HIV and Breastfeeding

HIV (human immunodeficiency virus) is said to be a virus that attacks the immune system making it more difficult for the body to fight infections and diseases. HIV is generally accepted as the cause of acquired immunodeficiency syndrome (AIDS) although several authors have documented controversy around this.¹²³⁴ Without treatment HIV/AIDS can be life-threatening and there is concern that HIV can be transmitted via body fluids such as blood, semen and breast milk. This article looks at current guidance with respect to breastfeeding when mothers are said to have an HIV infection.

HIV and breastfeeding

There is concern that HIV could be passed from mother to child in pregnancy, birth or breastfeeding. According to WABA (World Alliance for Breastfeeding Action) if no precautions are taken, the risk of an HIV positive mother passing the infection to her baby via breastfeeding is one in seven.⁵ It is important to note that:

1. Antiretroviral therapy helps prevent mother-to-child transmission of HIV. Transmission of HIV from mother to baby through pregnancy, birth and breastfeeding is said to be substantially reduced with the use of antiretroviral therapy (ART). ART may also be referred to as HAART (highly active antiretroviral therapy) or cART(combination antiretroviral therapy). If ART is taken for a sufficient length of time before the baby’s birth (13 weeks), rates of perinatal transmission are said to be below 5%.⁶
2. Breast milk inhibits HIV. A 2012 study suggests that breast milk can inhibit the spread of the HIV virus and most breastfed babies do not become infected despite frequent exposure via breast milk.⁷
3. Alternatives to breastfeeding can be risky for HIV-exposed babies (see below).

These three pieces of information have led to the latest health recommendations that mothers living with HIV can still breastfeed when certain conditions are met. The World Alliance for Breastfeeding Action (WABA) describes the conditions as follows:

Transmission of HIV through breastfeeding can be reduced to almost zero (between 0-1%) when:

• Upon diagnosis, pregnant women living with HIV have access to lifelong ART
• Mothers and/or their babies receive ART from early / mid-pregnancy and throughout the breastfeeding period
• ART is provided for at least 13 weeks prior to delivery to reduce viral load by the time of birth
• Mothers living with HIV breastfeed their babies exclusively for the first 6 months of life

Risks of replacement feeding in resource poor areas

Using artificial breast milk substitutes instead of mothers’ milk can increase the risk of infant illness/death because babies miss out on the health benefits and protection from disease that breast milk provides. This is especially true in resource poor areas. Additionally, in places where parents don’t have access to sterilising facilities, clean water, or a secure supply of industrially made milk—replacement feeding with infant formula is not safe. Not being breastfed therefore creates an even greater risk to health for the HIV-exposed baby. A 2016 statement from the World Health Organisation/UNICEF states:

In southern and eastern Africa, where child mortality rates are among the highest in the world, HIV infection is common and a leading cause of death. In these settings, use of commercial breast-milk substitutes and other replacement feeds among infants not exposed to HIV is associated with significantly increased morbidity and mortality. Moreover, the evidence for the long-term benefits of longer duration of breastfeeding for both maternal and child health outcomes, including child development and prevention of noncommunicable diseases, highlights the relevance of supporting breastfeeding in high- and low-income settings alike.

The same document discusses the conditions needed to formula feed safely:

Mothers known to be living with HIV should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status when specific conditions are met:

• (a) safe water and sanitation are assured at the household level and in the community; and
• (b) the mother or other caregiver can reliably provide sufficient infant formula milk to support the normal growth and development of the infant; and
• (c) the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and
• (d) the mother or caregiver can exclusively give infant formula milk in the first six months; and
• (e) the family is supportive of this practice; and
• (f) the mother or caregiver can access health care that offers comprehensive child health services.

Exclusive breastfeeding

Exclusive breastfeeding is most protective since feeding infant formula in addition to breast milk may increase the risk of transmitting HIV as well as affecting the baby’s general health. WABA explains:

Mixed feeding refers to feeding a baby breastmilk as well as other foods and/or liquids such as infant formula before the age of 6 months. Mixed feeding before 6 months increases the risk of HIV-transmission as well as morbidity and mortality due to infections.
The early introduction of other foods and liquids:

• Increase the risk of infection leading to diarrhoea, pneumonia, malnutrition and mortality
• May damage the baby’s gut through harmful microorganisms leading to increased risk of HIV transmission
• Lead to infrequent breastfeeding which may cause engorgement and mastitis and an increase in the viral load in breastmilk

However WHO clarifies that even mixed feeding or a short period of breastfeeding is better than no breastfeeding at all as long as the mother is taking HIV preventative treatment:

Is mixed feeding better than no breastfeeding at all, if the mother is on HIV treatment?
Yes. Mothers living with HIV can be reassured that ART reduces the risk of post-natal HIV transmission even when the baby is on mixed feeding. Although exclusive breastfeeding is recommended for the first 6 months, mixed feeding is better than no breastfeeding. Encouraging mothers living with HIV to breastfeed exclusively is still strongly advised because it benefits the infant in many ways including, reduced illness, and improved growth and development.

If a mother on HIV treatment plans to return to work or school, is a shorter duration of breastfeeding better than no breastfeeding at all?
Yes. Mothers and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding.

Useful resources

#1 World Health Organisation guidance on HIV and breastfeeding

Guidance on HIV and breastfeeding from WHO and UNICEF in 2010 was updated in 2016. The guidance is particularly targeted at countries with high rates of HIV in settings where diarrhoea, pneumonia and undernutrition are common causes of deaths of babies and children. However, they note the information may also apply to areas with a low HIV rate, depending on the rates and causes of infant and child deaths.⁸⁹ A Q&A page on the WHO website summarises:

Can mothers living with HIV breastfeed their children in the same way as mothers without HIV?
WHO recommends that all mothers living with HIV should receive life-long antiretroviral therapy (ART) to support their health and to ensure the wellbeing of their infants.
WHO released guidelines in July 2016 advising that, in countries that have opted to promote and support breastfeeding together with ART, mothers living with HIV who are on ART and adherent to therapy should breastfeed exclusively for the first 6 months, and then add complementary feeding until 12 months of age. Breastfeeding with complementary feeding may continue until 24 months of age or beyond.
Previously, WHO advice was to breastfeed for 12 months but then stop breastfeeding if a nutritionally adequate and safe diet could be provided.
The new guidance is based on scientific evidence that shows ART is very effective at preventing HIV transmission through breastfeeding as long as the mother is adherent to therapy.

#2 WABA resource: the HIV Kit 2018

Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource (2nd edition, 2018)  by World Alliance for Breastfeeding Action is a comprehensive resource covering information on HIV and breastfeeding in six sections. Section Two outlines guidelines and current recommendations for antiretroviral drugs (ARV), antiretroviral treatment (ART) and prophylaxis.

HIV and breastfeeding in developed countries

With antiretroviral therapy, the risk of mother to child transmission of HIV during pregnancy and childbirth is said to be reduced substantially to negligible levels. Continuing to take these medications during lactation while under medical supervision, is also said to virtually eliminate HIV transmission through breast milk.¹⁰. General advice however continues to promote formula feeding as the feeding method of choice in many high income countries; but with the concession that if a mother’s viral load is undetectable she should be supported to breastfeed. See the next section for information about breastfeeding with HIV from UK and USA.

Advice in the United Kingdom

National Health Service (NHS)

The UK’s National Health Services website recommends bottle feeding formula instead of breastfeeding to reduce the risk of transmitting HIV via breast milk. However if a mother’s viral load is undetectable, she may choose to breastfeed and mother and baby will be offered extra medical checks as there’s a small chance HIV may pass to the baby:

If you have HIV, you can reduce the risk of passing it to your baby by:

• taking antiretroviral drugs during pregnancy, even if you don’t need HIV treatment for your own health
• considering the choice between a caesarean or vaginal delivery with your doctor
• bottle feeding your baby with formula, rather than breastfeeding
• your doctor prescribing your baby antiretroviral drugs for about 4 weeks after they have been born

HIV can be passed to a baby through breastmilk. The chance of this happening is lower if your HIV viral load is undetectable (very low).
If you’re taking antiretroviral medicine and your viral load is undetectable, you may choose to breastfeed your baby. You and your baby will be offered extra checks as there’s a small chance HIV will pass to your baby.
Do not breastfeed your baby if your viral load is detectable.

The British HIV Association (BHIVA)

British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (2020 third interim update) section 9.4.1 p95 promote formula feeding for mothers living with HIV in the UK—regardless of their ART status. However, elsewhere, section 9.4.4 of the same document states that women who choose to breastfeed should be supported in their choice to do so—as long as they have a fully suppressed viral load, a good history of taking their medication regularly, and are in close contact with their health team for monthly reviews of mother and baby’s viral load throughout lactation and two months beyond. Further advice in the document includes to breastfeed for as short a time as possible, to exclusively breastfeed for the first six months, and to stop breastfeeding if they have mastitis or their child has gastrointestinal symptoms.  Their guidelines are summarised in the following patient information leaflet: HIV and Breastfeeding your Baby.

Advice in the USA

The American Academy of Pediatrics advocate replacement feeding (artificial formula milk) in the United States where replacement feeding can be done safely—see first excerpt below. However they offer specific guidance for the care of an HIV positive mother with a zero viral load if she wishes to breastfeed (second excerpt):

the only intervention to completely prevent HIV transmission via human milk is not to breastfeed, in the United States, where clean water and affordable replacement feeding are available, the American Academy of Pediatrics recommends that HIV-infected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy.

Regarding mothers who are on effective treatment who wish to breastfeed, the Committee recommend:

a pediatric HIV expert should be consulted on how to minimize transmission risk, including exclusive breastfeeding. Communication with the mother’s HIV specialist is important to ensure careful monitoring of maternal viral load, adherence to maternal therapy, and prompt administration of antimicrobial agents in instances of clinical mastitis. Infant HIV infection status should be monitored

Summary

HIV is said to have the potential to be transmitted from mother to child during pregnancy, birth and via breastfeeding. When considering transmission by breast milk, the situation is more complicated than advising mothers not to breastfeed. Replacement feeding by formula holds risks for the baby, particularly in low income countries where HIV rates tend to be the highest. There is a greater risk of infant deaths from babies receiving formula in these areas because (1) they are deprived of the many health benefits and support to the immune system that breast milk provides; and (2) parents may not have clean water or facilities to prepare formula safely. Antiretroviral therapy (ART) is said to significantly reduce the risks of mother to child transmission by reducing the mother’s viral load to virtually zero and breast milk seems to have an inhibitory effect on HIV. Current guidance from WHO/UNICEF, particularly in resource poor areas, says an HIV positive mother who receives ART and has no evidence of clinical, immune or viral failure should be supported to breastfeed for at least 12 months and can continue breastfeeding for up to two years or beyond if still taking protective medications.