Rationale for and Against Whether All Infants Should Receive Postnatal Prophylaxis While Breastfeeding
| In Favor | Against |
|---|---|
| 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. |