母乳喂养与 HIV：新政策的循证案例。
Breastfeeding with HIV: An Evidence-Based Case for New Policy.
机构信息
Marielle S. Gross, M.D., M.B.E., is a Hecht-Levi postdoctoral research fellow in the Berman Institute of Bioethics at Johns Hopkins University where she recently completed residency training in Gynecology & Obstetrics. She attended medical school at the University of Florida, and previously completed degrees in Philosophy, Jewish Ethics and Bioethics at Columbia University, the Jewish Theological Seminary, and New York University, respectively. Holly A. Taylor, Ph.D., M.P.H., is a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics and Associate Professor in the Department of Health Policy and Management (HPM), Bloomberg School of Public Health. Dr. Taylor received her B.A. from Stanford University, her M.P.H. from the School of Public Health at the University of Michigan and her Ph.D. in health policy with a concentration in bioethics from the Bloomberg School of Public Health, Johns Hopkins University. Cecilia Tomori, Ph.D., studied biology and education at Swarthmore College and obtained her Ph.D. in Anthropology from the University of Michigan in 2011. She completed a postdoctoral fellowship at Johns Hopkins School of Public Health and served as faculty there between 2013-2017. Jenell S. Coleman, M.D., M.P.H., is associate professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics with a joint appointment in the Department of Medicine and is the medical director of the John's Hopkins Women's Health Center. Dr. Coleman earned her M.D. from the University of Pennsylvania School of Medicine and completed Ob/Gyn residency at the University of California, Los Angeles. She completed a fellowship in reproductive infectious diseases at the University of California, San Francisco and received an M.P.H. from the University of California, Berkeley.
出版信息
J Law Med Ethics. 2019 Mar;47(1):152-160. doi: 10.1177/1073110519840495.
To help eliminate perinatal HIV transmission, the US Department of Health and Human Services recommends against breastfeeding for women living with HIV, regardless of viral load or combined antiretroviral therapy (cART) status. However, cART radically improves HIV prognosis and virtually eliminates perinatal transmission, and breastfeeding's health benefits are well-established. In this setting, pregnancy is increasing among American women with HIV, and a harm reduction approach to those who breastfeed despite extensive counseling is suggested. We assess the evidence and ethical justification for current policy, with attention to pertinent racial and health disparities. We first review perinatal transmission and breastfeeding data relevant to US infants. We compare hypothetical risk of HIV transmission from breastmilk to increased mortality from sudden infant death syndrome, necrotizing enterocolitis and sepsis from avoiding breastfeeding, finding that benefits may outweigh risks if mothers maintain undetectable viral load on cART. We then review maternal health considerations. We conclude that avoidance of breastfeeding by women living with HIV may not maximize health outcomes and discuss our recommendation for revising national guidelines in light of autonomy, harm reduction and health inequities.
为了帮助消除围产期 HIV 传播，美国卫生与公众服务部建议感染 HIV 的女性无论病毒载量或联合抗逆转录病毒治疗 (cART) 状况如何，都不要进行母乳喂养。然而，cART 极大地改善了 HIV 的预后，几乎消除了围产期传播，并且母乳喂养对健康的益处已得到充分证实。在这种情况下，感染 HIV 的美国女性怀孕的人数正在增加，对于那些尽管经过广泛咨询仍选择母乳喂养的人，建议采取减少伤害的方法。我们评估了现行政策的证据和伦理依据，并关注相关的种族和健康差异。我们首先回顾了与美国婴儿相关的围产期传播和母乳喂养数据。我们将来自母乳的 HIV 传播的假设风险与因避免母乳喂养而导致的婴儿猝死综合征、坏死性小肠结肠炎和败血症的死亡率进行了比较，发现如果母亲在 cART 下保持病毒载量不可检测，那么益处可能大于风险。然后，我们回顾了产妇健康方面的考虑因素。我们得出的结论是，感染 HIV 的女性避免母乳喂养可能无法最大限度地提高健康结果，并讨论了我们根据自主性、减少伤害和健康不平等来修订国家指南的建议。
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