1 00:00:00,000 --> 00:00:12,440 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:12,440 --> 00:00:16,280 podcast by Canadian infectious diseases physicians. 3 00:00:16,280 --> 00:00:21,640 I'm Summer Stewart, back again with Dr. Rupeena Purewal, pediatric infectious diseases physician 4 00:00:21,640 --> 00:00:23,540 from Saskatoon. 5 00:00:23,540 --> 00:00:28,880 In this episode, the Canadian Breakpoint invites Dr. Sarah Khan, pediatric infectious disease 6 00:00:28,880 --> 00:00:34,120 specialist at McMaster University in Hamilton, Ontario, to discuss infant feeding in the 7 00:00:34,120 --> 00:00:35,680 context of HIV. 8 00:00:35,680 --> 00:00:37,040 Dr. Purewal. 9 00:00:37,040 --> 00:00:40,960 Hi, welcome to another episode of our podcast, the Canadian Breakpoint. 10 00:00:40,960 --> 00:00:46,960 Today, we have a very special guest with us, Dr. Sarah Khan, who is a pediatric infectious 11 00:00:46,960 --> 00:00:52,000 disease specialist and associate professor in the Department of Pediatrics at McMaster 12 00:00:52,000 --> 00:00:53,000 University. 13 00:00:53,000 --> 00:00:58,200 She's the associate medical director for infection prevention and control with Hamilton 14 00:00:58,200 --> 00:00:59,800 Health Sciences. 15 00:00:59,800 --> 00:01:05,240 She completed her pediatrics residency and master's in health research methodology at 16 00:01:05,240 --> 00:01:11,840 McMaster, an ID fellowship and CTN postdoctoral fellowship in HIV at the Hospital for Sick 17 00:01:11,840 --> 00:01:12,840 Children. 18 00:01:12,840 --> 00:01:18,000 Her scholarly focus is in antimicrobial stewardship, infection control, and infant feeding in the 19 00:01:18,000 --> 00:01:19,360 HIV context. 20 00:01:19,360 --> 00:01:23,080 So thank you so much, Dr. Khan, for joining us today. 21 00:01:23,080 --> 00:01:27,060 And today we're going to be talking about a very important topic, which is regarding 22 00:01:27,060 --> 00:01:34,760 infant feeding in the HIV context, which as we just heard, Dr. Khan is one of our experts 23 00:01:34,760 --> 00:01:35,760 in this field. 24 00:01:35,760 --> 00:01:40,240 And so before starting the podcast, we do want to give a disclosure that everything 25 00:01:40,240 --> 00:01:46,120 we'll be discussing today will be solely for informational purposes only and not to coerce 26 00:01:46,120 --> 00:01:48,320 or promote an idea or product. 27 00:01:48,320 --> 00:01:50,880 Also, this topic is evolving. 28 00:01:50,880 --> 00:01:54,960 And when the consensus recommendations for infant feeding were established, CPARG and 29 00:01:54,960 --> 00:02:00,120 other members of the medical community involved in these guidelines agreed that as new evidence 30 00:02:00,120 --> 00:02:05,120 emerges, there will be ongoing evaluation of these recommendations. 31 00:02:05,120 --> 00:02:09,360 So at this time, these recommendations are based on expert opinion and not specifically 32 00:02:09,360 --> 00:02:11,560 on evidence-based medicine. 33 00:02:11,560 --> 00:02:16,840 Also, depending on the jurisdiction that you're practicing in, these guidelines may vary. 34 00:02:16,840 --> 00:02:21,740 These guidelines are solely developed as a guidance for families who may have the option 35 00:02:21,740 --> 00:02:26,800 of infant feeding with breast milk as opposed to exclusive formula feeding. 36 00:02:26,800 --> 00:02:31,480 This assessment is based on a case-by-case assessment and requires the involvement of 37 00:02:31,480 --> 00:02:36,320 a physician who's familiar with risk assessment in HIV care. 38 00:02:36,320 --> 00:02:40,280 Exclusive formula feeding remains the preferred method of infant feeding in the context of 39 00:02:40,280 --> 00:02:41,280 HIV. 40 00:02:41,280 --> 00:02:46,960 However, today we're going to discuss the approach to counseling a family or mother 41 00:02:46,960 --> 00:02:55,120 or mother of childbearing age for infants who are living or mothers who are living with 42 00:02:55,120 --> 00:03:00,800 HIV and would like to know the options of infant feeding. 43 00:03:00,800 --> 00:03:05,600 So thank you, Dr. Khan, for being here today and discussing such an important topic with 44 00:03:05,600 --> 00:03:11,560 us because for many years prior to this, we didn't have much guidance. 45 00:03:11,560 --> 00:03:16,760 And a lot of our centers have been providing care for mothers with HIV, but do not have 46 00:03:16,760 --> 00:03:22,040 really the other expertise or really an approach to this situation. 47 00:03:22,040 --> 00:03:23,720 I think it's coming up more and more. 48 00:03:23,720 --> 00:03:31,040 So without further ado, I do want to start by just kind of discussing why these consensus 49 00:03:31,040 --> 00:03:36,200 recommendations or why do the committee members decide to come up with these consensus recommendations 50 00:03:36,200 --> 00:03:38,240 if you can just speak a little bit about that. 51 00:03:38,240 --> 00:03:42,440 Yeah, thanks so much for having me and discussing this topic. 52 00:03:42,440 --> 00:03:44,440 It's very near and dear to my heart. 53 00:03:44,440 --> 00:03:49,840 And I think it's because this conversation has really evolved out of the realization 54 00:03:49,840 --> 00:03:55,600 that the community really had a lot of questions around this issue, but there was a lot of 55 00:03:55,600 --> 00:03:59,660 stigma about even talking about it in our clinical conversations. 56 00:03:59,660 --> 00:04:04,800 And so I think the committee had decided to come up with these recommendations really 57 00:04:04,800 --> 00:04:10,040 from a call from the community that we need more information, we need clarity on what 58 00:04:10,040 --> 00:04:14,960 is and isn't appropriate, because many women may have delivered in different contexts and 59 00:04:14,960 --> 00:04:17,720 be counseled very differently in different settings. 60 00:04:17,720 --> 00:04:22,000 And then they arrive in our clinical settings here in Canada and are told potentially very 61 00:04:22,000 --> 00:04:23,360 different guidance. 62 00:04:23,360 --> 00:04:28,400 And I think until there's clarity and there's really fulsome discussions with the community 63 00:04:28,400 --> 00:04:34,360 and their respective providers, are we really sort of missing a big part of what's so important 64 00:04:34,360 --> 00:04:37,860 to women living with HIV in their mothering experience? 65 00:04:37,860 --> 00:04:42,280 So I think it sparked from a call from the community, but I think it was recognition 66 00:04:42,280 --> 00:04:47,580 on the provider side that we need to understand this issue better and fully unpack it. 67 00:04:47,580 --> 00:04:52,080 And then I think the last sort of element to this was aid service organizations also 68 00:04:52,080 --> 00:04:56,760 lack the language, the resource and how to have a fulsome conversation, because there's 69 00:04:56,760 --> 00:05:02,160 such an integral part of women in their pregnancy planning and their postpartum experience. 70 00:05:02,160 --> 00:05:07,440 And if all of these spaces aren't really places for this kind of dialogue to happen, you know, 71 00:05:07,440 --> 00:05:11,760 that begs the need for, you know, an in-depth and evidence review. 72 00:05:11,760 --> 00:05:16,880 And I appreciate your intro to this podcast around its expert opinion, looking and leaning 73 00:05:16,880 --> 00:05:19,320 on the evidence we have to date. 74 00:05:19,320 --> 00:05:24,200 So I think that's sort of how I would summarize where and why this came to be. 75 00:05:24,200 --> 00:05:29,180 I'm probably one of those health care providers and community members that appreciate such 76 00:05:29,180 --> 00:05:34,840 guidelines coming out, because we are facing questions in regards to this. 77 00:05:34,840 --> 00:05:40,920 And you make a very valid point about, you know, where we have a lot of immigration to 78 00:05:40,920 --> 00:05:44,120 Canada and so there's different practices. 79 00:05:44,120 --> 00:05:47,040 And I think so a lot of these questions will come up. 80 00:05:47,040 --> 00:05:49,160 And so it's nice to have an approach. 81 00:05:49,160 --> 00:05:53,720 So I think before we start with the actual approach and kind of how and what context, 82 00:05:53,720 --> 00:05:59,360 how do we go about this for our listeners, because they may not be familiar with this. 83 00:05:59,360 --> 00:06:06,380 Can we just touch on some of the risk of transmission that we are known to us in regards to formula 84 00:06:06,380 --> 00:06:08,280 feeding versus breast milk? 85 00:06:08,280 --> 00:06:11,560 Yeah, that's I think integral to this conversation, right? 86 00:06:11,560 --> 00:06:14,720 Because I think at the end of the day, that's what everybody wants to know. 87 00:06:14,720 --> 00:06:15,720 What is the risk? 88 00:06:15,720 --> 00:06:19,480 And I think if we kind of take that step backwards and we talk about vertical transmission in 89 00:06:19,480 --> 00:06:24,960 general, if you offer no interventions, you know, we talk about a 10% risk of in utero 90 00:06:24,960 --> 00:06:31,040 transmission, and then around 10 to 15% from delivery alone, given the, you know, sharing 91 00:06:31,040 --> 00:06:34,880 of secretions and blood crossing different borders. 92 00:06:34,880 --> 00:06:41,200 And then again, with no intervention, breastfeeding has an additional 10 to 15% risk. 93 00:06:41,200 --> 00:06:46,680 Now obviously, we do so much to prevent that risk and bring that sort of number from 25% 94 00:06:46,680 --> 00:06:51,200 down to sort of, and I'll land at sort of between 0.5 and 3%. 95 00:06:51,200 --> 00:06:54,280 And I'll get I'll break down those numbers a little bit more for you. 96 00:06:54,280 --> 00:07:00,200 So there have been a few systematic reviews, some commissioned by the WHO to look at, okay, 97 00:07:00,200 --> 00:07:04,840 forget in utero, forget delivery, what is the breast milk risk of transmission in a 98 00:07:04,840 --> 00:07:09,560 well controlled mom with an undetectable viral load in pregnancy? 99 00:07:09,560 --> 00:07:14,760 And again, recognizing most of this data comes from low middle income context where breastfeeding 100 00:07:14,760 --> 00:07:19,640 is sort of part of what is part of the care for women living with HIV. 101 00:07:19,640 --> 00:07:23,720 The risk is quantified at depending on sort of what duration you cut off breastfeeding 102 00:07:23,720 --> 00:07:29,200 at terms of six months or 12 or 18 months, anywhere between sort of 0.4 to 3%. 103 00:07:29,200 --> 00:07:32,800 Now where and why is that sort of window so wide? 104 00:07:32,800 --> 00:07:37,160 Because we know that virologic monitoring that might be happening may be different from 105 00:07:37,160 --> 00:07:38,520 study to study. 106 00:07:38,520 --> 00:07:42,760 We know that, you know, this is mostly done in a trial setting, which may differ in real 107 00:07:42,760 --> 00:07:44,040 world context. 108 00:07:44,040 --> 00:07:48,160 We know there are different ART regimens used in these different trials, there's different 109 00:07:48,160 --> 00:07:52,760 prophylaxis offered to infant or not at all, depending on the trial. 110 00:07:52,760 --> 00:07:56,400 And so there's a range of what we describe as the risk. 111 00:07:56,400 --> 00:07:59,120 It's very much dependent on the duration of breastfeeding. 112 00:07:59,120 --> 00:08:03,760 And then there are a variety of factors that could sort of cause a blip, if you will, in 113 00:08:03,760 --> 00:08:05,640 terms of the risk of transmission. 114 00:08:05,640 --> 00:08:09,440 And those are sort of higher risk scenarios we allude to in the guideline. 115 00:08:09,440 --> 00:08:13,800 But if you're sort of going to ask for a higher number, it's somewhere in that range, 0.5 116 00:08:13,800 --> 00:08:15,320 to sort of 3%. 117 00:08:15,320 --> 00:08:19,520 And if you want a little more specifics, if we talk about the first four to six weeks, 118 00:08:19,520 --> 00:08:23,880 there's some data to suggest it's more like 0.7 to 1% per week, and then that risk drops 119 00:08:23,880 --> 00:08:27,120 off significantly to sort of 0.7% per month. 120 00:08:27,120 --> 00:08:32,560 And that's also partially related to breast milk composition in early postpartum phase, 121 00:08:32,560 --> 00:08:37,440 colostrum versus sort of later phases of breast milk, including the form milk and hind milk. 122 00:08:37,440 --> 00:08:40,360 So there's so many variables to consider. 123 00:08:40,360 --> 00:08:44,200 That's why this data is limited by many of those factors. 124 00:08:44,200 --> 00:08:48,880 But that's the best we can get to in terms of quantifying, recognizing it's not quite 125 00:08:48,880 --> 00:08:52,840 the same risks we might see in our context with differences in monitoring. 126 00:08:52,840 --> 00:08:53,840 Okay. 127 00:08:53,840 --> 00:08:57,520 And like we mentioned before, kind of depending on the jurisdiction you're practicing, there 128 00:08:57,520 --> 00:09:00,080 might be different medication, there's different approaches. 129 00:09:00,080 --> 00:09:03,160 And so those risks can vary. 130 00:09:03,160 --> 00:09:13,100 So in terms of when a family or a parent asks a prenatal physician or an obsgyne, questions 131 00:09:13,100 --> 00:09:20,640 in regards to infant feeding options, can they use their own breast milk in the context 132 00:09:20,640 --> 00:09:21,640 of feeding? 133 00:09:21,640 --> 00:09:24,080 How would you approach the situation? 134 00:09:24,080 --> 00:09:31,520 And so what factors do you think that those physicians and those caregivers need to take 135 00:09:31,520 --> 00:09:32,520 into account? 136 00:09:32,520 --> 00:09:33,840 Yeah, thanks for this question. 137 00:09:33,840 --> 00:09:38,520 I think this is probably the most important thing, that message that needs to kind of 138 00:09:38,520 --> 00:09:39,520 go out. 139 00:09:39,520 --> 00:09:42,160 And I think you highlighted a really good point. 140 00:09:42,160 --> 00:09:45,880 This is all about setting us up for success, setting everybody up for success. 141 00:09:45,880 --> 00:09:50,880 And so making sure these conversations happen as early as is reasonable in pregnancy, and 142 00:09:50,880 --> 00:09:56,440 really with both the maternal and the pediatric providers that will be involved in this conversation. 143 00:09:56,440 --> 00:10:01,480 Because there are multiple players that are part of setting this up for success. 144 00:10:01,480 --> 00:10:05,800 So I think that's kind of a key message I'd want to get out. 145 00:10:05,800 --> 00:10:10,000 Okay, so we've got all the people at the table, and we're starting to have this conversation 146 00:10:10,000 --> 00:10:14,560 and we really want to have it in the depth that every woman should be counseled on to 147 00:10:14,560 --> 00:10:17,760 sort of help navigate this complicated decision. 148 00:10:17,760 --> 00:10:22,760 I think there's probably about sort of six key things that we agreed as the group that 149 00:10:22,760 --> 00:10:26,080 we would really hope are part of these conversations. 150 00:10:26,080 --> 00:10:30,480 And one is that one we touched on already, you know, why is there a difference in guidelines 151 00:10:30,480 --> 00:10:33,400 in high versus low resource or low middle income contexts? 152 00:10:33,400 --> 00:10:38,200 Because I think a lot of women come to this table with sort of this, do you guys in this 153 00:10:38,200 --> 00:10:40,760 context just not get that it's possible? 154 00:10:40,760 --> 00:10:42,360 And that we've heard that from women. 155 00:10:42,360 --> 00:10:47,080 And I think that's a really important question that we sort of need to bring to light that 156 00:10:47,080 --> 00:10:49,160 there's a reason why there are differences. 157 00:10:49,160 --> 00:10:53,560 And it's because we're all sort of looking to the best outcome for mom and baby in the 158 00:10:53,560 --> 00:10:54,640 end, right? 159 00:10:54,640 --> 00:11:00,000 And most of the trials are based on HIV free infant survival and the recognition that there 160 00:11:00,000 --> 00:11:05,880 are a variety of causes of infant mortality in low middle income contexts and why breast 161 00:11:05,880 --> 00:11:10,520 feeding is actually preferred because of malnutrition, the dysentery, the challenges of getting potable 162 00:11:10,520 --> 00:11:11,600 water, right? 163 00:11:11,600 --> 00:11:16,800 And so explaining, I don't know if you have to go into AFAS criteria, accessible, feasible, 164 00:11:16,800 --> 00:11:20,920 affordable, safe and sustainable, but really the point being, yes, you may have been counseled 165 00:11:20,920 --> 00:11:22,480 one way and one pregnancy. 166 00:11:22,480 --> 00:11:26,160 And this is the reason why it's different in low middle income contexts. 167 00:11:26,160 --> 00:11:31,440 And the reason why we suggest or recommend formula feeding for women living with HIV in 168 00:11:31,440 --> 00:11:35,840 high resource context is because it eliminates that risk of postpartum transmission. 169 00:11:35,840 --> 00:11:40,440 Not to say that's the only sort of way to go, but this is why there are differences. 170 00:11:40,440 --> 00:11:43,480 That needs to be sort of laid plain a priori. 171 00:11:43,480 --> 00:11:46,880 Once you've sort of been able to get through that part of the conversation, I think it's 172 00:11:46,880 --> 00:11:52,600 important to talk about, you know, okay, so what is the risk and why is there a risk of 173 00:11:52,600 --> 00:11:56,600 breastfeeding transmission if a woman is undetectable, right? 174 00:11:56,600 --> 00:12:01,680 Because I think that emerging conversation of U equals U for sexual transmission is so 175 00:12:01,680 --> 00:12:07,000 important and is such an important element of HIV education, but it doesn't necessarily 176 00:12:07,000 --> 00:12:09,160 apply in the breastfeeding context. 177 00:12:09,160 --> 00:12:13,960 And explaining why that is, because we know from some of the breast milk science that 178 00:12:13,960 --> 00:12:19,720 has been done that even a woman with an undetectable plasma viral load may have cell associated 179 00:12:19,720 --> 00:12:20,920 virus. 180 00:12:20,920 --> 00:12:26,240 And cell associated virus means those T cells, those white blood cells in breast milk that 181 00:12:26,240 --> 00:12:31,120 are such an important part of why breast milk is good for sort of the immune system of the 182 00:12:31,120 --> 00:12:37,560 infant is also why HIV transmission could be occurring because yes, antigen virus are 183 00:12:37,560 --> 00:12:42,160 effective and reduce cell free virus, but they do not eliminate cell associated virus. 184 00:12:42,160 --> 00:12:47,320 And because there's such an important immune component of breast milk, those T cells are 185 00:12:47,320 --> 00:12:52,680 there and those T cells can actually be activated through the process of lactation. 186 00:12:52,680 --> 00:12:58,200 And so again, those T cells can sort of be turned on and be producing more active HIV 187 00:12:58,200 --> 00:13:01,240 upon lactation and upon ingestion by the infant. 188 00:13:01,240 --> 00:13:06,780 So explaining why virus can be in breast milk when it's not detectable in plasma. 189 00:13:06,780 --> 00:13:11,000 And then all the other elements that can further increase the immune response either in the 190 00:13:11,000 --> 00:13:17,720 breast component like mastitis, blocked ducts, cracked nipples or inflamed nipples and similarly 191 00:13:17,720 --> 00:13:21,640 immune activation or mucosal inflammation in the baby. 192 00:13:21,640 --> 00:13:26,920 So oral thrush, HSV stomatitis, gastroenteritis, all of those infections that could happen 193 00:13:26,920 --> 00:13:32,520 to any baby that could further increase the risk of cell associated virus transmission 194 00:13:32,520 --> 00:13:37,020 or even cell free virus transmission into the infant's plasma component. 195 00:13:37,020 --> 00:13:41,960 And so I think just to sort of in as lay terms as are possible, and I know I'm talking provider 196 00:13:41,960 --> 00:13:44,680 to provider here, so obviously different language is necessary. 197 00:13:44,680 --> 00:13:48,160 There's a lot of really helpful resources I'm sure we'll chat about at the end that 198 00:13:48,160 --> 00:13:53,200 kind of explain this in a really sort of easy way for patients to understand as well. 199 00:13:53,200 --> 00:13:56,920 But I think guidelines and the science of transmission are sort of point one we really 200 00:13:56,920 --> 00:13:58,840 think are important to cover. 201 00:13:58,840 --> 00:14:02,600 The other key piece would be, you know, what are the types of infant feeding? 202 00:14:02,600 --> 00:14:07,400 So there's exclusive breastfeeding, exclusive formula feeding, and then there's mixed feeding. 203 00:14:07,400 --> 00:14:12,440 And sort of the general consensus that mixed feeding may actually be a further increased 204 00:14:12,440 --> 00:14:17,820 risk of transmission because of multiple antigenic exposures to baby and that increased sort 205 00:14:17,820 --> 00:14:22,340 of potential immune response you might see and why mixed feeding should be avoided as 206 00:14:22,340 --> 00:14:27,000 much as possible in terms of if we are talking about breastfeeding potentially. 207 00:14:27,000 --> 00:14:31,960 I think the other sort of important element of that is really sort of walking through 208 00:14:31,960 --> 00:14:36,960 a woman walking through your patient around what it might look like if you formula feed 209 00:14:36,960 --> 00:14:40,520 and how you can, you know, safely access formula. 210 00:14:40,520 --> 00:14:46,020 Most provinces not all have free formula for women living with HIV for a full year. 211 00:14:46,020 --> 00:14:50,440 And so making sure they know how to mix formula, how to safely clean bottles like some of the 212 00:14:50,440 --> 00:14:52,640 stuff we take it for granted. 213 00:14:52,640 --> 00:14:55,400 But you know, women have voice that like, I didn't know what to do. 214 00:14:55,400 --> 00:14:58,280 I was just told this is your formula, figure it out. 215 00:14:58,280 --> 00:15:03,340 And whereas there's a lot more supports for breastfeeding for the general population. 216 00:15:03,340 --> 00:15:07,400 So we should be offering similar degree of support for women that may choose to formula 217 00:15:07,400 --> 00:15:08,400 feed. 218 00:15:08,400 --> 00:15:12,240 And the other element I'd add around what it might look like is can we do lactation 219 00:15:12,240 --> 00:15:13,240 suppression? 220 00:15:13,240 --> 00:15:14,240 Will that help? 221 00:15:14,240 --> 00:15:17,800 Because you can take cabergolene, a medicine shortly after delivery, so you can kind of 222 00:15:17,800 --> 00:15:19,480 shut down breast milk production. 223 00:15:19,480 --> 00:15:24,080 So there's not that added element of some women have described it as trauma that they're 224 00:15:24,080 --> 00:15:26,480 you know, lactating, but they can't feed their infant. 225 00:15:26,480 --> 00:15:32,000 And that's, you know, a real issue that we can address, like we can manage that for women. 226 00:15:32,000 --> 00:15:36,120 And then also sort of reduction of engorgement and all the other sort of physiologic processes 227 00:15:36,120 --> 00:15:38,640 that happen in a woman that is not going on to breastfeed. 228 00:15:38,640 --> 00:15:43,040 So I think walking through what it can look like if you formula feed, and then similarly 229 00:15:43,040 --> 00:15:48,400 walking through what is essential that we have to have in place if you choose to breastfeed. 230 00:15:48,400 --> 00:15:52,760 And that would be the importance of talking about, we really need to ensure that you're 231 00:15:52,760 --> 00:15:58,360 going to be able to take your ART after delivery, because life gets busy after you have a baby, 232 00:15:58,360 --> 00:15:59,360 right? 233 00:15:59,360 --> 00:16:02,160 We're not just talking about the you know, the mental health component of this, but also 234 00:16:02,160 --> 00:16:06,200 like your sleep, your sleep deprived, like you're stressed out, you have a whole other 235 00:16:06,200 --> 00:16:11,280 human to be managing and your health, you know, is also critically important for baby's 236 00:16:11,280 --> 00:16:12,280 health, right? 237 00:16:12,280 --> 00:16:16,160 And so making sure women can continue on their their ART, because that's kind of criteria 238 00:16:16,160 --> 00:16:17,160 one. 239 00:16:17,160 --> 00:16:20,240 And then also two being, you know, what is it going to look like around getting prophylaxis 240 00:16:20,240 --> 00:16:26,280 into infant because we are recommending medications for baby, triple therapy for the first four 241 00:16:26,280 --> 00:16:30,980 to six weeks, and then ideally monotherapy if everything is continuing thereafter. 242 00:16:30,980 --> 00:16:33,960 So making sure you're going to be able to kind of continue to get meds and give baby 243 00:16:33,960 --> 00:16:34,960 meds. 244 00:16:34,960 --> 00:16:39,280 And then similarly, the frequency of follow up, this is sort of every one to two months 245 00:16:39,280 --> 00:16:41,160 for mom to have a viral load done. 246 00:16:41,160 --> 00:16:44,440 That's not common for most adults that are otherwise detectable. 247 00:16:44,440 --> 00:16:47,800 And same for baby testing and blood work on baby because we have to make sure there's 248 00:16:47,800 --> 00:16:52,760 no toxicity from the ART, but also that there's no transmission that's occurred because again, 249 00:16:52,760 --> 00:16:55,560 treatment would definitely differ in that context. 250 00:16:55,560 --> 00:16:59,280 And then the other element of, you know, setting a woman up for success. 251 00:16:59,280 --> 00:17:04,680 So a lactation consultant is probably critical to make sure that mom knows how to how to 252 00:17:04,680 --> 00:17:08,720 ensure that she's making good and adequate milk, baby has a good suck and swallow a good 253 00:17:08,720 --> 00:17:12,120 lunch nipple health reduction of mastitis risk. 254 00:17:12,120 --> 00:17:16,760 All of those elements are so important to again set this pathway up for success. 255 00:17:16,760 --> 00:17:22,120 So I think those are really critical counseling elements that need to be clear for both pathways 256 00:17:22,120 --> 00:17:23,520 that might evolve. 257 00:17:23,520 --> 00:17:28,320 And then what triggers might merit a reassessment of the plan. 258 00:17:28,320 --> 00:17:32,720 So you know, if you are running into issues of a blip in mom's viral load or running into 259 00:17:32,720 --> 00:17:37,840 you know, serious mastitis, serious infection in baby that is now putting that risk number 260 00:17:37,840 --> 00:17:43,000 we may have talked about earlier into sort of a risk level that maybe is not in keeping 261 00:17:43,000 --> 00:17:47,720 with the goals of care from both the mom and the provider's perspective, but really laying 262 00:17:47,720 --> 00:17:53,440 clear what this is going to look like and what might be pivots in our pathway around 263 00:17:53,440 --> 00:17:58,680 when we may have to sort of consider stopping breastfeeding or you know, pumping and dumping 264 00:17:58,680 --> 00:18:01,440 for a period until we can get things back in control. 265 00:18:01,440 --> 00:18:05,600 There are strategies we can talk about, but I think everybody kind of needs to be going 266 00:18:05,600 --> 00:18:08,280 into this eyes wide open with clarity. 267 00:18:08,280 --> 00:18:13,320 And then can we feel that we really empowered a woman to make a fully informed decision 268 00:18:13,320 --> 00:18:18,000 and make the choice that's best for her, her family and safest for sort of long term outcomes 269 00:18:18,000 --> 00:18:19,000 for baby as well. 270 00:18:19,000 --> 00:18:23,520 Yeah, and I think you make a really good point because even in my own practice, we see, you 271 00:18:23,520 --> 00:18:29,280 know, sometimes we'll get a consult or we'll get involved very late in the course. 272 00:18:29,280 --> 00:18:34,080 And at that point, it's, you know, the baby's delivered, the first feeding has to occur 273 00:18:34,080 --> 00:18:35,680 very quickly. 274 00:18:35,680 --> 00:18:42,320 And so I, we are trying at least in our province to, you know, educate our prenatal care providers 275 00:18:42,320 --> 00:18:48,480 to say it's okay to actually do a prenatal counseling session with an infectious disease 276 00:18:48,480 --> 00:18:50,640 physician there. 277 00:18:50,640 --> 00:18:54,040 And we're more than happy to help with kind of talking about this risk of transmission 278 00:18:54,040 --> 00:18:59,440 and really making the moms aware because I think there's sometimes lack of knowledge 279 00:18:59,440 --> 00:19:04,640 on that side because, you know, it'll be my friend also did this, but not knowing the 280 00:19:04,640 --> 00:19:08,440 extent of, you know, what the involvement is. 281 00:19:08,440 --> 00:19:11,560 And I think that is always risk-first benefit for every case. 282 00:19:11,560 --> 00:19:16,080 And that's kind of why it's really important to really have this already in place and set 283 00:19:16,080 --> 00:19:22,680 up and really understand what are the reasons that mom is motivated to do this. 284 00:19:22,680 --> 00:19:25,800 And I think that always helps with compliance, right? 285 00:19:25,800 --> 00:19:30,560 And so, and then making sure that we're there along the way for the support. 286 00:19:30,560 --> 00:19:37,320 So having lactation there, having all of, you know, mom knowing when she can or cannot, 287 00:19:37,320 --> 00:19:42,600 like when is the pump and dump protocol have to kick in? 288 00:19:42,600 --> 00:19:46,200 Because I think these are the challenges that we're facing in our communities. 289 00:19:46,200 --> 00:19:50,400 And so I think really involving them early on, and like you said, when it's the right 290 00:19:50,400 --> 00:19:54,960 time is probably difficult to tell, but once they start engaging, I think once you're entering 291 00:19:54,960 --> 00:19:59,880 your third trimester, I think it's important to start having these discussions with the 292 00:19:59,880 --> 00:20:00,880 moms. 293 00:20:00,880 --> 00:20:01,880 Yeah. 294 00:20:01,880 --> 00:20:05,200 You brought up a really good point around understanding the rationale or the motivations 295 00:20:05,200 --> 00:20:10,160 for it, because sometimes those motivations, you can actually potentially provide other 296 00:20:10,160 --> 00:20:14,800 strategies or solutions to get around it and fear of involuntary disclosure and sort of 297 00:20:14,800 --> 00:20:19,520 extended family or cultural pressures that if I don't breastfeed, then everyone's going 298 00:20:19,520 --> 00:20:25,200 to know and sort of ways or language you can provide that empowers a mom to sort of respond 299 00:20:25,200 --> 00:20:31,520 to family members as to, yep, this is why I'm formula feeding and it has nothing overly 300 00:20:31,520 --> 00:20:32,520 related to HIV. 301 00:20:32,520 --> 00:20:36,600 And I think, you know, women may not be aware of sort of other strategies that we've used 302 00:20:36,600 --> 00:20:37,680 in the past. 303 00:20:37,680 --> 00:20:41,360 Something like, well, I required a lot of pain control after my delivery and that amount 304 00:20:41,360 --> 00:20:44,720 of pain control was too high and too risky to breastfeed through. 305 00:20:44,720 --> 00:20:46,760 And so unfortunately, I was unable to breastfeed. 306 00:20:46,760 --> 00:20:51,560 There are ways sometimes that you can provide if you understand the reasoning why. 307 00:20:51,560 --> 00:20:54,560 And I think that's so critical to this conversation. 308 00:20:54,560 --> 00:20:58,440 And you also raised a really good point about making sure the right support people are there. 309 00:20:58,440 --> 00:21:02,240 You know, if a partner is heavily influential on a decision around this, they should be 310 00:21:02,240 --> 00:21:03,240 in the room, right? 311 00:21:03,240 --> 00:21:07,120 Of course, based on what the woman is telling you she's feeling comfortable and safe with, 312 00:21:07,120 --> 00:21:12,080 I think that's so important because it is a family-centered approach, this decision, 313 00:21:12,080 --> 00:21:14,800 and we really should be sort of adopting that. 314 00:21:14,800 --> 00:21:20,760 And I think really understanding the risks with mixed feeding is important too, because 315 00:21:20,760 --> 00:21:27,640 I think a lot of us in the initial days, your milk isn't in, so they may get a little bit 316 00:21:27,640 --> 00:21:33,000 nervous in terms of, is my baby getting enough feeding at this point? 317 00:21:33,000 --> 00:21:38,720 And so in a normal situation, adding formula if they're not gaining weight is more realistic 318 00:21:38,720 --> 00:21:39,720 of an approach. 319 00:21:39,720 --> 00:21:42,520 But in this context, that's not really the approach. 320 00:21:42,520 --> 00:21:47,560 And so kind of guiding and counseling around and really remembering that it's mom and baby 321 00:21:47,560 --> 00:21:48,800 that we're worried about, right? 322 00:21:48,800 --> 00:21:52,240 And so we need to make sure that mom feels comfortable. 323 00:21:52,240 --> 00:21:58,360 If we do have to start weaning, we have medications, we can support her through the pain, et cetera, 324 00:21:58,360 --> 00:22:00,860 of breast engorgement, that type of thing. 325 00:22:00,860 --> 00:22:05,200 And then really understanding that there are risks for the baby if there is mixed feeding. 326 00:22:05,200 --> 00:22:07,440 And so kind of emphasizing that. 327 00:22:07,440 --> 00:22:10,080 That's what I've noticed in my practice too. 328 00:22:10,080 --> 00:22:16,020 So in terms of most of our providers, they're probably familiar, listeners are more familiar 329 00:22:16,020 --> 00:22:17,560 with understanding the criteria. 330 00:22:17,560 --> 00:22:24,080 So we're really talking about low risk, undetectable viral load, the motivation to continue to 331 00:22:24,080 --> 00:22:29,360 stay on antiretrovirals for the mom is really important because you really have to stay 332 00:22:29,360 --> 00:22:31,160 undetectable throughout. 333 00:22:31,160 --> 00:22:36,720 And then ensuring that they understand that there's blood work and antiretrovirals involved. 334 00:22:36,720 --> 00:22:41,040 Are there any other criteria that should be met for women or for clinicians to kind of 335 00:22:41,040 --> 00:22:45,440 say that, yes, breastfeeding, I can go ahead and have these discussions? 336 00:22:45,440 --> 00:22:49,960 I think you kind of hit the nail on the head there around the adherence, the ability to 337 00:22:49,960 --> 00:22:54,440 kind of have both the monitoring for both mom and baby throughout. 338 00:22:54,440 --> 00:22:59,480 And then, you know, in some situations, add this as sort of a supplement to the guidelines 339 00:22:59,480 --> 00:23:04,960 is for some women, you might want to have them sort of sign this agreement. 340 00:23:04,960 --> 00:23:09,480 And it's not necessarily because, you know, medical legal from a provider side, it's for 341 00:23:09,480 --> 00:23:13,640 the woman to really kind of be clear on what this is going to look like. 342 00:23:13,640 --> 00:23:18,400 And also because there may be situations where if a mom ends up in a walk-in clinic or in 343 00:23:18,400 --> 00:23:24,680 another situation, and then somehow breastfeeding gets disclosed, having a document like that 344 00:23:24,680 --> 00:23:29,640 can actually empower mom to say, no, my HIV care providers are well aware of this. 345 00:23:29,640 --> 00:23:35,080 And we've agreed on X, Y, and Z principles, and therefore there's no need for like CAS 346 00:23:35,080 --> 00:23:39,120 referral or legal implications, which I think is another huge concern that the community 347 00:23:39,120 --> 00:23:43,320 has around what is the potential risk of going down this pathway. 348 00:23:43,320 --> 00:23:46,680 And so I think that's another, it's not a prerequisite, but it's something that may 349 00:23:46,680 --> 00:23:51,480 empower sort of both parties to really feel like the depth and the understanding of the 350 00:23:51,480 --> 00:23:54,960 things that have been chatted about are very clear to everyone involved kind of thing. 351 00:23:54,960 --> 00:24:00,040 So that's something that may be an added consideration that can be helpful for both sides. 352 00:24:00,040 --> 00:24:01,040 Yeah. 353 00:24:01,040 --> 00:24:06,160 And I think it also prevents confusion because I've had sometimes providers call and say, 354 00:24:06,160 --> 00:24:08,600 you know, I thought it was not recommended. 355 00:24:08,600 --> 00:24:11,000 And so in this case, why is it? 356 00:24:11,000 --> 00:24:15,640 And so I think obviously as we become more and more educated in this area and really 357 00:24:15,640 --> 00:24:19,840 understanding this and having these consensus recommendations, I think it's one of the first 358 00:24:19,840 --> 00:24:25,320 steps to really raising this question and bringing it up because I know when I did my 359 00:24:25,320 --> 00:24:31,640 training in infectious disease, we didn't have a lot of recommendations or official 360 00:24:31,640 --> 00:24:33,160 expert opinion on this. 361 00:24:33,160 --> 00:24:37,200 So I think this document has definitely changed and helped my practice. 362 00:24:37,200 --> 00:24:41,700 So I think it is probably the same for many of our listeners out there. 363 00:24:41,700 --> 00:24:46,840 So going back to the consensus recommendations, we talked a little bit about after the counseling 364 00:24:46,840 --> 00:24:51,600 expert, so with families and what the recommendations are in terms of like what this really means 365 00:24:51,600 --> 00:24:52,800 for their infant. 366 00:24:52,800 --> 00:24:54,640 We talked about blood work. 367 00:24:54,640 --> 00:25:01,560 I think an important change for me in the recommendations was the preferred ARTs that 368 00:25:01,560 --> 00:25:08,240 were recommended for the infant versus kind of the alternative recommendations. 369 00:25:08,240 --> 00:25:13,560 And so for our listeners, because we're really used to having triple therapy, the entire 370 00:25:13,560 --> 00:25:18,480 duration of breastfeeding, whether that's three months plus. 371 00:25:18,480 --> 00:25:23,280 And so some of the recommendations, you did mention that the risk of transmission in that 372 00:25:23,280 --> 00:25:27,280 first four to six weeks weekly is a little bit greater. 373 00:25:27,280 --> 00:25:31,920 So coming from that standpoint, I can see why the recommendations were made, but maybe 374 00:25:31,920 --> 00:25:37,640 we can touch on what is the preferred recommendation for the ARTs for the infant. 375 00:25:37,640 --> 00:25:42,760 So what we had kind of landed on, honestly, this was not easy decisions to sort of land. 376 00:25:42,760 --> 00:25:45,920 There was a lot of discussion that went back and forth on this. 377 00:25:45,920 --> 00:25:49,360 In the end, it's interesting to sort of hear your perspective around like, I thought it 378 00:25:49,360 --> 00:25:50,840 would be triple all the way. 379 00:25:50,840 --> 00:25:54,440 And there were definitely folks on that side of the table. 380 00:25:54,440 --> 00:26:00,800 We actually are considered the most conservative among the UK, US, and Canadian guidelines 381 00:26:00,800 --> 00:26:02,120 with where we landed. 382 00:26:02,120 --> 00:26:05,520 But where we did land, which was your question, is combination therapies, adipine, limivir, 383 00:26:05,520 --> 00:26:08,640 and nevarapine for the first sort of four to six weeks. 384 00:26:08,640 --> 00:26:11,880 And then as you alluded to, that being sort of the highest risk. 385 00:26:11,880 --> 00:26:17,760 And then followed by monotherapy with nevarapine until four weeks after cessation of breastfeeding. 386 00:26:17,760 --> 00:26:19,160 There are definitely alternatives. 387 00:26:19,160 --> 00:26:23,800 And obviously you want to consider baseline resistance known in mom to factor into some 388 00:26:23,800 --> 00:26:25,760 of your decision making. 389 00:26:25,760 --> 00:26:31,720 We did land that way simply because we did want to have some degree of prophylaxis for 390 00:26:31,720 --> 00:26:35,480 the infant, which is different than the US and the UK for sure. 391 00:26:35,480 --> 00:26:41,400 But did the risk merit triple the entire duration and the potential risk of toxicity? 392 00:26:41,400 --> 00:26:45,720 And also the reality that there may be situations where risk could kind of go up transiently 393 00:26:45,720 --> 00:26:47,120 like we talked about. 394 00:26:47,120 --> 00:26:52,160 And having that sort of safety valve of going back to triple in those scenarios was sort 395 00:26:52,160 --> 00:26:56,840 of that medium ground we felt that was reasonable based on what we understand today. 396 00:26:56,840 --> 00:27:01,520 That said, I think this needs to be reevaluated as we get more data. 397 00:27:01,520 --> 00:27:05,120 And this is sort of what we landed and it's not perfect. 398 00:27:05,120 --> 00:27:09,220 And one can definitely consider the alternate regimens that we propose, which as you alluded 399 00:27:09,220 --> 00:27:10,800 to is triple the entire duration. 400 00:27:10,800 --> 00:27:15,440 But I think that we did want to leave some leeway for a provider to consider individual 401 00:27:15,440 --> 00:27:18,280 patient risk factors and factor that in of course. 402 00:27:18,280 --> 00:27:23,760 And for somebody who practices this, I feel like one of the rate limiting steps of having 403 00:27:23,760 --> 00:27:29,240 to stop breastfeeding is actually side effects from some of these medications. 404 00:27:29,240 --> 00:27:36,000 And so really seeing that the consensus recommendations were kind of aiming towards reducing the number 405 00:27:36,000 --> 00:27:40,920 of medications after kind of that highest risk portion of weeks. 406 00:27:40,920 --> 00:27:45,760 I think it's nice to see that we have an option now. 407 00:27:45,760 --> 00:27:50,600 Not seeing that any of the other medications, like Nevarapine, also has some risks, but 408 00:27:50,600 --> 00:27:56,240 we see less bone marrow suppression, which is one of probably in my practice, probably 409 00:27:56,240 --> 00:28:02,080 the number one reason I've had to stop and have mom wean breastfeeding. 410 00:28:02,080 --> 00:28:07,680 And it's disheartening because they put in all this work and this effort and they agreed 411 00:28:07,680 --> 00:28:10,840 to having the infant have such frequent blood work. 412 00:28:10,840 --> 00:28:15,640 But then you get to this physiological nadir, which gets exaggerated. 413 00:28:15,640 --> 00:28:20,320 And then the problem becomes you just have to come off because you can't sustain the 414 00:28:20,320 --> 00:28:21,820 bone marrow at that point. 415 00:28:21,820 --> 00:28:29,240 So is that something, was that weighed in when the recommendations were put together? 416 00:28:29,240 --> 00:28:35,000 That was definitely a huge factor because what really benefit are we achieving with 417 00:28:35,000 --> 00:28:40,080 the triple at that phase compared to sort of the risk of toxicity? 418 00:28:40,080 --> 00:28:45,600 And so I think that played in significantly in terms of a rationale for are we attaining 419 00:28:45,600 --> 00:28:49,160 that much more risk reduction by the addition of triple for the entire duration? 420 00:28:49,160 --> 00:28:53,640 And so that was a huge factor as to sort of why we felt that the risk reduction was adequate 421 00:28:53,640 --> 00:28:55,440 enough with Nevarapine alone. 422 00:28:55,440 --> 00:29:00,960 And then I think we've answered some questions around when to obviously pump and dump and 423 00:29:00,960 --> 00:29:04,240 when should we discontinue breastfeeding? 424 00:29:04,240 --> 00:29:07,880 So I think where can we find these consensus recommendations? 425 00:29:07,880 --> 00:29:12,420 Because I think having this document available is super important. 426 00:29:12,420 --> 00:29:19,500 And then what other resources can we provide either families or providers to give to families? 427 00:29:19,500 --> 00:29:24,160 So we definitely welcome readers to check out our published guidelines, which are in 428 00:29:24,160 --> 00:29:25,160 Jami. 429 00:29:25,160 --> 00:29:27,200 You can, I think, do a quick Google search. 430 00:29:27,200 --> 00:29:30,200 That's how I typically stumble on them. 431 00:29:30,200 --> 00:29:31,200 Yeah. 432 00:29:31,200 --> 00:29:36,320 So just like Canadian CPARG infant feeding HIV guidelines, Jami, you can search that 433 00:29:36,320 --> 00:29:37,320 up. 434 00:29:37,320 --> 00:29:42,920 And then similarly, just to sort of see how other models exist, there's definitely the 435 00:29:42,920 --> 00:29:47,880 WHO, the VIVA, and the DHHS guidelines for the provider sort of space. 436 00:29:47,880 --> 00:29:52,600 And then in terms of patient populations, the OHDN and KD are actually currently working 437 00:29:52,600 --> 00:29:54,840 on a more specific resources. 438 00:29:54,840 --> 00:29:58,760 But in terms of what currently exists, VIVA has a nice little leaflet. 439 00:29:58,760 --> 00:30:02,280 It's called Healthy Mums Healthy Tums that you can search up. 440 00:30:02,280 --> 00:30:08,360 And then similarly, Katie has a prevention page on pregnancy and infant feeding. 441 00:30:08,360 --> 00:30:13,760 There is a consensus statement out of the well project that speaks to some of this risk. 442 00:30:13,760 --> 00:30:18,760 And that's another way to sort of look at this conversation as well. 443 00:30:18,760 --> 00:30:23,000 But I also would urge providers to take a look at the mothering study as well, which 444 00:30:23,000 --> 00:30:25,360 is now, I think, over a decade old. 445 00:30:25,360 --> 00:30:27,960 But I think it's still relevant to these conversations. 446 00:30:27,960 --> 00:30:33,400 And I think only when you start to understand the complexity of this issue, do you start 447 00:30:33,400 --> 00:30:37,840 to see why this investment in time and energy around this is so important. 448 00:30:37,840 --> 00:30:41,520 And I think the mothering study is sort of a seminal study that really hit the nail on 449 00:30:41,520 --> 00:30:45,600 the head of how important of an issue this is for women and therefore as providers, how 450 00:30:45,600 --> 00:30:50,160 much we need to start really speaking to this issue in more clear terms. 451 00:30:50,160 --> 00:30:51,160 That's fair. 452 00:30:51,160 --> 00:30:55,680 And I know that our listeners are probably asking, so how do we kind of what's the future 453 00:30:55,680 --> 00:31:00,800 of feeding in this context, in the HIV context? 454 00:31:00,800 --> 00:31:05,720 And is there something that providers can help with in terms of surveillance, right? 455 00:31:05,720 --> 00:31:10,280 Because if there's ongoing, could we submit cases somewhere? 456 00:31:10,280 --> 00:31:12,200 Is this in the works? 457 00:31:12,200 --> 00:31:13,360 Great question. 458 00:31:13,360 --> 00:31:17,240 So there was a case series that the Canadian data that was sort of pulled together and 459 00:31:17,240 --> 00:31:22,640 published, we also contributed to a US paper that combined both the Canadian and US experience 460 00:31:22,640 --> 00:31:23,640 around breastfeeding. 461 00:31:23,640 --> 00:31:25,080 But you're right. 462 00:31:25,080 --> 00:31:28,980 I think what we really need, and actually that's the last recommendation of our guideline, 463 00:31:28,980 --> 00:31:32,160 is a true sort of fulsome data registry. 464 00:31:32,160 --> 00:31:36,640 I'm really cognizant of the word surveillance in this context, but we're really sort of 465 00:31:36,640 --> 00:31:40,680 trying to get to that point where we'll have a fulsome registry where we can really collect 466 00:31:40,680 --> 00:31:46,320 these essential data points that can help us inform what is or isn't the best practice 467 00:31:46,320 --> 00:31:49,320 here because what we have is expert opinion. 468 00:31:49,320 --> 00:31:53,320 What we need is real world experience because a lot, as we mentioned, those RCTs, not in 469 00:31:53,320 --> 00:31:57,760 our context, not necessarily generalizable to us, but we're all getting more experience 470 00:31:57,760 --> 00:32:00,160 with this and from that we should all be learning. 471 00:32:00,160 --> 00:32:02,160 And so we're working towards that. 472 00:32:02,160 --> 00:32:04,200 We're asking PI for that funding. 473 00:32:04,200 --> 00:32:08,400 But as HIV care providers, if you're asked to submit this data into a registry, we know 474 00:32:08,400 --> 00:32:12,920 it's extra work, but we really think these data points are so integral to collect. 475 00:32:12,920 --> 00:32:17,160 So we ask that you support any initiative if you're asked to collect some of that data 476 00:32:17,160 --> 00:32:20,400 for this important evidence that's in evolution. 477 00:32:20,400 --> 00:32:25,560 There are other elements that I think still are needed in terms of the breast milk science. 478 00:32:25,560 --> 00:32:28,800 We need to know what is those risks in the first few weeks? 479 00:32:28,800 --> 00:32:31,560 Is there a difference between warm milk, hind milk, colostrum? 480 00:32:31,560 --> 00:32:35,200 What ARTs are truly getting through breast milk and what aren't? 481 00:32:35,200 --> 00:32:39,200 What is the risk of resistance because of ART exposures to the babies? 482 00:32:39,200 --> 00:32:44,680 So I think real Canadian or at least high resource setting data on this breast milk 483 00:32:44,680 --> 00:32:46,080 science needs to be done. 484 00:32:46,080 --> 00:32:48,360 And I think a lot of different groups are looking into that. 485 00:32:48,360 --> 00:32:53,120 I think that's such important work that hopefully will get funded and supported by clinicians 486 00:32:53,120 --> 00:32:56,100 like yourselves and in enrolling patients to these studies. 487 00:32:56,100 --> 00:32:58,120 And I think that there's more to come. 488 00:32:58,120 --> 00:33:02,840 I think that knowledge translation, how are we communicating this to our patients? 489 00:33:02,840 --> 00:33:08,560 How are ASOs able to leverage and use this data in terms of really packaging this in 490 00:33:08,560 --> 00:33:12,320 a way that's meaningful to the community and helpful to the community? 491 00:33:12,320 --> 00:33:16,480 We need to have anti-racist and anti-oppressive approaches to this conversation. 492 00:33:16,480 --> 00:33:20,640 There's very different cultural nuances that need to be considered and much, much important 493 00:33:20,640 --> 00:33:23,240 social science work that needs to happen in that realm. 494 00:33:23,240 --> 00:33:27,240 And I think, you know, we're all looking to the broadly neutralizing antibody question 495 00:33:27,240 --> 00:33:31,080 and whether that will really make breastfeeding sort of simpler and easier. 496 00:33:31,080 --> 00:33:34,440 So I think there's lots of exciting data to come. 497 00:33:34,440 --> 00:33:38,960 And I think as HIV care providers staying up to date on this and bringing forward ideas 498 00:33:38,960 --> 00:33:41,440 and contributing to this work is going to be so important. 499 00:33:41,440 --> 00:33:42,440 Noah, fantastic point. 500 00:33:42,440 --> 00:33:43,440 Yeah. 501 00:33:43,440 --> 00:33:49,000 And I think, you know, and this is just the start of we've seen a lot of changes in HIV 502 00:33:49,000 --> 00:33:54,160 care, especially in the pediatric world over the last few years, especially since I've 503 00:33:54,160 --> 00:33:55,240 been practicing. 504 00:33:55,240 --> 00:33:58,920 And so I think you make a really good point in staying up to date. 505 00:33:58,920 --> 00:34:04,080 And one of our reasons for this podcast is to help our listeners do that. 506 00:34:04,080 --> 00:34:11,100 And so we are so thankful that we had someone come from an expert opinion side of things 507 00:34:11,100 --> 00:34:15,400 and really helped us understand some of the consensus recommendations. 508 00:34:15,400 --> 00:34:20,480 And I think a lot of us, you know, don't have a lot of information in this field. 509 00:34:20,480 --> 00:34:26,240 And so it makes that fear and we kind of stay within our boundaries to say, you know, this 510 00:34:26,240 --> 00:34:28,760 is the information that's been provided to us. 511 00:34:28,760 --> 00:34:33,440 This is how, you know, we've done it in the past, but remembering that there are newer 512 00:34:33,440 --> 00:34:38,200 advances and that we should be keeping up to date with what the rest of the world and 513 00:34:38,200 --> 00:34:40,700 then the rest of our country is doing as well. 514 00:34:40,700 --> 00:34:45,760 So one of the reasons why we wanted to bring you onto the podcast and so I guess for kind 515 00:34:45,760 --> 00:34:51,600 of last minute things for our listeners, is there anything that a key message that you 516 00:34:51,600 --> 00:34:57,880 wanted to provide to our listeners who consist of HIV providers, pharmacists, those that 517 00:34:57,880 --> 00:35:02,480 probably residents, medical students, really part of the learning community? 518 00:35:02,480 --> 00:35:08,400 I think what I've learned so much in doing this work has been we need to be listening 519 00:35:08,400 --> 00:35:14,320 to the community because they're the ones, their voices are asking these questions before 520 00:35:14,320 --> 00:35:16,080 we even think about them, right? 521 00:35:16,080 --> 00:35:19,760 And I think even in our clinical encounters, there needs to be a lot more listening and 522 00:35:19,760 --> 00:35:20,760 a lot less talking. 523 00:35:20,760 --> 00:35:25,920 And I feel like I talked through like a lot of things here, but you brought up that really 524 00:35:25,920 --> 00:35:30,040 important point of like, what are the motivations that are driving these decisions? 525 00:35:30,040 --> 00:35:36,360 Because until we understand what the community is facing and what their concerns are, are 526 00:35:36,360 --> 00:35:40,800 we going to be able to sort of address or meet those needs in terms of the clinical 527 00:35:40,800 --> 00:35:41,800 care component? 528 00:35:41,800 --> 00:35:47,760 So I guess that's sort of a learning that I've continued to sort of do throughout this. 529 00:35:47,760 --> 00:35:51,640 And I think it's that real engagement and partnership that's going to move this issue 530 00:35:51,640 --> 00:35:54,780 forward and provide the best outcomes for both mom and baby. 531 00:35:54,780 --> 00:35:57,600 And I think that's what everyone's goal is at the end of this. 532 00:35:57,600 --> 00:35:58,900 Well, thank you so much, Dr. Khan. 533 00:35:58,900 --> 00:36:02,520 We really appreciate you coming on the podcast today. 534 00:36:02,520 --> 00:36:09,320 And hopefully we can have some future episodes if there's any other updates to the recommendations. 535 00:36:09,320 --> 00:36:14,420 Thank you for the initial introduction to the current consensus recommendations. 536 00:36:14,420 --> 00:36:20,360 And I'm sure our listeners are very pleased to hear that there is some guidance out there 537 00:36:20,360 --> 00:36:23,320 and how to access it and some resources. 538 00:36:23,320 --> 00:36:25,240 Thank you so much for taking the time today. 539 00:36:25,240 --> 00:36:26,240 Great. 540 00:36:26,240 --> 00:36:28,200 Thanks so much for the conversation. 541 00:36:28,200 --> 00:36:32,720 Thank you, Dr. Pirwal and Dr. Khan, for this interesting discussion. 542 00:36:32,720 --> 00:36:34,280 Have a topic suggestion? 543 00:36:34,280 --> 00:36:41,880 Email us at thecanadianbreakpoint at gmail.com and follow us on ex, formerly Twitter, at 544 00:36:41,880 --> 00:36:43,520 CA Breakpoint. 545 00:36:43,520 --> 00:36:59,160 See you again soon at the Canadian Breakpoint.