Infant Feeding PWH

My Perspective on the New US Infant Feeding Recommendations for People With HIV

Released: April 06, 2023

William R. Short, MD, MPH, FIDSA

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Key Takeaways

Updated DHHS guidelines recommend supporting PWH who are virologically suppressed and wish to breastfeed.
Use of suppressive maternal ART or daily infant single-agent ART can reduce the risk of HIV transmission from breastfeeding to <1%.
Engaging Child Protective Services is not an appropriate response to the infant feeding choices of PWH.

A 27-year-old cisgender woman with HIV who is currently 16 weeks’ pregnant expresses a desire to learn more about breastfeeding after delivery. She is currently receiving antiretroviral therapy (ART) and has had a suppressed HIV-1 RNA for the past 3 years. How would you best counsel her on infant feeding?

Infant Feeding by PWH

Choosing a method for feeding a baby is one of the most important decisions a new parent makes, and this decision can be complicated by mixed messages from healthcare professionals who are uncomfortable discussing infant feeding with people with HIV (PWH). It is well known that breastfeeding benefits the infant in many ways, including protection against a variety of conditions like asthma, obesity, ear infections, and sudden infant death syndrome.

DHHS Guideline Updates

US guidelines have historically discouraged breastfeeding by PWH because of the potential risk of HIV transmission to the infant through breast milk. In January 2023, however, the US Department of Health and Human Services (DHHS) released its annual update to the perinatal HIV guidelines and for the first time recommended a greater focus on patient-centered shared decision-making about infant feeding choices.

DHHS now recommends that PWH who are receiving ART and have a sustained undetectable HIV-1 RNA and who choose to breastfeed should be supported, as should PWH who choose to formula feed. If breastfeeding is chosen, exclusive breastfeeding for the first 6 months of life vs mixed feeding (eg, breastfeeding and formula) is recommended. It is also explicitly stated that engaging Child Protective Services or similar agencies is not an appropriate response to the infant feeding choices of an individual with HIV.

Breastfeeding Can Be Safe for PWH

With the use of current ART, rates of HIV transmission through breastfeeding are low (<1%), but not zero. Gaps in our knowledge persist regarding how to best support PWH who choose to breastfeed their infants.

For example, should the ART be maternal only or maternal and infant? Suppressive maternal ART or infant daily dosing with a single antiretroviral medication reduces the risk of transmission to <1% during the course of 6 months of exclusive breastfeeding. However, no study to date has been powered to evaluate whether combining maternal ART and infant ART can further lower the transmission risk.

And should breastfeeding be exclusive? In the earlier ART era, one study demonstrated that the risk of transmission of HIV through breastfeeding can be up to 11 times higher in infants exposed to both breast milk and infant formula or solid foods (mixed feeding) than those who were exclusively breastfed during the first 6 months of life. The extent to which mixed feeding may increase the risk of HIV transmission compared with exclusive breastfeeding when the breastfeeding parent is on suppressive ART in the current ART era is unknown.

Implementing DHHS Recommendations

Historical US data show that retention in care and maintaining viral suppression in the postpartum period can be challenging for PWH. Before the implementation of the new DHHS guidelines, case series of PWH in the United States who chose to breastfeed their infants demonstrated that many postpartum PWH experienced stigmatization and lack of lactation support to promote exclusive breastfeeding. Until effective evidence-based tools exist, these issues will remain threats to successfully implementing the updated DHHS guideline recommendations on infant feeding by PWH.

My Approach
In this 27-year-old cisgender woman who is 16 weeks’ pregnant and wishes to breastfeed, I would discuss with her the data and updated DHHS guideline recommendations to support safe breastfeeding in PWH who remain virologically suppressed. I would encourage continued ART adherence to support her as well as her child’s health.

Your Thoughts?
How do you approach infant feeding conversations with your pregnant or postpartum PWH? Join the conversation by posting a comment below.

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