Rationale for and Against Whether All Infants Should Receive Postnatal Prophylaxis While Breastfeeding

In FavorAgainst
A large portion (∼50%) of vertical transmission currently occurs during the breastfeeding period.Studies have not shown that adding infant prophylaxis to effective maternal treatment further reduces transmission risk.
Risk of transmission throughout breastfeeding is dynamic, with maternal viremia difficult to monitor or predict; maternal viremia during breastfeeding is common even among mothers who maintain suppression during pregnancy.More effective oral treatment with dolutegravir and new long-acting formulations offer the prospect of unprecedented coverage and durability of virologic suppression in breastfeeding women.
Maternal adherence to treatment is difficult to sustain throughout the breastfeeding period; approaches to support nonadherent women to achieve viral suppression and to predict lapses in adherence are inadequate.Predictors of maternal nonadherence have been identified (including younger age, new HIV diagnosis, late presentation to care, and non-disclosure) and can be used to target additional prevention measures.
Infants deserve resources and interventions that offer direct protection and do not rely on maternal treatment.Limited resources should focus on optimizing maternal adherence and access to good care.
Routine infant care can serve as a platform to maintain infants on prophylaxis throughout breastfeeding.It is difficult to maintain infant prophylaxis over long periods of time; there is significant loss to follow-up by 1 year of life.
New injectable and long-acting formulations limit the visibility of infants receiving prophylaxis and could reduce concerns about stigma.Providing prophylaxis to infants raises issues of disclosure of maternal infection status.
Many mothers fall out of care, thus, interventions that do not depend on maternal clinic attendance are needed.New point-of-care viral load testing will make monitoring of mothers easier.
Simplified, safer options that have potential for greater efficacy for postnatal prophylaxis are in development.Addressing underlying drivers of maternal treatment failure will benefit both the infant and the mother.