Is Breastfeeding Safe for HIV Positive Parents?

New Guidance from the American Academy of Pediatrics

In a reassuring update for HIV positive parents considering breastfeeding, the American Academy of Pediatrics (AAP) has revised its recommendations. Historically, the AAP advised against breastfeeding for individuals with Human Immunodeficiency Virus (HIV) due to the potential risk of transmission to infants. Recent research, however, indicates that this risk is significantly minimized when the parent is on antiretroviral medication and maintains an undetectable viral load.

A Shift in Recommendations

The AAP now endorses shared decision-making between parents and healthcare providers regarding infant feeding for those with HIV who wish to breastfeed. This change marks a notable departure from the previous guidance established in 1985, which categorically discouraged breastfeeding in HIV positive mothers.

Dr. Lisa L. Abuogi, MD, MSc, FAAP, the lead author of the clinical report, emphasized, “While avoiding breastfeeding is the only option to guarantee that the virus is not transmitted, pediatricians should be ready to offer family-centered and nonjudgmental support for people who desire to breastfeed.” This updated policy, published in June 2024 in the journal Pediatrics, highlights the importance of breastfeeding for both infants and their parents. It also ensures that HIV positive individuals receive equivalent access to information and support as those without the virus.

Understanding the Risks of Breastfeeding

Approximately 30% of mother-to-child HIV transmission occurs through breastfeeding, particularly when the mother is not receiving antiretroviral (ARV) treatment or is not virally suppressed. The transmission risk is highest within the first 4-6 weeks of an infant’s life, with a 5-6% chance of transmission. This risk decreases over time but remains present throughout the breastfeeding period at around 0.9% monthly.

Research shows that the risk of HIV transmission through breast milk drops to below 5% when ARVs are utilized and to less than 1% when the mother is on ARV therapy with an undetectable viral load. The AAP encourages mothers to consider this minimal risk against the myriad of health, psychosocial, and financial benefits associated with breastfeeding.

AAP Recommendations for HIV Positive Mothers

To safeguard both the mother and infant, the AAP recommends that pediatricians take the following steps:

1. **Confirm the HIV Status of Pregnant Individuals**: This allows for appropriate counseling on infant feeding and promotes perinatal HIV testing.

2. **Support Breastfeeding for Mothers with HIV**: Support should be provided when mothers meet specific criteria, including prompt initiation of antiretroviral treatment, maintained viral suppression, consistent access to treatment, and a commitment to ongoing treatment during the breastfeeding period.

3. **Offer Counseling and PrEP Referrals**: Pregnant and postpartum individuals at heightened risk of acquiring HIV—such as those who inject drugs or have partners with unsuppressed HIV—should receive counseling regarding the potential transmission risk through breast milk and referrals for pre-exposure prophylaxis (PrEP) medications.

Each individual’s circumstances are unique. If there are concerns regarding HIV and infant feeding, including breastfeeding, it is advisable to consult a healthcare provider. They can offer personalized advice and support based on specific needs and situations.

References

American Academy of Pediatrics shifts position on breastfeeding for people with human immunodeficiency virus. Available at: https://www.aap.org/en/news-room/news-releases/aap/2024/american-academy-of-pediatrics-shifts-position-on-breastfeeding-for-people-with-human-immunodeficiency-virus/ (Accessed: 16 November 2024).

Abuogi L, Noble L, Smith C; COMMITTEE ON PEDIATRIC AND ADOLESCENT HIV; SECTION ON BREASTFEEDING. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics. 2024;153(6):e2024066843. doi:10.1542/peds.2024-066843.

Goga A, Coutsoudis A. HIV and Infant Feeding. In: Mehta S, Finkelstein JL, editors. Nutrition and HIV: Epidemiological Evidence to Public Health. New York (NY): CRC Press; 2018 May 15. Chapter 7. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572226/#doi:10.1201/9781351058193-7.