Outbreaks, Alerts & Hot Topics: HIV and Infant Feeding Today: Pediatric Providers as Advocates Supporting Informed Choice

Column Author: Diane Petrie, FNP-BC, AAHIVS, AACRN, CPN

Column Editor: Chris Day, MD | Director, Transplant Infectious Disease Services; Medical Director, Travel Medicine Program

Until recently, United States Department of Health and Human Services (DHHS) recommended avoidance of breastfeeding for women living with HIV (WLWH). However, in January 2023, the US DHHS Guidelines for Perinatal HIV Infection were updated to say, “People with HIV should receive evidence-based, patient-centered counseling to support shared decision-making about infant feeding.” Where did this change in recommended practices come from and what exactly is being recommended?

There is substantial experience with promotion of breast milk in WLWH and their infants in resource-limited countries. Infant feeding with maternal breastmilk has been recommended since 2010 when the World Health Organization (WHO) started to encourage and promote infant feeding practices among WLWH, also prioritizing anti-retroviral treatment (ART) for those mothers. Data from resource-limited countries since 2010 have shown that the risk of transmission of HIV during breastfeeding for WLWH adherent to antiretroviral therapy (ART) is less than 1% and even lower for those initiating ART during the first trimester or prior to conception. These findings have led to increasing interest in the U.S. for changing the breastfeeding and breastmilk recommendations for WLWH and their infants. In some locations in the U.S., allowing WLWH the option of breastfeeding, with appropriate counseling about the risks of this choice, has been standard practice for several years.

The 2023 DHHS guidelines note, “Multiple experts and community organizations have called for a patient-centered approach to infant feeding decision making and for parents with HIV to have access to the information, support, and tools necessary to make informed infant feeding decisions.” Evidence from our colleagues in resource-limited settings has shown that a multi-disciplinary approach coupled with counseling of best practices can decrease the risk of infant transmission and create a safe space for parents to be included in infant feeding decision-making. For this reason, the guidelines provide risk-reduction strategies and guidance acquired from experience in resource-limited settings and note that small studies completed in resource-rich countries (Great Britain, Germany, Canada, Australia, and the U.S.) have not led to transmission of HIV in the setting of maternal viral suppression.

While the guidelines state that the only way to eliminate the risk of HIV transmission is by the utilization of properly prepared formula or pasteurized donor human milk, they recommend that individuals on ART with sustained, undetectable HIV viral load who chose to breastfeed should be supported in this decision without fear of the engagement of Child Protective Services or similar agencies.

Transmission Risk Reduction Strategies Include:

• Those choosing to breastfeed should be counseled early in pregnancy regarding the potential risks and benefits of breastfeeding and counseled that exclusive breastfeeding for the first 6 months is recommended over mixed feeding or early introduction of solids.

• Those experiencing mastitis or other breast infection should be encouraged to temporarily stop feeding until the infection has resolved and infants with oral thrush should be promptly treated.

• Mothers should be provided early and active support for breastfeeding throughout pregnancy and post-partum periods by a multi-disciplinary team including case management/social work, lactation support, maternity care provider, infant provider and HIV Care providers for mother and infant.

• Mothers experiencing viremia should either temporarily stop breastfeeding, pump and flash heat breastmilk before providing to the infant, or provide previously pumped milk until viral load < 50 copies can be ensured.

• Persisting viremia at repeat blood draw is an indication for cessation of breastfeeding as there is an elevated risk of post-natal transmission reported in those mothers with detectable viral load.

For the general population, we do not hesitate to recommend breastfeeding as a superior option for the health of infants and their mothers noting “that many acute and chronic pediatric disorders, such as otitis media, acute diarrheal disease, lower respiratory illnesses, sudden infant death syndrome (SIDS), inflammatory bowel disease, childhood leukemia, diabetes mellitus, obesity, asthma, and atopic dermatitis, occur less frequently among children who were breastfed as infants” (Meek & Noble, Pediatrics, 2022).

We have an opportunity to support and provide counseling on risk-reduction to support this guideline-based, shared decision-making to promote the best health outcomes for infants and their mothers. Almost two years following these updated guidelines, WLWH in our region are not being given the option of breastfeeding and in some cases are denied the opportunity to participate in any decision-making regarding infant feeding, despite their own adherence to ART and evidence to suggest they can safely breastfeed.

As health care providers, it is time to change our perspectives based on the evidence and work together with our patients and multi-disciplinary care teams to emphasize the full benefits of breastfeeding for mothers and infants while providing the support and education needed for WLWH and their infants to breastfeed safely when they choose this option.

References

1. 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. Geneva: World Health Organization; 2016. Evidence and recommendations. Available from: https://www.ncbi.nlm.nih.gov/books/NBK379865/
2. Meek, Joan and Lawrence Noble, Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics July 2022; 150 (1): e2022057988. 10.1542/peds.2022-057988
3. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Department of Health and Human Services. Year. Available at https://clinicalinfo.hiv.gov/en/guidelines/perinatal. Accessed 10/16/2024. [Infant Feeding for Individuals with HIV in the United States].
4. Powell AM, Knott-Grasso MA, Anderson J, Livingston A, Rosenblum N, Sturdivant H, Byrnes KC, Martel K, Sheffield JS, Golden WC, Agwu AL. Infant feeding for people living with HIV in high resource settings: a multi-disciplinary approach with best practices to maximise risk reduction. Lancet Reg Health Am. 2023 May 29; 22:100509. Doi: 10.1016/j.lana.2023.100509. PMID: 37287494; PMCID: PMC10242550.