An Update to Clinical Guidelines: HIV and Breastfeeding in the United States

The Clinical Guidelines on Infant Feeding for Individuals with HIV in the United States were updated in January 2023. The guidelines now incorporate breastfeeding options for people with HIV on antiretroviral therapy with sustained undetectable viral load levels in the blood.

Link to new Clinical Guidelines

The updated 2023 guidelines note:

1. The infant feeding options that eliminate the risk of HIV transmission are commercial milk formula and pasteurized donor human milk.
2. The risk of HIV transmission while breastfeeding is less than 1% (but not zero) for people with HIV on antiretroviral therapy with sustained undetectable viral load through pregnancy and postpartum.
3. If breastfeeding is chosen, exclusive breastfeeding up to 6 months of age is recommended over mixed feeding (i.e., breast milk and formula), acknowledging that there may be intermittent need to give formula (e.g., infant weight loss, milk supply not yet established, mother not having enough stored milk). Solids should be introduced as recommended at 6 months of age, but not before. (Comment/question on this below.)
4. The postpartum period can be difficult for all parents. Ensuring that parents have access to both a supportive clinical team and peer support in the postpartum period is beneficial in promoting medication adherence and viral load monitoring
5. Access to a lactation consultant or lactation support provider with expertise in supporting breastfeeding by individuals with HIV is beneficial.
6. As most studies of breastfeeding in mothers with HIV were conducted in resource-limited settings, more information is needed about the risk of HIV transmission through breastfeeding in high-resource settings and when individuals are adherent to ART with sustained viral suppression starting early in pregnancy.
7. It is inappropriate to engage Child Protective Services or similar services in response to infant feeding choices of people with HIV.
8. Breastfeeding provides numerous health benefits to both the infant (e.g., reduction in asthma, gastroenteritis, and otitis media) and the parent (e.g., reduction in hypertension; type 2 diabetes; and breast and ovarian cancers)

I am a bit confused by #3. This suggests that intermittently giving formula along with the breastfeeding may be ok. I thought formula can cause inflammation and irritation in the neonatal GI track due to cow’s milk protein which could possibly allow the virus to get into the infant’s system if the human milk contained the virus. I will stay tuned on that one.

The guidelines provide a section on situations to consider stopping or modifying breastfeeding such as the breastfeeding parent having a detectable viral load or developing mastitis or bleeding nipples.

Previous clinical guidelines in the United States did not recommend breastfeeding for individuals with HIV in the United States due to the potential of HIV transmission in human milk.

This is great news. Our hospital is working hard to offer clear communication to staff on this topic and maximum support to individuals who choose this feeding option.