Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Today, we are pleased to have Diane Petrie with us again. Diane was with us back in 2021 to discuss the current trends with pediatric HIV. And today, she will be sharing information about HIV and breastfeeding. If you haven't listened to that episode from back in 2021, I highly recommend going back and listening because it really gives a great foundation to what we are talking about today.

So, Diane is a family nurse practitioner in our Infectious Diseases Department at Children's Mercy and she is a certified HIV specialist through the American Academy of HIV Medicine plus so much more. Welcome back to the podcast, Diane.

Diane Petrie: Thank you, ladies. It is great to be back on the podcast with you all, and I'm honored to get to sit alongside with so many great guests and topics that you guys have been featuring. I can't believe it's already been three years since we last chatted about HIV. It's really been great to continue my work here at Children's Mercy in the Infectious Diseases Division. Of course, I am also staying busy with my three little ones at home, are now seven, five, and three. So, life is very fun and very full in the Petrie household.

Host 1: Oh, my gosh. I can't believe you're youngest is three now.

Diane Petrie: Yes, our COVID babies are growing up.

Host 1: How time flies when we're having fun. But we are so lucky to have you back as a guest.

Diane Petrie: Thank you.

Host 1: I would love to kind of just jump in and have you shed some light and elaborate on your work as a certified HIV specialist.

Diane Petrie: Sure. I would love to do that. So, I have been certified through the American Academy of HIV Medicine for several years. Now, I think I got my first certification in 2019. And the American Academy of HIV Medicine has options for certification for physicians, for advanced practice providers, and for pharmacists for certification in HIV.

So, every couple of years, you go through and have to have a certain number of HIV-specific continuing education credits. You have to then every couple of years also retake the certification exam, which I just finished again in December to recertify. But it's a really great credential and there's a couple of options, like I said. So, I am technically a specialist, because I still see patients versus the expert or the pharmacist level of certification. But it's a cool opportunity for advanced practice providers because it's the same certification test that physicians take. So when you're collaborating with other people in the field, other people outside of Children's Mercy, it gives you a level of recognition that is just really cool to get to sit alongside and say, you know, I have the same credential as you, even though I'm not a physician.

So, that's great. I'm also certified through the HIV and AIDS Nursing Certification Board, who certifies advanced practice nurses, RNs and LPNs, who are working in HIV care. So, kind of having both sides of that is something that I wanted to work towards as I was doing more with HIV here at Children's Mercy.

Host 2: That's great. Being able to have that education and credentialing really to do what you're doing, I think, is great. And like you said, it definitely, I'm sure, kind of gives you a confidence boost and gives you that, I don't know if I'd call it street credit, when you're dealing with community providers and such. So, definitely keeps you up to date on everything. Can you update us a little bit on the incidence of HIV in newborns? Because we're going to talk a bit more about newborns and such. So, tell us a little bit more about the incidence.

Diane Petrie: Yes, I would love to talk about this, because HIV incidence in newborns, if you look back over like the last 15 years or so of HIV world, is one of the great public health victories of our country in our HIV epidemic. We've seen over the years since we've started, you know, testing all pregnant women and providing treatment for those women who test positive and treatment for infants born to those moms, we have seen a hugely significant decrease in the level of transmissions to newborns. So over the past several years, you can see the downtrends to where even in 2017, 2018, 2019, we're talking like 30s to 40s is the number of HIV diagnoses in infants over those years. So, it's a very low number every year. It's primarily for those moms who don't have access to or haven't been able to keep with their prenatal care followup. So, they just, in most cases, don't even know they have HIV until that time of delivery when they get tested, and then you see some transmission to infants in that time period.

In 2021 is the most recent data the CDC has put out. And in that case, there were 53 cases of HIV diagnosed in 2021 for children under 12. They don't differentiate the ages specifically, because the numbers are so low. Presumably most of those were perinatally acquired, but they don't give us quite how many were infants or maybe some were diagnosed when they were a little bit older that just hadn't been caught in that perinatal time period.

Host 1: Well, it sounds like, from what you're saying, perinatal HIV exposure is really low and the risks are pretty low now with technology and medication. So, can you help us understand, is there a grading score or a tool that is used to say very low risk versus high risk or something to that nature?

Diane Petrie: For a long time, we have utilized different risk factors and criteria for that to help us determine when a baby is born to a mom living with HIV. What kind of prophylaxis do they need? What kind of treatment do they maybe need during that postpartum period? And it originally had mostly been into kind of low risk or higher risk infants, and we had different levels of medications and things that we use for that. And those continue, and we've seen with treatment improvements, I kind of add to, at our facility, a very low risk category that I think opens up some of these moms to even more options like breastfeeding and things that we'll talk about. But those infants who are born to very low risk mothers, we would say that is a mom who has received at least 10 weeks of consecutive treatment during pregnancy, has what we call viral suppression, so that her viral load count during pregnancy is less than 50 copies for a duration of time during pregnancy, especially in those last few weeks of pregnancy, kind of 36 weeks and on and at the time of delivery. This is the mom who has good adherence, no concerns with medicines, has been keeping them down, has had good prenatal care. And in that case, those infants are very low risk, one, that they're going to be transmitting HIV through the pregnancy and delivery process, and we're now finding that information that's also very low risk for those moms in the breastfeeding time period. There's kind of those three different time frames where we imagine that, or we know that kids can acquire HIV. So, in the uterus, during the birth process and then postpartum during breastfeeding are kind of the three most common times that infants get HIV from their mom. And so, we try to find different ways that we can prevent transmission at every one of those steps along the way.

So, infants born to low risk moms, maybe they had adequate prenatal care, but for some reason they weren't able to meet that criteria. Maybe they had an interruption in treatment, maybe they had a little jump in their viral load, you know, to 200 copies or something that's low, but not quite undetectable or maybe they for some reason had another treatment interruption or maybe they had their infant born early and didn't have all of that testing or that time period, we would say that's low risk for those infants still, but it's not very low risk. There maybe is a little bit higher risk of transmission of HIV.

And then, we have those infants born to higher risk moms. So, those are moms who maybe they didn't receive any prenatal care. They didn't have access to HIV treatment or antiretrovirals while they were pregnant. Maybe they were diagnosed with acute or primary HIV infection during that pregnancy, especially mid-pregnancy onward. Those are all a lot higher risk of transmission to the infant, just like it's a higher risk for anybody who gets HIV. The time period when their viral load initially goes super, super high early in infection is the time that they're most likely to spread HIV to other people. And unfortunately, that's the time most people have no idea that they have HIV. So, it's just kind of the tricky part of that virus and our ability to test during that timeframe. It makes it easier to spread to infants living inside of mamas, just like it is easy to pass sexually or other transmission methods.

The same thing with moms who maybe have some concerns with adherence during pregnancy. They're having a hard time taking their medicines. When I took care of adults years ago, I had some moms who just really had a hard time with keeping medicines down with their nausea. And so, it was hard to keep their viral load under control during pregnancy. So, those infants have a higher risk of HIV transmission. So, we watch them a lot more closely.

Host 2: That is such a great breakdown. It made it so easy for me to follow. So, that makes so much sense. Well, so let's talk a bit more about HIV and breastfeeding. So, it's somewhat of a newer topic in the United States, and we have talked about this before we did this podcast. You had mentioned that it's somewhat been met with some provider fear and stigma. So, what information would you want to share with our community to kind of alleviate this fear?

Diane Petrie: It really has been, and there is a lot of fear and stigma still related to HIV in general. And so, our infants and our breastfeeding moms are no different. The HIV epidemic is 43 years old now, and there are many providers, maybe even in our facility, who were here practicing early on in the days when we were just finding out about it, learning about it. And so, they've had their entire career to be embedded in their mind that this is dangerous and life-threatening to infants, which it absolutely can be, in the perfect storm, so to speak. But nowadays, and thanks to so many of our advances in testing and treatment and testing of pregnant women, even in our, you know, adolescents and kids and adults who get diagnosed with HIV, it's really turned from more of what we would say was a death sentence, you know, in the early 1990s to now a manageable chronic infection. Many people who are living with HIV, they take one pill once a day. Those treatments work fantastically where somebody who has a super high viral load in the millions can be undetectable in a matter of weeks. And so, it's just really great for those patients living with HIV.

But as we have learned more about how to protect patients, how to fight this virus, how to help keep people healthy for a long time, we also have to change our mindset about how we practice in all the ways that HIV affects patients. And so, what we know about breastfeeding specifically is really significant. It's been since the early 1990s that women living with HIV have been breastfeeding across the world. In a lot of resource-limited countries, especially if you're thinking about places in Southern Africa where the HIV epidemic was just devastating, they were also coupled with extreme poverty and other things that meant even for those moms living with HIV, breastfeeding was still the safest option for their infant because they lacked safe food sources, they lacked access to formula and things that we have here in the developed world. And so, thankfully, the healthcare providers and the moms in those countries, largely in those regions of the world, were willing to study the risk of transmission to the infants who were breastfeeding and finding what are the safest ways that we can let these moms breastfeed to prevent that maternal to child transmission of HIV during the breastfeeding season.

And so even though this is newer to us in the U.S. And other parts of the developed world, it's been going on, thinking about from the early '90s, we're talking about for 30 years that many places have been allowing and even really advocating for breastfeeding in moms living with HIV to help keep their infant alive from other risks of diarrheal diseases and other things from contaminated food and water.

And so, really, Europe kind of helped us lead the way, as they do in some things, but Great Britain and Germany have been having changes to their HIV and breastfeeding policies and kind of recommendations at a national level for at least the last five years or so. And it's just kind of in the last couple of years that Canada and now the U.S. are following along in their suit to see it. So, we're seeing other places in the developed world really implementing these practices that have been done in resource-limited places for a long time. And what's really encouraging is that throughout all of the studies that have been happening both in Africa and in Europe and Canada and now the U.S., we're seeing there's still a less than 1% risk of transmission, especially when moms and infants are in that very low risk category. Whereas, if you were to think, what is the risk of transmission of HIV where there is zero interventions, it's like 15-45% chance that a mom will transmit HIV to an infant during pregnancy, labor and delivery, or breastfeeding with no interventions. But with all of these interventions in place, less than 1% is a really good number when you're looking at the numbers of moms living across the world. And so, it's really encouraging to see that.

Host 1: That's very encouraging. And I have a followup question that's probably a little educationally naive, but I am assuming that the mothers continue to take their medication during that time of breastfeeding, then that it's safe to do so to keep the viral load down?

Diane Petrie: Absolutely. And that is one of the key components to what we've learned has made the breastfeeding safe. We can measure virus load in the blood, and we can know that in the bloodstream there's no detectable virus. It's been a little bit trickier for researchers to find ways to measure virus load in the breast milk. We do know that there have still been, like I said, that small number of transmissions that it's like 0.6%, is kind of the percentage across the world when studied of transmissions still to infants. Most of those when you read the fine print in the studies have attributed back to what they think is poor adherence to the treatment. Most of those who have said, "I've taken my treatment every single day," we haven't seen those transmissions.

But what's encouraging is that we've had so many improvements in pediatric HIV that a lot of these moms are taking regimens that are safe for infants to take anyway. So if an infant were to be diagnosed with HIV, these are the same medicines that they would be taking. Also, they've been able to trace those medication levels in the breast milk and find out that they're really negligible how much is transmitted. And so, the providers for both the mom and baby do work to make sure those mothers are on safe treatment that's not going to affect baby, but it is key that those mothers are committed to stay on their treatment to protect the infants from transmission.

Host 2: I mean, that's amazing. Well, I was born in the '80s, so, I mean, just what I remember of HIV and Magic Johnson and all the things that I was exposed to, this is just so great to hear, everything that you just said and how really, I mean, that seems super low, low risk.

Diane Petrie: Yeah, it is really a low risk. It's what they call a shared decision-making process, we're not out there telling moms. There's no risk of transmission at all, because we don't fully know yet. From all the evidence we have, that's good evidence with lots of mom baby dyads across the world, it's a really, really low risk. And you have that shared decision-making with a mom to say, "Here's our really, really low risk." We've learned some things too, like how can we do it the safest way to reduce that risk even further? Like encouraging moms, they found that exclusive breastfeeding during the first six months is better than like mixed feeding or any early introduction of solids. So, we encourage moms to do that. We make sure mom is on treatment, has good follow up, is having monthly virus load testing, so we can watch really closely to make sure that she's helping to protect both her own health, but also risk of transmission. We do continued testing for the infant, even past the initial postpartum period to also continue to make sure that they are not having any concerns of transmission and really working with moms, and then also a multidisciplinary team, lactation consultants and OB and mom's HIV provider to say, "Are we making sure mom has good breast care, good access to resources to make sure she's doing this in a safe way?"

So, it's really cool to see, it's moved from this just providers say, "I can't do that." Especially in our role at a pediatric center, we know the benefits of breastfeeding to mom, to baby, especially even in the years past that initial time period after birth, and so to be able to offer these moms that same thing that's no longer mixed messaging, like, "Oh, breast is best, except for you, it's not for you." So, it feels really good and really special to be able to let moms have a part of that kind of special bonding with their infants. When I think a lot of the moms that I see in my clinic, they already carry a lot of guilt and a lot of just shame from having to expose their baby to this and their mama heart hurts. And so, it's really cool to be able to help them walk through this and say, "Let's find a safe way for you to bond with your baby in the way you want to feed your baby."

Host 1: Yeah. And those shared decision-makings, I like that terminology, we tend to use that a lot in the medical world with our patients. And it's so important to be able to give them options. And I think that it's amazing the work that you're doing and the medical advances that are allowing those types of decisions to be able to be made and having the mothers have those types of choices that she can make to be informed and make those decisions. So, nice work.

Diane Petrie: Thank you. It's encouraging and fun and it's fun to be able to empower people to take charge of their own health. And I think it really helps us with HIV stigma as a whole and lots of other things as we continue to advance our work in that field. So, it's cool.

Host 2: Absolutely. Well, we really appreciate you coming on. And clearly, you are an expert. Thank you so much for sharing all of this information. We like to end on this same question that we've done this whole season. So, this season it is what would your younger self high five you for now?

Diane Petrie: I love that. Because I'm with you, Tobie. I was born in, you know, the 1980 somethings.

Host 1: You all are babies. Babies, babies, babies.

Diane Petrie: But yes, my younger self is feeling further away than my current self. I think that the thing in this season right now has really been, I would call it self-advocacy and setting boundaries. You know, once you get kind of settled into yourself and you know your passion, you know your skill sets and giftings and even, you know, your shortcomings, it's really becoming easier to use those things to keep yourself aligned and to guide your life decisions, your steps, all those things, your priorities, your time management. My younger self would have probably said yes to everything to the point of burnout and would have maybe deprioritize things that were most important to me to help make someone else happier, to do something I thought that I should do, even though I didn't really, I don't necessarily want to. Surely, there's parts of all of our lives that we don't want to do, but I think there's different things that we're almost kind of called or purposed to do that we should lean into that.

And so, my younger self would high five me for just realizing that no is a full sentence. It doesn't always have to have a rationale behind it. I think as you grow in your leadership, the things that you say no to define you more than the things you say yes to. And so in this season, I've been really proud to prioritize my life around the things I'm most passionate about that I'm called to do and that bring me the most joy.

Host 1: I love that. No is a full sentence. I love everything about that. So Diane, you are an expert, a mentor, a leader to many, and we highly, highly, highly, appreciate you being on our podcast once again.

Diane Petrie: Well, thank you guys so much. It's such a fun opportunity and I love catching up with both of you.

Host 2: Thanks again, and thank you all for listening to the Advanced Practice Perspectives podcast.