Willumsen, Juana Francisca; (2000) Subclinical mastitis and HIV-1 in South African women. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

HIV is transmitted from mother-to-child through breastmilk and without antiretroviral prophylaxis can account for up to half of the vertical transmission observed. Virus may be present in the milk, but not result in infection in the breastfed infant and little is known about which factors influence viral shedding. Two studies were conducted in Durban. South Africa, an area of high HIV seroprevalence, to test the hypothesis that during subclinical mastitis (as indicated by raised breastmilk sodium:potassium ratio (Na/K)) viral shedding into breastmilk increases and high levels of breastmilk inflammatory cytokines cause damage to the infant intestinal mucosa (thereby allowing virus to enter the infant circulation. In a cross-sectional study the prevalence of subclinical mastitis among 321 lactating mothers of unknown HIV status was 25.7% (only in one breast in 18.5% of all mothers). Breastmilk Na/K correlated with the inflammatory cytokine IL-8. Mothers who had exclusively breastfed their infant in the previous 24 hours had lower Na/K ratios than those who had supplemented breastmilk with formula. Interestingly, mothers who had given complementary foods in addition to breastmilk had the lowest Na/K ratios. A cohort study of 145 HIV-infected women and their infants during the first 3 months of lactation breastmilk Na/K ratio is strongly associated with viral load and there is an interaction between feeding mode and Na/K. Exclusive breastfeeding during early lactation resulted in significantly lower breastmilk viral load than mixed feeding, but this effect was reduced at later time points. There was no association between breastmilk IL-8 and infant intestinal permeability. It is important to note that breastmilk Na/K only predicted between 11 and 26% of viral load and any intervention to reduce the prevalence of subclinical mastitis would be expected to have a small impact on the overall rate of mother-to-child transmission of HIV.

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