HIV and Infant Feeding / Chestfeeding

The key takeaways for parents in this article are:

• Breastfeeding with HIV is considered to be very low risk when the nursing parent adheres to antiretroviral therapy (ART) and exclusively nurses their baby for at least 6 months.
• For parents on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during and after pregnancy, the risk of transmission through nursing is less than 1%, but not zero.
• The risks of not using human milk need to play a role in decision-making when discussing infant feeding options.
• Parents living with HIV who decide to nurse their children should receive family-centered, evidence-based information that emphases all feeding options that are available which align with their parenting goals.

The guidelines for infant feeding with families living with HIV have changed and as a result the support you receive from La Leche League Leaders and healthcare providers needs to reflect these changes.

The World Health Organization (WHO) supports breastfeeding as the recommended feeding option for all families and their infants, including those families living with HIV, as long as they are under the care of healthcare providers and follow their antiretroviral treatment (ART, also referred to as ARV). The WHO recommends exclusive nursing/chestfeeding for the first six months and continued nursing for two years or longer. (WHO. 2016, 2021, 2023; South African Dept. of Health, 2019; Western Cape Gov’t Health, 2018)

While our past resources, such as that from the European AIDS Clinical Society, have recommended that parents living with HIV not nurse nor provide their babies with their own milk, this has changed. Since 2010, it is widely acknowledged that people with HIV should receive evidence-based, patient-centered counseling about infant feeding and that their feeding goals should play key roles in their infant feeding plans. This includes feeding their babies directly from their own body and with their own milk.

So what does nursing/chestfeeding with HIV look like?

While it is true that HIV can be transmitted during the perinatal period (pregnancy, labor, birth and lactation), we now know that for persons taking their antiretroviral treatment as prescribed as well as receiving appropriate planned care and follow up, this “risk” is extremely low. The risk is dependent on the “viral load,” an indication of how much virus can be found in your blood. Viral loads of <50c/ml are regarded as being undetectable.

In 2023, a study indicated that for a person who is taking ART and has an undetectable viral load during at least the third trimester of pregnancy and childbirth, as well as continuing to be ART adherent post-birth, with appropriate check ins with healthcare providers to measure their viral load, the chances of the baby acquiring HIV are less than 1% (NIH, 2023, 2024). A parent with an undetectable viral load, ongoing care and appropriate medications can and should consider nursing their babies directly from their body as the first option for nutrition for their baby.

Exclusive breastfeeding for the first 6 months of life is not only associated with decreased risk of HIV infection, it is also associated with improved survival for both parent and child with decreased risks of bowel, respiratory, and stomach infections for the infant and increased postpartum health for the birthing/nursing parent (WABA, n.d; Western Cape Gov’t Health, 2018). It is important to remember that nursing must be exclusive for the first six months of a child’s life. This means that the baby gets nothing else to eat or drink other than breastmilk or medication until around six months. Complimentary feeding can then be added and nursing can continue until both mother and baby have decided otherwise (WHO HIV/AIDS: Infant feeding and nutrition 21 Nov 2021).

There are also resources that consider the use of antiretroviral medications for infants directly after birth, which further acts as a precaution and supports the use of human milk consumption by the newborn (WHO. 2016; South African Dept. of Health, 2019; CDC, 2024; NIH 2023).
Families living with HIV that have shorter goals other than nursing at least 12 months should be reassured that exclusive nursing/chestfeeding for 6 months has numerous and valuable benefits that support normal growth and health milestones. It should be noted that not providing human milk to a newborn is a departure from the recommended best practice and comes with risks, especially for infants with compromised immune systems and those living with HIV.

Continuing to nurse your baby with cracked and/or bleeding nipples while HIV positive is possible. While the goal is to avoid getting damaged nipples in the first place, we can be reassured that nursing our babies while we heal damaged skin on nipples is possible. As long as we are following the prescribed care plan of antiretroviral medication with a low detectable viral load, the risk of transmission remains less than 1% (Adult Primary Care (APC) Guide 2019/2020).

Please remember that if you have any concerns about transmitting the HIV infection to your baby, contacting a healthcare provider who is a current subject matter expert is of vital importance. Ask your healthcare providers if they are aware of the new guidelines or are knowledgeable in lactation with HIV. Contacting your local La Leche League Leader can help you find local support in your location.
If your baby is also living with HIV, then there is no reason not to nurse your baby or not to provide your own milk as this meets all your baby needs for optimal and normal growth.

How can La Leche Leaders support HIV positive families?

Leaders supporting families with questions about HIV and nursing/chestfeeding can refer them to the most current and up-to-date recommendations for their location, as well as have a list of current healthcare providers who are current subject matter experts and of HIV specific resources and organizations for support.To summarize, the best available research so far shows that the risk of postpartum transmission (through breastfeeding) can be reduced to almost zero if you:

• Have active and ongoing care from a knowledgeable healthcare provider along with viral load testing.
• Are receiving sufficient antiretroviral (ART) medications for a long enough time to achieve an undetectable viral load three to four months before birth (Chibwesha, 2018).
• All medications are taken as prescribed.
• Studies confirm that early introduction of antiretroviral medications (ART) play a key role in safely suppressing HIV viral loads when used within hours of birth and that this medication is safe for those babies whose parents are HIV positive. (Johns Hopkins University School of Medicine policies)

La Leche League Resources for further reading:

Update on HIV and Breastfeeding, Pamela Morrison, 2019
Breastfeeding for HIV-Positive Mothers, Pamela Morrison, 2018
HIV and Breastfeeding, La Leche League International, 2024

Resources:

Bispo S, Chikhungu L, Rollins N, Siegfried N, Newell ML. (2017, Feb 22). Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. J Int AIDS Soc. 20(1):21251. doi: 10.7448/IAS.20.1.21251. PMID: 28362072; PMCID: PMC5467610.

CDC. (2024, May 10). HIV and Breastfeeding. Breastfeeding Special Circumstances. https://www.cdc.gov/breastfeeding-special-circumstances/hcp/illnesses-con ditions/hiv.html.Chantry CJ, Young SL, Rennie W, Ngonyani M, Mashio C, Israel-Ballard K, Peerson J, Nyambo M, Matee M, Ash D, Dewey K, Koniz-Booher P. (2012, May 1). Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 months of age in urban Tanzania, J.Acquir Immune Defic Syndr. 1;60(1):43-50. doi: 10.1097/QAI.0b013e31824fc06e.Chapman, S. (2016, Jan 29). Lancet Breastfeeding Series is a call to action. [Blog]. Cochrane UK.

Chibwesha, Luoga E et al. (2018), Brief Report: No HIV Transmission From Virally Suppressed Mothers During Breastfeeding in Rural Tanzania. J Acquir Immune Defic Syndr, 2018;79(1):e17-e20, https://www.ncbi.nlm.nih.gov/pubmed/29781882.

Chibwesha CJ, Giganti MJ, Putta N, Chintu N, Mulindwa J, Dorton BJ, Chi BH, Stringer JS, Stringer EM. (2011). Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr. 2011 Oct 1;58(2):224-8. doi: 10.1097/QAI.0b013e318229147e.

Daniels, B., Spooner, E., & Coutsoudis, A. (2022). Getting to under 1% vertical HIV transmission: lessons from a breastfeeding cohort in South Africa. BMJ Global Health, 7(9), e009927. https://doi.org/10.1136/bmjgh-2022-009927.

European AIDS Clinical Society. (2020). Guidelines, version 10.1, https://www.eacsociety.org/files/guidelines-10.1_30032021_1.pdf

Gilleece, Y., Byrne, L., Bamford, A., Lyall, H., Seery, P., & Tariq, S. (2022). Interim BHIVA position statement on HIV and mixed infant feeding. https://www.bhiva.org/file/639b0a86a19c7/BHIVA-position-statement-on-HI V-and-mixed-infant-feeding.pdf.Gross, M. S., Taylor, H. A., Tomori, C., & Coleman, J. S. (2019). Breastfeeding with HIV: An Evidence-Based Case for New Policy. The Journal of Law, Medicine & Ethics, 47(1), 152–160. https://doi.org/10.1177/1073110519840495.

Silere-Maqetseba, Guo, S., & Sherman, G. G., (2023). Eliminating Vertical Transmission of HIV in South Africa: Establishing a Baseline for the Global Alliance to End AIDS in Children. Diagnostics, 13(15), 2563–2563. https://doi.org/10.3390/diagnostics13152563.

NIH, (2023), Infant Feeding for Individuals with HIV in the United States. Clinicalinfo.hiv.gov.

NIH, (2024, January 31). Overview: Recommendations for Antiretroviral Drugs Use During Pregnancy, Clinicalinfo.hiv.gov. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arv-dru gs-pregnancy-overview#:~:text=Overview

South African National Department of Health, (2019). Guideline for the Prevention of Mother to Child Transmission of Communicable Infections. https://www.knowledgehub.org.za/system/files/elibdownloads/2019-10/PMT CT%20Guideline%2028%20October%20signed.pdf Adult Primary Care (APC) Guide (2019/2020) – Updated | Department of Health Knowledge Hub. Knowledgehub.health.gov.za, https://www.knowledgehub.org.za/elibrary/adult-primary-care-apc-guide-20 192020-updated

Statistics South Africa. (2022) Mid-Year Population Estimates 2022, https://www.statssa.gov.za/publications/P0302/P03022022.pdf.

UNAIDS. (2020, Feb). How are babies becoming infected with HIV in Africa? https://www.unaids.org/en/resources/presscentre/featurestories/2020/february/20200211_babies-becoming-infected-with-hiv-in-africa.

Van de Perre P, Goga A, Ngandu N, Nagot N, Moodley D, King R, Molès JP, Mosqueira B, Chirinda W, Scarlatti G, Tylleskär T, Dabis F, Gray G. (2021, April 3). Eliminating postnatal HIV transmission in high incidence areas: need for complementary biomedical interventions. Lancet.397(10281):1316-1324. doi: 10.1016/S0140-6736(21)00570-5. PMID: 33812490.

Western Cape Government Health,(2018). Consolidated Guidelines for HIV Treatment. https://www.westerncape.gov.za/assets/departments/health/wc_hiv_consolidated_guidelines_march_2018_0.pdf.

WABA. (n.d.), Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource. (World Alliance for Breastfeeding Action. Retrieved June 26, 2024, from https://waba.org.my/understanding-international-policy-on-hiv-and-breastfe eding-a-comprehensive-resource/)

WHO. (2016) Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. (n.d.). https://www.who.int/publications/i/item/9789241549707.

WHO. (2021). HIV/AIDS: Infant feeding and nutrition. https://www.who.int/news-room/q-a-detail/hiv-aids-infant-feeding-and-nutrition.

WHO. (2023). Infant and young child feeding. World Health Organization.[Factsheet]