Updated Guidelines on Breastfeeding in HIV-Positive Mothers

HIV-positive mothers with undetectable viral load can now safely breastfeed their infants, according to recently updated recommendations.¹  Previously, HIV-positive women were not encouraged to breastfeed, limiting their choices on how to care for and feed their infants. This change aligns with new evidence-based literature and promotes equity in health care by offering HIV-positive mothers the same breastfeeding opportunities as those without the virus.

Breastfeeding infants has been a consistent debate between those who believe “fed is best” regardless of means, and those who strongly believe that breast milk is the superior way to deliver nutrients to babies. Regardless of opinion, one cannot deny there are many benefits to breastfeeding for both mother and baby. One meta-analysis by Prentice suggests that breastfeeding diminishes morbidity and mortality in infants, reducing the chances of common ailments, like diarrhea, as well as reducing the prevalence of more serious conditions like sudden infant death syndrome (SIDS).² In addition, health outcomes later in life, such as type 2 diabetes mellitus (T2DM), have also been shown to be reduced in those who were breastfed.²

Mothers who choose to breastfeed may also experience benefits to their health, including a lowered risk of breast cancer, cardiovascular disease, depression, and other common morbidities.² Many comorbidities whose risk is potentially lowered with breastfeeding overwhelmingly affect minority populations.¹  Breastfeeding also aids in the bonding of mother and baby.³

2023 Updated Guidelines for Breastfeeding with HIV¹

• Women with HIV who are receiving antiretroviral therapy (ART) and have consistent viral suppression should be counseled on the options of formula feeding, feeding with banked donor milk, or breastfeeding.
• Individuals who choose to breastfeed should be counseled on and supported in adherence to ART, viral suppression, and engagement in postpartum care for themselves and their babies.
• Exclusive breastfeeding is recommended, with the understanding that brief periods of replacement feeding may be necessary.

HIV Transmission and Screening

HIV is a bloodborne viral disease that is predominately passed via horizontal transmission during sexual intercourse, needle-sharing, and other means of contact with blood or other bodily fluids from an infected individual. However, vertical transmission from mother to offspring may occur as well. This can be through the placenta, during delivery via the birth canal, or in breast milk postnatally.⁴  

The current recommendation for screening for HIV in high-risk populations, which includes pregnant patients, is once annually.⁵  Upon a positive result, patients should follow up with a medical professional who can provide them counseling on preventing transmission, disclosure to sexual partners, maintaining a healthy lifestyle, and medication options, including the use of antiretroviral therapy (ART). It is vital to explain to patients that a normal and healthy life is possible with this diagnosis, so long as they follow recommendations set in place by national health agencies, such as the World Health Organization (WHO). These expert organizations are responsible for providing health care providers with evidence-based and effective guides for how to best manage diseases, like HIV, in order to prevent progression to more serious illnesses and to maximize positive outcomes.

Pre-exposure prophylaxis (PrEP) therapy is a regimen given to individuals who may be at high risk for contracting HIV.⁶  This can include those with risky sexual behaviors, intravenous drug users, or those who live in an area with a high rate of HIV transmission.⁶ The current PrEP medication consists of tenofovir disoproxil fumarate/emtricitabine (TDF/FDC), which inhibits viral replication if an individual is infected.⁶

Vertical transmission rates have dramatically decreased, if not eliminated, by the use of ART, including PrEP in many countries with a high HIV prevalence.⁷ In the United States, patients with HIV commonly have unplanned pregnancies, with many patients unaware they are HIV-positive. With access to proper prenatal care, PrEP, ART, and postpartum neonatal testing, the prevalence of neonatal HIV rates has starkly decreased.⁷

In countries where HIV is more prevalent, screening practices have begun to improve with many initiatives, including increased access to PrEP therapy, testing, and education by external organizations, including the President’s Emergency Plan for AIDS Relief (PEPFAR) programs.⁸ However, more initiatives should be taken to provide ART to nations where resources may be lacking. By doing so, rates of HIV transmission will decrease as affected individuals can achieve an undetectable viral load on these medications.

HIV in Pregnancy and Postpartum

Optimal care from the beginning of pregnancy should be provided to every patient, regardless of HIV status. However, those with HIV who want to breastfeed should be properly educated by their medical providers on what options are available to them and how to provide their child with the best health outcomes. Guidelines for breastfeeding in HIV-positive mothers vary depending on population, location, and access to resources. However, with recent guideline updates, mothers should be able to make the decision they believe is best for themselves and their babies, with help from a medical provider.

Through the continued worldwide use of ART, HIV has been transformed from a fatal disease to a chronic yet manageable diagnosis. ART suppresses viral replication, which decreases the viral load in infected persons until they are considered unable to transmit the disease.⁶ Before the usage of ART for HIV, the passage of this disease through breast milk was up to 50%.⁹ However, with the revolution of these medications, there is hope that viral load can be decreased to levels where transmission via breastfeeding can be eliminated. Recent studies have demonstrated this, showing that an undetectable viral load in the blood correlates with an undetectable viral load in breast milk.⁹

Safety of ART During Pregnancy

This raises the important consideration of the safety of ART during pregnancy and the postpartum period for both mother and infant. Multiple medications have been shown to be safe and effective in lowering maternal viral load and improving transmission outcomes during pregnancy and birth.¹⁰It is vital to discuss the best medication regimen with patients, as other comorbidities may impact drug efficacy.¹⁰

Multiple antiretroviral medications on the market are safe in pregnancy, including dolutegravir, efavirenz, and raltegravir.¹¹ The most current guidelines, as of 2022, suggest the regimen for ART in pregnancy consists of 3 drugs: tenofovir/emtricitabine (TAF/XTC) with dolutegravir.⁶ These options have been studied and deemed safe during breastfeeding, with minimal drug transfer to the infant and negligible adverse outcomes.⁷

A review by Cardenas et al found evidence that suggests that HIV-positive mothers who wish to breastfeed should do so exclusively, without supplementing with formula, as this mixed-feeding technique has been associated with an increased risk of vertical transmission.⁷ This is because infants who are given supplemental formula may experience a higher likelihood of an inflammatory response or a compromised intestinal barrier, both of which could lead to increased rates of HIV transmission through breast milk.⁷

The outlook for HIV-positive patients who wish to breastfeed in less developed countries continues to improve. The World Health Organization (WHO) released its most recent guidelines for ART in pregnancy in 2015, titled Option B+, which provides guidelines and recommendations to lower the risk and rate of vertical transmission of the disease (Table).¹² These countries have less access to formula compared with more resource-rich nations, and breastfeeding allows for a cost-effective form of providing nutrients to infants. Under these most recent guidelines, antiretroviral therapy is initiated in HIV-positive mothers and continues for the rest of their lives.¹²

Table. WHO’s Option B+ Program: Antiretroviral Therapy for HIV-Positive Mothers and Infants¹²

Who	What	When	Where	Why
HIV-positive women who are pregnant or breastfeeding	Lifelong ART for breastfeeding mothers	Beginning at HIV diagnosis, regardless of CD4 count	Areas with a high prevalence of mother-to-infant transmission of HIV, ex: Sub-Saharan Africa	Reduce maternal-infant transmission of HIV and encourage safe breastfeeding
Neonates with HIV-positive mothers	4 to 6-week course of ART	Beginning at birth, regardless of whether they are breastfed or formula-fed	Areas with a high prevalence of mother-to-infant transmission of HIV, ex: Sub-Saharan Africa	Reduce maternal-infant transmission of HIV

Another aspect of preventing vertical transmission of HIV is the effectiveness and safety of administering ART to breastfeeding infants. Option B+ currently suggests neonates who are breastfed be given ART for up to 6 weeks of life and advises HIV-positive mothers to exclusively breastfeed for the first 6 months of life.¹² HIV prophylaxis in infants in the US is a debated topic with no clear consensus. However, the Department of Health and Human Services gives options for administering ART to neonates ranging from 2 weeks up to 6 weeks prophylactically.¹ Additionally, a cohort study conducted by Persaud et al examined the efficacy of administering ART to HIV-positive neonates 48 hours after birth. This study found that initiating ART this early greatly reduced, if not suppressed, viral DNA count in the patients that were followed up to 2 years of age.¹³ Typically, the decision to give an infant ART will be made by both the mother and the provider after extensive consideration and discussion.

Although it may be ambitious for underdeveloped countries with higher rates of HIV, it is recommended in the US that breastfed infants be tested for HIV multiple times from birth to 6 months if mothers are positive.¹ It is also recommended they continue to be tested after weaning to ensure a lack of transmission. Researchers believe that more studies should be conducted to truly determine if the benefit of infant prophylaxis against HIV outweighs the risks surrounding treatment.¹

Providers must emphasize the importance of adherence to therapy to reduce the risk of transmission by maintaining a negligible viral load.⁷ A qualitative, interview-based study by DiClemente-Bosco et al conducted in South Africa suggested pregnant women living with HIV were more likely to be adherent to their ART regimen if they had familial or spousal support.³The authors noted better outcomes when the patients themselves felt empowered and motivated to maintain their health status.³

Reproductive and Patient Autonomy

Reproductive autonomy has historically been a hard-fought right for women all over the world, especially those living with HIV. This disease overwhelmingly affects Black women who continue to face racial discrimination in the health care sphere. Doubt and distrust of health care providers may be heightened in this population, which can contribute to patients not seeking care or asking questions on what options may benefit their situation.

Reducing the stigma around HIV continues to be a battle faced by health care practitioners and those with the disease. Education surrounding the reduction of vertical transmission can minimize the fear of many mothers.

Patient autonomy and empowerment should not be compromised based on HIV status and have been linked to increased adherence to ART,³ decreasing the rate of transmission of HIV through breastmilk in the postnatal period. By expanding care and creating an environment in which patients can access resources, the mothers are more likely to adhere to their antiretroviral therapy regimens.³ A survey by Bukkems et al indicated that women with HIV are most likely to base their decision to breastfeed on the advice of their health care provider, highlighting the significant influence practitioners have on their patients’ personal choices.¹⁴

 Health care providers must approach this responsibility with care, ensuring that HIV-positive mothers’ desire to breastfeed is not dismissed without thorough education and a clear explanation of all available options. While guidelines are established to improve patient outcomes and should be followed and updated accordingly, they also play a crucial role in promoting equity across different demographic groups and empowering patients to make informed decisions about living healthy lives.³

Regardless of HIV status or any other parameter, it is important that the medical community continues to research how to improve patient outcomes both physically and mentally.

Breastfeeding Trends

Breastfeeding rates vary throughout the world, with the strongest practice in less developed countries, particularly in African and South Asian countries.² This may be attributed to less access to resources, like formula, finances, or cultural practices. It must be noted that these areas, especially Sub-Saharan Africa, have the highest rates of HIV infection worldwide.¹⁵

Many underdeveloped countries not only have a higher prevalence of HIV but also infant mortality because of nutrient deficiencies beginning at birth.¹⁶ Current programs that provide prenatal care to expectant mothers help combat this by offering nutrient supplements. These can be transmitted through breast milk, allowing infants to acquire more nutrients and have better mortality outcomes overall.¹⁷

Saving money by not purchasing commercially-made formula allows breastfeeding mothers the ability to provide themselves with adequate nutrition, which is directly reflected in the neonatal health benefits contained in their breast milk.¹⁷ These financial and nutritional benefits to both mother and baby should be considered when guidelines are created relating to those living with HIV. Allowing HIV- positive mothers the option to breastfeed has the potential to improve health outcomes for infant populations in underdeveloped nations.¹⁷

Conclusion

As more research continues to be conducted on the benefits of infant prophylaxis, the duration of ART in expectant mothers, and fully eliminating the risk of vertical transmission, the choice to breastfeed in the HIV-positive population should be a joint decision between patients and providers with the best outcomes in mind for both mother and baby. Access to health care, a strong support system, and a commitment to medication adherence all play a crucial role in ensuring the safety of breastfeeding for an HIV-positive mother and her child. If these factors are carefully considered and adequate patient education is provided, the recently updated guidelines allow HIV-positive patients to have more agency about their sexual and reproductive health.