Without major announcement, in February 2023, the Centers for Disease Control and Prevention (CDC) changed their breastfeeding policy for HIV-infected mothers and no longer recommend advising against breastfeeding.
The new recommendation gets closer to the updated 2010 World Health Organization (WHO) guideline on HIV and infant feeding. Before 2010, “WHO guidance on HIV and infant feeding (UNICEF et al., 2003; WHO et al., 2006) recommended an individualized approach in which women living with HIV would be counselled on feeding options according to their household circumstances.”
The new CDC guideline acknowledges that, “For mothers on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during pregnancy, the risk of transmission through breastfeeding is less than 1%, but not zero,” as determined in the PROMISE Study.
The guideline goes on to recommend “patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.” Read the full document here.
“This change in HIV policy serves as a reminder to always check sources. New research findings and policy reconsiderations make it imperative that the most up-to-date information is available to the families we serve,” Healthy Children Project’s Karin Cadwell PhD, RN, FAAN, IBCLC, ANLC comments.
In the U.S., HIV diagnoses among women have declined in recent years; still, nearly 7,000 women received an HIV diagnosis in 2019. (The CDC has commented on the effect of the COVID-19 pandemic: “Data for 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state and local jurisdictions. While 2020 data on HIV diagnoses and prevention and care outcomes are available, we are not updating this web content with data from these reports.”)
How does the U.S. compare in their recommendations to other high-income countries?
The British HIV Assocation’s 2018 guidelines for the management of HIV in pregnancy and postpartum states that “Women who are virologically suppressed on cART with good adherence and who choose to breastfeed should be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation and the requirement for extra maternal and infant clinical monitoring” among other recommendations for helping manage lactation in HIV-positive mothers.
A National Health Service (NHS) Greater Glasgow and Clyde document Management of infants born to HIV positive mothers reads: “There is now evidence from developing countries that breast feeding while mum’s viral load is fully suppressed is safe, and BHIVA/CHIVA no longer regard a decision to breast feed as grounds for referral to child protection services. For HIV positive women who choose to breast feed, maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. The mother’s viral load should be tested monthly to ensure that HIV virus remains undetectable; this testing will be undertaken by the obstetric/ID team. It is recommended that breastfeeding be exclusive, and completed by the end of 6 months.”
You can learn more about Canada’s approach here and Switzerland’s here.
From Africa to Appalachia, Stephanie L. Martin’s, PhD, CLC research on nutrition during pregnancy, lactation, and childhood, has gone beyond nutrition alone.
In a world where infant feeding is commonly reduced to input and output, “perfect” latches and weighted feeds, Martin’s work illuminates the added benefit of improved relationships and communication.
In Zambia for instance, Martin and her colleagues have looked at how to engage family members to support nutrition in women living with HIV and their children.
Twenty years ago, when antiretroviral therapy (ART) was less accessible, the risk of transmitting HIV through breastfeeding was high. Today though, with an increase in availability and access to ART, the World Health Organization (WHO) recommends the use of antiretroviral drugs as a safe way to prevent postnatal transmission of HIV through breastfeeding.
Still, Martin has found that mothers talk about their fears of transmitting HIV to their infants the same way they did two decades ago. Mothers often use unfounded strategies like breastfeeding for shorter durations, breastfeeding less often or offering other liquids in an effort to limit the risk of transmission. So, Martin and her team have counseled mothers not to cut feedings short. Martin shares that her most recent Lactation Counselor Training has offered new insight.
“I’m going to change things in our counseling materials based on what we learned in the CLC training [in regard to] how we phrase things about breastfeeding for longer periods of time; if there is efficient milk transfer, we don’t need to focus on this longer length of time,” she explains.
Additionally, in an effort to reduce caregivers offering infants under six months food or drink other than breastmilk, alternative soothing recommendations were offered. Martin remembers one mother who tried the suggestions to calm her crying baby. The mother reported that propping her infant onto a specific shoulder alleviated the baby’s discontent. “I don’t know what it was about that shoulder, but she stopped crying,” Martin quotes the mother, noting the importance of empowering mothers and caregivers through counseling.
When asked if she’s optimistic about the future of maternal child health, Martin answers with a slightly tense laugh: “I feel like I have to say yes.” Martin goes on to explain the inspiring work of ABN and all of the lactation care providers she’s interacted with.
“If they were in charge of the world, it would be such a better place,” she begins.
“When I think about them, I feel optimistic. I’d like to see different laws that are supportive of women’s health and families. We have all the right people to make positive changes.”
Throughout human history, breastfeeding has been depicted in art. In fact, the milk of a goddess was thought by ancient peoples to be the source of our galaxy and has been realized into several artworks like The Origin of the Milky Way by Jacopo Tintoretto (c. 1518-1594).
In celebration of breastfeeding expressed through visual arts, we’ve compiled a list of contemporary artists and their work below. For more, you can follow @breastfeedingart on Instagram which features an eclectic compilation of breastfeeding art throughout history to present day.
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Some days Susan Gold, RN, BSN, ACRN misses her ignorance. Since 2003, Gold has embarked on over 30 trips to various locations in East Africa where she teaches sexual and reproductive health and offers humanitarian aid.
Recalling one of her first visits to a clinic in Nairobi, Kenya, Gold describes a young mother, around 18-years-old, who arrived holding her severely malnourished infant against her breasts infected with such severe mastitis that her skin had split. This mother had been thrown out of her home for being HIV-positive and was breastfeeding and formula feeding her baby.
[Some background: Infant feeding has been complicated by the HIV epidemic. In the early 2000s, Gold explains that HIV-positive women were taught to formula feed to lower the risk of transmission to their babies, but with little to no access to clean water, babies were becoming severely ill. What’s more, in societies where breastfeeding is the norm, exclusive formula feeding is often an indication of one’s HIV status, which remains highly stigmatized. And formula is expensive, so many mothers choose mixed feeding, increasing the rate of HIV transmission, because formula irritates the GI system and gives the virus a pathway. By 2010, WHO issued new recommendations that stated that all mothers who tested positive should receive effective antiretroviral treatment (ART) which could lower risk of transmission during exclusive breastfeeding to virtually zero. In 2016, WHO extended the recommended duration of breastfeeding for HIV-positive mothers to 24 months. Effectiveness is dependent on consistency though, and Gold explains that mothers can develop resistance because there isn’t always access to ART.]
Gold was able to give the mother antibiotics, but the care that she and her infant required was beyond what Gold could offer. Considering the dyad’s condition and Gold’s limited resources, she says she’s certain that they died.
Reflecting on the suffering she witnessed and lives lost, that’s when Gold misses her ignorance most, but she says, “To know is to do.”
“For me it’s not a news story I can ignore, it’s names and faces,” she remarks.
Most recently, Gold spent several weeks in Dar es Salaam, Tanzania on a Nelson Mandela Fellowship Reciprocal Exchange Fellowship Grant where she partnered with Dr. Omari Mahiza, a pediatrician at Amana Regional Referral Hospital, focusing their efforts on combating pediatric malnutrition and education on family planning.
Gold has found that most Americans hold a “shallow view” of the continent. Her frustration with the stereotypes associated with Africa runs deep.
“It’s either starving children or a safari,” she begins. “It’s so painful for me to see that displayed so many times. There is such a tendency [in America] to dehumanize people who are not like us… We set ourselves as the standard. Their culture is not a failed attempt to be our culture. Success doesn’t have to look like us or be measured against us.”
Alongside her humanitarian work, Gold hopes to shatter the stereotypes, to bring awareness to the paradox of direness and vibrancy in East Africa.
Gold reminisces: “I love the African sun on my face, the bright colors and motion, the culture that is built around the family and friends, that you’re never expected to do it alone, the generosity of spirit, the sounds and smells, the warm welcomes and the optimism.”
Acutely aware of “an inherent imbalance of power” and the concept of White Saviorism, Gold uses the Swahili term Tuko sawa, which means “We are all the same”, as the foundation of her work.
We all want healthy children and families and a future with opportunities to provide long, healthy, prosperous lives, she expounds.
Beyond this core belief, Gold says that she always develops relationships with the people she works with.
“I educate myself on the origins and current status of their culture. I don’t tell people what to do, I share my experiences and expertise. I always learn from them.”
Doing more with less
Ingenuity is something she’s gathered from working alongside East Africans.
For instance, Gold was struck by the engineering of incubators for very sick babies at St. Joseph’s Hospital in Moshi, Tanzania.
If there is electricity, she explains, the heat is controlled by the number of light bulbs lit. The wood absorbs the heat, the aluminum components absorb and reflect heat, the mattress absorbs heat but also protects the baby, and the lid retains the heat but allows for monitoring of the baby. Mosquito netting is fashioned around the system.
A recent Lancet Global Health Publication, Revealing the prevalence of “hidden hunger”, released estimates of two billion people worldwide with one or more micronutrient deficiencies, noting that this is a gross underestimate. The hunger and deficiencies that Gold and her colleagues witness are rarely hidden and often quite obvious.
Gold observes that all of the women breastfeed in the low-income neighborhoods she visits.
The struggle, she says, is getting enough nutrition for the women to sustain milk production and have energy to feed their babies. During her most recent visit, Gold reports that almost none of the 35 families had food in the home.
Reporters of the new estimates for micronutrient malnutrition point out that processed fortified foods and micronutrient powders can be an easy answer to hunger, but they don’t create sustainability of local and indigenous foods and create conflict of interest issues with industry.
Gold adds that low income community members can’t afford to buy industry developed foods consistently. Lack of access to clean water is also a barrier.
“And you can’t depend on outside groups to sustain you,” she continues.
“We didn’t see any processed food at all because there is no market for it,” Gold says of visiting seven different neighborhoods in the low income region of Dar es Salaam. Instead, small markets with locally-grown fruits and vegetables prevail, but access to protein is a challenge.
As medically indicated, ready-to-use therapeutic food (RUTF) packets of fortified peanut butter issued by UNICEF are given out through health clinics. But Gold notes that sometimes parents sell these packets for money.
A challenge but not insurmountable
North of Dar es Salaam, in Moshi, Gold brings a portable printer that doesn’t require Wifi to the small hospital where she volunteers. She gifts each postpartum mother a printed 4×6 photo of herself and her baby.
“You don’t know how many of these babies are going to survive due to the high infant mortality rate.”
There’s a long moment of silence between us on the video call.
Then Gold expresses her frustration and anger, “The world can fix this, but chooses not to.”
She urges us to educate ourselves and others. Vote for people who have a vision of the world as one world, she says.
For those interested in making financial contributions or donations like baby clothes, children’s books, or toy cars, email Gold at email@example.com.
Follow Gold’s organization Talking Health Out Loud on Facebook here.
For an interesting discussion on Numeracy Bias, check out this episode of Hidden Brain. Numeracy bias is described this way: “…When you see one person suffering, you feel like, ‘Oh, I can do something for that person.’ But when you hear that a whole country has a refugee crisis, you tend not to get involved because you feel like, ‘Well, this is overwhelming. I don’t think I can do anything about this, so I’m not going to engage.’…It turns out that people who have experienced a high level of lifetime adversity are immune to this bias.”
Art is multifunctional. It can be used to enhance or furnish a space, to document history, to simply fill a wall, to convey a message or emotion or expression, to entertain. Art can do some or all of these things and more. While “art and health have been at the center of human interest from the beginning of recorded history,” the healing properties of art have only begun to be acknowledged in Western medicine in the past few decades, with art therapy first recognized as a profession in 1991. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804629/ ]
The New Mexico Breastfeeding Task Force (NMBTF) is at the forefront of harnessing the power of art. Recognizing that art is medicine, the task force includes supporting lactation and breastfeeding/chestfeeding through art as a priority initiative, providing scholarships to chapters that take on the initiative.
“We are leaders in acknowledging how much art means to our communities,” says NMBTF Core Team Leader Siboney A. Rodriguez-Gallegos, LMSW, CLC. “When we can put those skills to paper or canvas or wall or bench or city bus, I think that we’re just barely starting to explore what can be done with that. I am really proud of our chapters.”
In Valencia County, April Vasquez and Rosa Sisneros and other team members are working with artist Ana June to create the outline of a mural which will be painted collectively by community members on August 6. The unveiling of the mural will be held August 13.
“We want to include the community as much as we can with this project,” Vasquez shares.
The imagery is being created on a large canvas making the art moveable and less likely to be destroyed when building ownership changes or buildings are razed, like a past mural project by Betsy Casanos which was painted over when building ownership changed. Putting the art on canvas also allows for reprinting so that the art can be shared on other products and disseminated more widely, Rodriguez-Gallegos explains.
“It’s so exciting,” Vasquez begins. “There were a bunch of emotions getting it together… It’s happening!”
Further south, Las Cruces County Chapter co-chairs Dr. Martha Morales and Melissa Marie Lopez and members are working with artist Kate Pults. This mural too is being created on canvas to avoid its potential demise on a fixed structure.
“Pults holds families, mothers and babies in many ways and we are thrilled to have her put those gifts in art form,” Rodriguez-Gallegos shares.
NMBTF has sponsored past mural projects here, here and here. An extension of the projects, you can find corresponding coloring pages of the murals here.
The coloring pages are often distributed at community outreach events and in hospital settings like the antepartum unit and for parents who have babies in the NICU.
Rodriguez shares her gratitude and pride in some closing thoughts: “All of our chapters put so much heart into the work that they do. It feels really good to be able to support [them]. The task force is really heading in a new direction to ensure we’re coming from an equitable lens, supporting our families, communities and wellness.”
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