US Pediatricians Reverse Guidelines Suggesting HIV-Positive Mothers Not Breastfeed

The American Academy of Pediatrics, NIH, and CDC all now suggest, with the right medications, breastfeeding benefits outweigh the risk of HIV transmission.

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Women with HIV can now breastfeed their babies as long as they are taking medications that effectively suppress the virus that causes AIDS, according to an updated guideline published in a new clinical report. The guideline is a policy change from the American Academy of Pediatrics (AAP), the top pediatrician group in the country.

The clinical report reverses recommendations from the 1980s, which marked the start of the HIV epidemic, as medications can reduce the risk of transmitting HIV through breast milk. Previously, it was thought that the risk of HIV transmission outweighed the benefits of breastfeeding in high-income countries. Contrastingly, in low- to middle-income countries, guidelines suggested that the benefits outweighed the risks.

The AAP still recognizes that replacement feeding, such as formula or donor human milk, is the only option to prevent postnatal transmission of HIV completely.

“However, pediatric health care professionals should be prepared to provide infant feeding counseling and a family-centered, culturally sensitive, harm reduction approach for people with HIV on ART (antiretroviral therapies) with sustained viral suppression who desire to breastfeed,” the organization wrote in its report.

Recommendations Hinge on Antiretroviral Therapies

While medications such as maternal antiretroviral therapies (ARTs) and prophylactic infant antiretrovirals (ARVs) don’t eliminate transmission risk, they can reduce it. Around the world, around 30 percent of perinatal HIV transmissions occur as a result of breastfeeding, but those cases typically occur when the mother is not taking virus-suppressing medications. The risk of infection is highest during an infant’s first four to six weeks of life, where it hovers between 5 percent and 6 percent. The risk declines to less than 1 percent each month during breastfeeding, the AAP wrote.

The organization said that HIV-positive women interested in breastfeeding after pregnancy should initiate ARTs before or early in pregnancy. The medication must keep the viral load below 50 copies per milliliter, which indicates sustained viral suppression.

In addition to suggesting that these breastfeeding women take ARTs, the guidelines recommend that infants be fed exclusively breast milk for the first six months. The AAP noted that research shows that switching between breast milk and formula can disrupt an infant’s gut integrity, affecting its susceptibility to infections. The report also highlighted that abrupt weaning is associated with a higher risk of HIV transmission, as the viral load is higher following abrupt weaning.

Breastfed infants should be screened for HIV at different intervals throughout the first six months and up to six months after weaning, the AAP wrote.

Health Care Professionals and Federal Agencies Aligned

The new policy comes a little more than a year after the National Institutes of Health (NIH)and the U.S. Centers for Disease Control and Prevention (CDC) also reversed decades-old recommendations against breastfeeding by women with HIV.

The NIH stated in its January 2023 update that breastfeeding by women with HIV may be permitted as long as they are taking ARTs and have sustained, undetectable viral loads throughout pregnancy and in the postpartum period.

Additionally, the NIH notes that it is “inappropriate to engage Child Protective Services (CPS) or similar services in response to infant feeding choices” by women with HIV.

Breastfeeding provides ample benefits for both mother and child, including bonding, nutrition, and immune support. Limiting a woman’s ability to breastfeed may further increase the health risks that a woman with HIV may already have, including obesity, diabetes, and reproductive cancers.

“For these reasons, the American Academy of Pediatrics (AAP) supports breastfeeding, along with appropriate complementary foods introduced at approximately 6 months, as long as desired for 2 years or beyond,” the organization wrote in the report.