a study of breastfeeding and postpartum health. METHODS HIV-infected and uninfected women in Lusaka were followed regularly from late pregnancy to 16 weeks postpartum. Infant weight and length were measured at birth, 6 and 16 weeks. Infant HIV status could not be specifically determined in this cohort so comparisons were between all infants of HIV-uninfected mothers (n = 184) and those infants of HIV-infected mothers who were known to be alive and showed no clinical evidence of HIV infection at age 2-4 years (n = 85). RESULTS Most infants were exclusively or predominantly breastfed until 16 weeks. At all time points infants of HIV-infected mothers tended to have lower weight and length standard deviation (Z) scores (significant for weight at 6 weeks; P = 0.04), even after adjustment for their lower gestational age at birth, compared with infants of uninfected mothers. In multivariate analyses the major factors affecting weight or length at 6 or 16 weeks of age were birth weight or length, and maternal subclinical mastitis, primiparity and weight during pregnancy. CONCLUSIONS Early growth of infants of HIV-infected mothers is less than that of uninfected mothers, in part associated with subclinical mastitis, and this effect cannot be overcome with intensive support of mothers to follow international recommendations regarding exclusive breastfeeding.
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Affiliation(s)
- M Makasa
- Lusaka District Health Management Team, Lusaka, Zambia
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Lehman DA, Farquhar C. Biological mechanisms of vertical human immunodeficiency virus (HIV-1) transmission. Rev Med Virol 2007; 17:381-403. [PMID: 17542053 DOI: 10.1002/rmv.543] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the absence of interventions, 30-45% of exposed infants acquire human immunodeficiency virus type 1 (HIV-1) through mother-to-child transmission. It remains unclear why some infants become infected while others do not, despite significant exposure to HIV-1 in utero, during delivery and while breastfeeding. Here we discuss the correlates of vertical transmission with an emphasis on factors that increase maternal HIV-1 levels, either systemically or locally in genital secretions and breast milk. Immune responses may influence maternal viral load, and data suggest that maternal neutralising antibodies reduce infection rates. In addition, infants may be capable of mounting HIV-specific cellular immune responses. We propose that both humoral and cellular responses are necessary to reduce infection because cell-free as well as cell-associated virus appears to play a role in vertical transmission. These distinct forms of the virus may be targeted most effectively by different components of the immune system. We also discuss the use of antiretrovirals to reduce transmission, focusing on the mechanisms of action of regimens currently used in developing country settings. We conclude that prevention relies not only on reducing maternal HIV-1 levels within blood, genital tract and breast milk, but also on pre- and/or post-exposure prophylaxis to the infant. However, HIV-1 has the capacity to mutate under drug pressure and rapidly acquires mutations conferring antiretroviral resistance. This review concludes with data on persistence of low-level resistance after delivery as well as recent guidelines for maternal and infant regimens designed to limit resistance.
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Affiliation(s)
- Dara A Lehman
- Department of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Kasonka L, Makasa M, Marshall T, Chisenga M, Sinkala M, Chintu C, Kaseba C, Kasolo F, Gitau R, Tomkins A, Murray S, Filteau S. Risk factors for subclinical mastitis among HIV-infected and uninfected women in Lusaka, Zambia. Paediatr Perinat Epidemiol 2006; 20:379-91. [PMID: 16911016 DOI: 10.1111/j.1365-3016.2006.00746.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Subclinical mastitis, defined as raised milk sodium/potassium (Na/K) ratio, is associated with poor infant growth and, among HIV-infected women, with increased milk HIV viral load. We conducted a longitudinal cohort study in Lusaka, Zambia, in order to investigate the relative importance of several potential causes of subclinical mastitis: maternal infection, micronutrient deficiencies and poor lactation practice. Women (198 HIV-infected, 189 HIV-uninfected) were recruited at 34 weeks' gestation and followed up to 16 weeks postpartum for collection of information on their health, their infant's health, infant growth and infant feeding practices. Milk samples were collected from each breast at 11 postpartum visits and blood at recruitment and 6 weeks postpartum. The geometric mean milk Na/K ratio and the proportion of women with Na/K ratio > 1.0 in one or both breasts were significantly higher among HIV-infected than among uninfected women. Other factors associated with the higher mean Na/K ratio in univariable analyses were primiparity, high maternal alpha(1)-acid glycoprotein (AGP) at 6 weeks, maternal overall morbidity and specific breast symptoms, preterm delivery, low infant weight or length, infant thrush and non-exclusive breast feeding. In multivariable analyses, primiparity, preterm delivery, breast symptoms, HIV status and raised AGP were associated with the raised Na/K ratio. Thus the main factors associated with subclinical mastitis that are amenable to intervention are poor maternal overall health and breast health. The impact of improved postpartum health care, especially management of maternal infections and especially in primiparous women, on the prevalence of subclinical mastitis and its consequences requires investigation.
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