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To breast feed or not has long been a difficult question for women with human immunodeficiency virus (HIV) in high-income countries, as undetectable HIV in maternal plasma does not translate to zero risk of transmission while breastfeeding, and clean water and formula are readily available. Recent, and more permissive, changes in US and other high-income-country guidelines regarding breastfeeding underscore this issue and acknowledge the information gaps that are essential for informed maternal choice and provider management. These include lack of guidance as to routine monitoring of mothers during lactation, type and length of prophylaxis for infants, and lack of data on factors associated with increased breast-milk viral load and risk of transmission. Ancillary to data are the education and staffing needs for providers participating in the management of breastfeeding individuals. Future studies of breast-milk transmission will need to evaluate these gaps so that we can move transmission to zero., Competing Interests: Potential conflicts of interest. S.N. reports support as International Maternal Pediatrics Adolescent AIDS Clinical Trial (IMPAACT) Network PI; National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Mental Health (NIMH), and Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). G.A. reports grants or contracts as IMPAACT Network LC PI ; NIAID, NIMH, and NICHD for MSM and Substances Cohort at UCLA Linking Infections Noting Effects, Scientific Advisor & Repository Director NIDA; ACTG LC Network PI; NIAID, NIMH, and NICHD for UCLA-CDU CFAR Core Director NIAID; Trial of Human Oligosaccharide-based Synbiotics for HIV Exposed Uninfected NICHD Investigator for ATN Scientific Leadership Group, NICHD; Effects of Human Milk Oligosaccharides and Gut Microbiome on Growth and Morbidity in HIV-Exposed Uninfected Infants MPI NICHD for The Impact of COVID-19 Pandemic on Severe Mental Illness Investigator, Investigator, NIMH. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: In September 2002, possible transmission of West Nile virus via human milk was reported for the first time., Methods: Since 2003, the Centers for Disease Control and Prevention collected reports of maternal or infant West Nile virus illness during the breastfeeding period. All of the reported instances were reviewed. In addition, milk samples from women infected during pregnancy were tested for West Nile virus RNA and West Nile virus-specific antibodies., Results: Six infants were reported to have breastfed from mothers with West Nile virus fever. Five of the 6 infants had no illness or detectable antibodies to West Nile virus in serum after onset of maternal illness. One infant who was not tested and developed a rash was otherwise well 1 week after onset of maternal illness. In addition, 2 infants were reported to have developed West Nile virus illness while breastfeeding; preceding maternal illness was not documented. Two breastfed infants whose mothers acquired West Nile virus fever in the last week of pregnancy developed West Nile virus-specific antibodies; both infant infections could have been congenitally acquired. Of 45 milk samples from women infected with West Nile virus during pregnancy, 2 had West Nile virus RNA, and 14 had immunoglobin M antibodies to West Nile virus., Conclusions: Of 10 reported instances since 2003 of maternal or infant West Nile virus illness while breastfeeding, transmission of West Nile virus through human milk could neither be ruled out nor confirmed for 5 cases; in 5 others, serologic tests indicated no vertical transmission. Transmission of West Nile virus through breastfeeding seems to be rare, but more information is needed.

In the United States, concerns over the transmission of infectious diseases have led to donor human milk generally being subjected to pasteurization prior to distribution and use. The standard method used by North American milk banks is Holder pasteurization (63 degrees C for 30 minutes). The authors undertook an experiment to validate the effects of a high-temperature short-time (HTST) pasteurization process (72 degrees C for 16 seconds) on the bioburden of human milk. It was concluded that HTST is effective in the elimination of bacteria as well as of certain important pathogenic viruses.

West Nile virus (WNV) has spread across the United States causing annual outbreaks since its emergence in 1999. Although severe disease develops only in about 1% of infections, WNV has claimed a total of 564 lives in the 5 years from 1999 to 2003. Observation of flaccid paralysis due to WNV infection at a higher incidence than previously documented and the devastating mortality recorded in infected American bird species triggered concerns about a potentially enhanced virulence of this virus. Here we summarize recent observations made during the American outbreaks regarding host range and transmission modes of WNV, and discuss epidemiological aspects of the emergence of this pathogen in the new habitat.

Transmission of human immunodeficiency virus type 1 (HIV-1) through breastfeeding has been conclusively demonstrated. The risk of such transmission has been quantified, the timing has been clarified, and certain risk factors for breastfeeding transmission have been identified. In areas where infant formula is accessible, affordable, safe, and sustainable, avoidance of breastfeeding has represented one of the main components of mother-to-child HIV-1 transmission prevention efforts for many years. In areas where affordable and safe alternatives to breastfeeding may not be available, interventions to prevent breastfeeding transmission are being investigated. Complete avoidance of breastfeeding by HIV-1-infected women has been recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention and remains the only means by which prevention of breastfeeding transmission of HIV-1 can be absolutely ensured. This technical report summarizes the information available regarding breastfeeding transmission of HIV-1.

Over the past decade, much progress has been made in understanding the risk factors and timing of perinatal HIV transmission. Even more impressive have been the successful clinical trials with antiretrovirals, such as ZDV, ZDV-3TC, and nevirapine, that demonstrated significant reductions in the risk for infant infection. Within the United States and Europe, these trial results have led to rapid implementation and dramatic decreases in new perinatal HIV cases since 1994. An immediate challenge is to rapidly translate the short-course antiretroviral trial results with ZDV and nevirapine into public health policy and practice in resource-poor settings, where almost 600,000 neonates continue to become infected by mother-infant HIV transmission each year. Physicians must also test strategies to further decrease the risk for infant HIV infection during the breast-feeding period.

Breast-feeding provides nutritional, immunological, and psychological benefits. It protects children from mortality and morbidity associated with diarrheal diseases, pneumonia and other infections. Breast feeding has also been shown to prolong the interval between births and thereby improve child survival and maternal health. However, studies suggest that in certain populations, breast feeding may account for nearly 14% of perinatal human immunodeficiency virus type 1 (HIV-1) transmission. It is therefore important that the risk of HIV-1 infection through breast feeding be weighed against the morbidity and mortality associated with bottle feeding. This paper discusses the literature dealing with breast feeding in women with HIV-1 infection. Specifically, the review addresses the issues surrounding infant mortality in areas of different HIV-1 prevalence where breast-feeding or bottle-feeding may be employed. Analysis suggests that the benefits of breast-feeding or bottle-feeding may be employed. Analysis suggests that the benefits of breast-feeding can substantially outweigh the putative risk of HIV-1 transmission unless the prevalence of HIV-1 infection is high or the difference in mortality between breast-fed and bottle-fed infants is very low.