Introduction Transmission through breastfeeding remains important for mother-to-child transmission (MTCT) in resource-limited settings. We quantify the relationship between cell-free (RNA) and cell-associated (DNA) shedding of HIV-1 virus in breastmilk and the risk of postnatal HIV-1 transmission in the first 6 months postpartum. Materials and Methods Thirty-six HIV-positive mothers who transmitted HIV-1 by breastfeeding were matched to 36 non-transmitting HIV-1 infected mothers in a case-control study nested in a cohort of HIV-infected women. RNA and DNA were quantified in the same breastmilk sample taken at 6 weeks and 6 months. Cox regression analysis assessed the association between cell-free and cell-associated virus levels and risk of postnatal HIV-1 transmission. Results There were higher median levels of cell-free than cell-associated HIV-1 virus (per ml) in breastmilk at 6 weeks and 6 months. Multivariably, adjusting for antenatal CD4 count and maternal plasma viral load, at 6 weeks, each 10-fold increase in cell-free or cell-associated levels (per ml) was significantly associated with HIV-1 transmission but stronger for cell-associated than cell-free levels [2.47 (95% CI 1.33–4.59) vs. aHR 1.52 (95% CI, 1.17–1.96), respectively]. At 6 months, cell-free and cell-associated levels (per ml) in breastmilk remained significantly associated with HIV-1 transmission but was stronger for cell-free than cell-associated levels [aHR 2.53 (95% CI 1.64–3.92) vs. 1.73 (95% CI 0.94–3.19), respectively]. Conclusions The findings suggest that cell-associated virus level (per ml) is more important for early postpartum HIV-1 transmission (at 6 weeks) than cell-free virus. As cell-associated virus levels have been consistently detected in breastmilk despite antiretroviral therapy, this highlights a potential challenge for resource-limited settings to achieve the UNAIDS goal for 2015 of eliminating vertical transmission. More studies would further knowledge on mechanisms of HIV-1 transmission and help develop more effective drugs during lactation.
References
[1]
UNAIDS (2011) Global Report: UNAIDS report on the global AIDS epidemic. WHO library Cataloguing-in-Publication Data. 2011. Geneva, UNAIDS.
[2]
Newell ML (2003) Antenatal and perinatal strategies to prevent mother-to-child transmission of HIV infection. Trans R Soc Trop Med Hyg 97: 22–24.
[3]
Cooper ER, Charurat M, Mofenson L, Hanson IC, Pitt J, et al. (2002) Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr 29: 484–494.
[4]
European Collaborative Study (2005) Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. Clin Infect Dis 40: 458–465.
[5]
Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H, et al. (2008) Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS 22: 973–981.
[6]
WHO Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants: recommendations for a public health approach. WHO Library Cataloguing-in-Publications Data. 2010.
[7]
European Collaborative Study (1992) Risk factors for mother-to-child transmission of HIV-1. Lancet 339: 1007–1012.
[8]
Gupta A, Bhosale R, Kinikar A, Gupte N, Bharadwaj R, et al. (2011) Maternal tuberculosis: a risk factor for mother-to-child transmission of human immunodeficiency virus. J Infect Dis 203: 358–363.
[9]
Ayouba A, Nerrienet E, Menu E, Lobe MM, Thonnon J, et al. (2003) Mother-to-child transmission of human immunodeficiency virus type 1 in relation to the season in Yaounde, Cameroon. Am J Trop Med Hyg 69: 447–449.
[10]
Mmiro FA, Aizire J, Mwatha AK, Eshleman SH, Donnell D, et al. (2009) Predictors of early and late mother-to-child transmission of HIV in a breastfeeding population: HIV Network for Prevention Trials 012 experience, Kampala, Uganda. J Acquir Immune Defic Syndr 52: 32–39.
[11]
Rousseau CM, Nduati RW, Richardson BA, John-Stewart GC, Mbori-Ngacha DA, et al. (2004) Association of levels of HIV-1-infected breast milk cells and risk of mother-to-child transmission. J Infect Dis 190: 1880–1888.
[12]
Pillay K, Coutsoudis A, York D, Kuhn L, Coovadia HM (2000) Cell-free virus in breast milk of HIV-1-seropositive women. J Acquir Immune Defic Syndr 24: 330–336.
[13]
Richardson BA, John-Stewart GC, Hughes JP, Nduati R, Mbori-Ngacha D, et al. (2003) Breast-milk infectivity in human immunodeficiency virus type 1-infected mothers. J Infect Dis 187: 736–740.
[14]
Semba RD, Kumwenda N, Hoover DR, Taha TE, Quinn TC, et al. (1999) Human immunodeficiency virus load in breast milk, mastitis, and mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 180: 93–98.
[15]
Rousseau CM, Nduati RW, Richardson BA, Steele MS, John-Stewart GC, et al. (2003) Longitudinal analysis of human immunodeficiency virus type 1 RNA in breast milk and of its relationship to infant infection and maternal disease. J Infect Dis 187: 741–747.
[16]
John GC, Nduati RW, Mbori-Ngacha DA, Richardson BA, Panteleeff D, et al. (2001) Correlates of mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission: association with maternal plasma HIV-1 RNA load, genital HIV-1 DNA shedding, and breast infections. J Infect Dis 183: 206–212.
[17]
Van de Perre P (1999) Mother-to-child transmission of HIV-1: the ‘all mucosal’ hypothesis as a predominant mechanism of transmission. AIDS 13: 1133–1138.
[18]
Koulinska IN, Villamor E, Chaplin B, Msamanga G, Fawzi W, et al. (2006) Transmission of cell-free and cell-associated HIV-1 through breast-feeding. J Acquir Immune Defic Syndr 41: 93–99.
[19]
Neveu D, Viljoen J, Bland RM, Nagot N, Danaviah S, et al. (2011) Cumulative exposure to cell-free HIV in breast milk, rather than feeding pattern per se, identifies postnatally infected infants. Clin Infect Dis 52: 819–825.
[20]
Slyker JA, Chung MH, Lehman DA, Kiarie J, Kinuthia J, et al. (2012) 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 7: e29777.
[21]
Valea D, Tuaillon E, Al Tabaa Y, Rouet F, Rubbo PA, et al. (2011) CD4+ T cells spontaneously producing human immunodeficiency virus type I in breast milk from women with or without antiretroviral drugs. Retrovirology 8: 34.
[22]
Bland R, Coovadia H, Coutsoudis A, Rollins N, Newell M (2010) Cohort profile: mamanengane or the Africa centre vertical transmission study. Int J Epidemiol 39: 351–360.
[23]
Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 369: 1107–1116.
[24]
Cassol S, Gill MJ, Pilon R, Cormier M, Voigt RF, et al. (1997) Quantification of human immunodeficiency virus type 1 RNA from dried plasma spots collected on filter paper. J Clin Microbiol 35: 2795–2801.
[25]
Willumsen JF, Newell ML, Filteau SM, Coutsoudis A, Dwarika S, et al. (2001) Variation in breastmilk HIV-1 viral load in left and right breasts during the first 3 months of lactation. AIDS 15: 1896–1898.
[26]
Rouet F, Chaix ML, Nerrienet E, Ngo-Giang-Huong N, Plantier JC, et al. (2007) Impact of HIV-1 genetic diversity on plasma HIV-1 RNA Quantification: usefulness of the Agence Nationale de Recherches sur le SIDA second-generation long terminal repeat-based real-time reverse transcriptase polymerase chain reaction test. J Acquir Immune Defic Syndr 45: 380–388.
[27]
Ghosh MK, Kuhn L, West J, Semrau K, Decker D, et al. (2003) Quantitation of human immunodeficiency virus type 1 in breast milk. J Clin Microbiol 41: 2465–2470.
[28]
Chege D, Chai Y, Huibner S, McKinnon L, Wachihi C, et al. (2010) Evaluation of a quantitative real-time PCR assay to measure HIV-specific mucosal CD8+ T cell responses in the cervix. PLoS One 5: e13077.
[29]
Tasker S, Peters IR, Mumford AD, Day MJ, Gruffydd-Jones TJ, et al. (2010) Investigation of human haemotropic Mycoplasma infections using a novel generic haemoplasma qPCR assay on blood samples and blood smears. J Med Microbiol 59: 1285–1292.
[30]
Houzet L, Paillart JC, Smagulova F, Maurel S, Morichaud Z, et al. (2007) HIV controls the selective packaging of genomic, spliced viral and cellular RNAs into virions through different mechanisms. Nucleic Acids Res 35: 2695–2704.
[31]
Gantt S, Carlsson J, Shetty AK, Seidel KD, Qin X, et al. (2008) Cytomegalovirus and Epstein-Barr virus in breast milk are associated with HIV-1 shedding but not with mastitis. AIDS 22: 1453–1460.
[32]
Chung MH, Kiarie JN, Richardson BA, Lehman DA, Overbaugh J, et al. (2008) Highly active antiretroviral therapy versus zidovudine/nevirapine effects on early breast milk HIV type-1 Rna: a phase II randomized clinical trial. Antivir Ther 13: 799–807.
[33]
Lehman DA, Chung MH, John-Stewart GC, Richardson BA, Kiarie J, et al. (2008) HIV-1 persists in breast milk cells despite antiretroviral treatment to prevent mother-to-child transmission. AIDS 22: 1475–1485.
[34]
Goldman AS, Garza C, Nichols BL, Goldblum RM (1982) Immunologic factors in human milk during the first year of lactation. J Pediatr 100: 563–567.
[35]
Ruff AJ, Coberly J, Halsey NA, Boulos R, Desormeaux J, et al. (1994) Prevalence of HIV-1 DNA and p24 antigen in breast milk and correlation with maternal factors. J Acquir Immune Defic Syndr 7: 68–73.
[36]
Van de Perre P, Simonon A, Hitimana DG, Dabis F, Msellati P, et al. (1993) Infective and anti-infective properties of breastmilk from HIV-1-infected women. Lancet 341: 914–918.
[37]
Guay LA, Hom DL, Mmiro F, Piwowar EM, Kabengera S, et al. (1996) Detection of human immunodeficiency virus type 1 (HIV-1) DNA and p24 antigen in breast milk of HIV-1-infected Ugandan women and vertical transmission. Pediatrics 98: 438–444.
[38]
Semrau K, Ghosh M, Kankasa C, Sinkala M, Kasonde P, et al. (2008) Temporal and lateral dynamics of HIV shedding and elevated sodium in breast milk among HIV-positive mothers during the first 4 months of breast-feeding. J Acquir Immune Defic Syndr 47: 320–328.
[39]
Lewis P, Nduati R, Kreiss JK, John GC, Richardson BA, et al. (1998) Cell-free human immunodeficiency virus type 1 in breast milk. J Infect Dis 177: 34–39.
[40]
Nduati RW, John GC, Richardson BA, Overbaugh J, Welch M, et al. (1995) Human immunodeficiency virus type 1-infected cells in breast milk: association with immunosuppression and vitamin A deficiency. J Infect Dis 172: 1461–1468.
[41]
Department of Health (2010) Clinical guidelines: PMTCT (Prevention of Mother-to-Child Transmission). Pretoria, South African Naional AIDS Council.
[42]
KwaZulu Natal Provincial Deaprtment of Health Protocol for the phased implementation of a comprehensive package of care for the revention of mother to child transmission of HIV in KwaZuluNatal. Version 4ed: 2003.
[43]
Chung MH, Kiarie JN, Richardson BA, Lehman DA, Overbaugh J, et al. (2007) Independent effects of nevirapine prophylaxis and HIV-1 RNA suppression in breast milk on early perinatal HIV-1 transmission. J Acquir Immune Defic Syndr 46: 472–478.
[44]
Bennetto-Hood C, Aldrovandi GM, King JR, Woodman K, Ashouri N, et al. (2007) Persistence of nevirapine in breast milk after discontinuation of treatment. Clin Infect Dis 45: 391–394.
[45]
Chung MH, Kiarie JN, Richardson BA, Lehman DA, Overbaugh J, et al. (2005) Breast milk HIV-1 suppression and decreased transmission: a randomized trial comparing HIVNET 012 nevirapine versus short-course zidovudine. AIDS 19: 1415–1422.
[46]
Antinori A, Perno CF, Giancola ML, Forbici F, Ippolito G, et al. (2005) Efficacy of cerebrospinal fluid (CSF)-penetrating antiretroviral drugs against HIV in the neurological compartment: different patterns of phenotypic resistance in CSF and plasma. Clin Infect Dis 41: 1787–1793.
[47]
Thomas TK, Masaba R, Borkowf CB, Ndivo R, Zeh C, et al. (2011) Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding–the Kisumu Breastfeeding Study, Kenya: a clinical trial. PLoS Med 8: e1001015.
[48]
de Vincenzi I (2011) Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. Lancet Infect Dis 11: 171–180.
[49]
Kilewo C, Karlsson K, Ngarina M, Massawe A, Lyamuya E, et al. (2009) Prevention of mother-to-child transmission of HIV-1 through breastfeeding by treating mothers with triple antiretroviral therapy in Dar es Salaam, Tanzania: the Mitra Plus study. J Acquir Immune Defic Syndr 52: 406–416.
[50]
Chasela CS, Hudgens MG, Jamieson DJ, Kayira D, Hosseinipour MC, et al. (2010) Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med 362: 2271–2281.
[51]
Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, et al. (2010) Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med 362: 2282–2294.
[52]
Shapiro RL, Ndung’u T, Lockman S, Smeaton LM, Thior I, et al. (2005) Highly active antiretroviral therapy started during pregnancy or postpartum suppresses HIV-1 RNA, but not DNA, in breast milk. J Infect Dis 192: 713–719.
[53]
John-Stewart G, Mbori-Ngacha D, Ekpini R, Janoff EN, Nkengasong J, et al. (2004) Breast-feeding and Transmission of HIV-1. J Acquir Immune Defic Syndr 35: 196–202.
[54]
Becquart P, Chomont N, Roques P, Ayouba A, Kazatchkine MD, et al. (2002) Compartmentalization of HIV-1 between breast milk and blood of HIV-infected mothers. Virology 300: 109–117.
[55]
Khamduang W, Jourdain G, Sirirungsi W, Layangool P, Kanjanavanit S, et al. (2011) The interrelated transmission of HIV-1 and cytomegalovirus during gestation and delivery in the offspring of HIV-infected mothers. J Acquir Immune Defic Syndr 58: 188–192.
[56]
Bland RM, Becquet R, Rollins NC, Coutsoudis A, Coovadia HM, et al. (2007) Breast health problems are rare in both HIV-infected and HIV-uninfected women who receive counseling and support for breast-feeding in South Africa. Clin Infect Dis 45: 1502–1510.
[57]
UNAIDS (2010) Getting to Zero: 2011–2015 strategy Joint United Nations Programme on HIV/AIDS. WHO library Cataloguing-in-Publication Data. 2010. Geneva, UNAIDS.
