In the United States, an estimated few thousand pregnant women are living with HIV, with 3,525 reported cases in 2019. Traditionally, it has been recommended that mothers with HIV avoid breastfeeding, even when on antiretroviral therapy. However, the American Academy of Pediatrics (AAP) has recently revised its guidelines for infant feeding among parents with HIV. This change aligns with the latest recommendations from the U.S. Department of Health and Human Services and is outlined in an updated report published in the June 2024 issue of Pediatrics.
The new clinical report, “Infant Feeding for Persons Living With and at Risk for HIV in the United States,” was published online on May 20, 2024. This evidence-based update marks a significant shift from decades of advising against breastfeeding for parents with HIV.
“Research now shows that the risk of HIV transmission through breastfeeding is quite low when the lactating parent is on antiretroviral treatment and has no detectable viral load,” said Dr. Lisa L. Abuogi, lead author of the report. “While avoiding breastfeeding is the only surefire way to prevent virus transmission, pediatricians should be prepared to provide family-centered and nonjudgmental support for those who wish to breastfeed.”
Key Recommendations for Pediatric Health Care Professionals
The report includes comprehensive guidelines to help pediatric health care professionals minimize perinatal HIV transmission while promoting the health of both parents and infants and ensuring health equity. Here are the main points:
- Understand HIV Status: Pediatricians should know the HIV status of pregnant individuals to provide appropriate counseling and encourage perinatal HIV testing. Those diagnosed with HIV should be promptly linked to treatment.
- Support Breastfeeding: Pediatricians should be ready to support HIV-positive parents who wish to breastfeed if they:
- Began antiretroviral treatment early in or before pregnancy
- Maintain viral suppression
- Have continuous access to antiretroviral treatment
- Are committed to adhering to treatment consistently during breastfeeding
- Counsel High-Risk Individuals: Pregnant and postpartum individuals at high risk of acquiring HIV, such as those who inject drugs or have HIV-positive partners who are not virally suppressed, should be informed about the risks of breastfeeding and referred for pre-exposure prophylaxis (PrEP) medications.
Without treatment, HIV can be transmitted to infants during pregnancy, delivery, or breastfeeding. However, daily antiretroviral medications can keep HIV-positive individuals healthy and significantly reduce the risk of transmission.
Research finds that the risk of HIV transmission via breastfeeding from a parent on antiretroviral treatment with a suppressed viral load is less than 1%. This minimal risk should be balanced against the numerous health, psychosocial, and financial benefits of breastfeeding. Reflecting this understanding, the CDC has updated its position to support shared decision-making regarding infant feeding for parents with HIV who wish to breastfeed. The AAP, a long-time advocate of breastfeeding, now extends this support to parents with HIV on successful treatment.
Dr. Abuogi highlights the remarkable strides made over the past few decades in reducing perinatal HIV transmission in the US. “Healthcare professionals, researchers, and people with HIV have made amazing strides toward eliminating perinatal transmission of HIV,” she said. “We encourage families to share information with their pediatricians about HIV and discuss what will work best for them when it comes to feeding their baby.”
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