Development and Implementation of an Interdisciplinary Model for the Management of Breastfeeding in Women With HIV in the United States: Experience From the Children's Hospital Colorado Immunodeficiency Program.

BACKGROUND: Women with HIV in high-income settings have increasingly expressed a desire to breastfeed their infants. Although national guidelines now acknowledge this choice, detailed recommendations are not available. We describe the approach to managing care for breastfeeding women with HIV at a single large-volume site in the United States. METHODS: We convened an interdisciplinary group of providers to establish a protocol intended to minimize the risk of vertical transmission during breastfeeding. Programmatic experience and challenges are described. A retrospective chart review was conducted to report the characteristics of women who desired to or who did breastfeed between 2015 and 2022 and their infants. RESULTS: Our approach stresses the importance of early conversations about infant feeding, documentation of feeding decisions and management plans, and communication among the health care team. Mothers are encouraged to maintain excellent adherence to antiretroviral treatment, maintain an undetectable viral load, and breastfeed exclusively. Infants receive continuous single-drug antiretroviral prophylaxis until 4 weeks after cessation of breastfeeding. From 2015 to 2022, we counseled 21 women interested in breastfeeding, of whom 10 women breastfed 13 infants for a median of 62 days (range, 1-309). Challenges included mastitis (N = 3), need for supplementation (N = 4), maternal plasma viral load elevation of 50-70 copies/mL (N = 2), and difficulty weaning (N = 3). Six infants experienced at least 1 adverse event, most of which were attributed to antiretroviral prophylaxis. DISCUSSION: Many knowledge gaps remain in the management of breastfeeding among women with HIV in high-income settings, including approaches to infant prophylaxis. An interdisciplinary approach to minimizing risk is needed.

Medical opinion on abortion in Jamaica: a national Delphi survey of physician, nurses, and midwives.

A national sample of 120 Jamaican physicians, public health nurses, and licensed midwives participated in a two-stage Delphi survey to identify medical opinion on proposed liberlization of Jamaica's abortion law, and to predict the likely impact of such legislative action on existing health and family planning services. More than 80 percent of the respondents favored legalization of abortion, and most supported changes in the health service delivery system to accommodate the expected demand. They believed that clandestine abortion, involving pharmacists and physicians, is already widely practiced.

PIP: In Jamaica, existing law declares the act of abortion to be a felony although the law is rarely if ever enforced. A pregnant woman who seeks abortion and anyone helping her to obtain one is subject to prosecution. Many doctors are unwilling to face the possibility of legal confrontation. The purposes of this study were to provide policymakers with an overview of attitudes and opinions of those who must implement policy on abortion, to identify a consensus of informed opinion among medical personnel concerning proposed changes in law or policy on abortion, and to elict judgments of the magnitude of illegal abortion as a public health problem. The Delphi survey method has many variations, but a common feature is the repeated interrogation of respondents on their expectations and understandings regarding a particular issue. During the 1st round of data gathering, 120 informants were interviewed at length regarding abortion. After analysis of Round 1 data, and informing participants of results, those participating had an opportunity to reconsider their previous answers and to clarify ambiguous responses. The natural sample for Round 1 consisted of 70 physicians, 16 public health nurses, and 34 licensed midwives. The sample for Round 2 consisted of 65 physicians and 37 nurses and midwives. Also sought were the views of 20 physicians, not included in the random sample, who had been outspoken on the abortion issue. Licensed physicians and pharmacists were reported to be the most active in performing illegal abortions. The incidence of complications was reported to be greater when the abortions were performed by pharmacists. The predicted effect of liberalization of abortion laws on the use of contraceptive methods was that interest in such use would be increased. But an increase in the number of abortions was anticipated if such legislation were passed. Most doctors were in favor of the procedure of ''menstrual extraction'' but believed it should be subject to the same controls as regular abortion. However, many thought that nurses and others might be permitted to use this method. Survey results showed that there is a very solid support in the 3 segments of the medical community for liberalization of the abortion laws and for modifications in health services to care for an increased demand for abortions. The danger of a rapidly expanding population with already inadequate resources was ranked as a top social problem. Since the practice of abortion among Jamaican women is already widespread, a nonrestrictive abortion law finds general support within the medical community. Government action to relax curbs on abortion is described as an evolutionary, not a revolutionary step.