High Level of HBV DNA Virus in the Breast Milk Seems not to Contraindicate Breastfeeding

We present here a case of an HIV-HBV co-infected mother who exposed her child to a significant HBV infectious inoculum via breast milk, likely due to a hepatitis flare or an acute HBV infection. The mother-child couple was enrolled in the Kesho Bora study; a randomized controlled trial evaluating maternal prophylactic strategies to reduce HIV transmission through breastfeeding. 4 At week 6 postdelivery, a > ten fold elevation of alanine transaminase (ALT: 750 IU/L) was observed in a 20 years old mother. This mother was included in the control arm receiving short course antenatal zidovudine and singledose intrapartum nevirapine in accordance with per national guidelines at the time. Serological testing confirmed HBV infection (positivity for HBsAg) and ruled out hepatitis A and C infections. Serum and breast milk samples were retrospectively assessed for for HBV DNA levels at week 2 at week 2 and 12 using a standardized qPCR method (HBV Generic PCR, Omunis, Montpellier, France). Significant levels of HBV DNA were found in both left and right breast milk samples at week 2 post-delivery (> 10 3 log10 HBV DNA IU/mL) whereas, ALT level was normal (12 IU/ml). HBsAg levels were also quantified in breast milk (>10 1 IU/ml) using a quantitative assay (Architect HBsAg QT assay, Abbott, Chicago, IL). A dramatic decrease in the levels of HBV DNA and HBsAg was observed in both serum and breast milk at week 12 post-delivery (Table 1). Serum and breast milk became negative for HBsAg 6 months after delivery without detection of anti-HBs antibody. The newborn was infected neither by HIV nor by HBV despite a vaccine schedule starting at week 6. Protective anti-HBs titers were observed in response to HBV vaccination (>ten mIU/mL) at month 12. We estimate that the intestinal mucosa of the infant was in contact with more than one million HBV particles/per day based on a daily consumption of 300 ml during the first weeks of life. Although HBV infection is a major health concern worldwide, very few studies have explored HBV DNA