HIV (human immunodeficiency virus) is a virus that attacks the immune system making it more difficult for the body to fight infections and diseases. Although there isn’t a cure, modern treatments (antiretroviral therapy or ART) mean most people with HIV can live a long and healthy life. Without treatment, HIV can be life-threatening. HIV is found in body fluids such as blood, semen and breast milk.
HIV and breastfeeding
Without appropriate treatment, HIV can be passed from mother to child by pregnancy, birth or breastfeeding. However:
- Antiretroviral therapy can prevent mother-to-child transmission of HIV. Research has shown that transmission of HIV from mother to baby through pregnancy, birth and breastfeeding can be substantially reduced with use of antiretroviral therapy. Antiretroviral therapy (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 below 5% 1.
- 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 milk23.
- Alternatives to breastfeeding can be risky for HIV-exposed babies (see below).
These three pieces of information have led to the latest recommendations that mothers living with HIV can still breastfeed under certain conditions. The World Alliance for Breastfeeding Action (WABA) describes the conditions in a 2015 statement as follows:
Breastfeeding by HIV-Positive mothers can be made safe when they:
- are diagnosed before or during early pregnancy.
- have received full antiretroviral therapy (ART) for at least 13 weeks prior to the birth of their babies.
- have an undetectable viral load.
- are adherent to their ART.
- administer prescribed antiretroviral prophylaxis to their babies from birth to 4 weeks to protect from virus acquired at birth
- practise exclusive breastfeeding during their babies’ first 6 months of life.
- continue breastfeeding with appropriate complementary foods for up to a year, or even longer, unless or until safe replacement feeding would enhance HIV-free survival.
Risks of replacement feeding in resource poor areas
Artificial breast milk substitutes can increase infant illness and deaths anywhere in the world but especially in resource poor areas. In areas where parents have no sterilising facilities, unclean water, or an uncertain supply of industrially made milk, replacement feeding is not safe. This creates an even greater risk to health for the HIV-exposed baby who is not breastfed:
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.
Breastfeeding remains of crucial importance to the health of HIV-exposed infants since non-breastfed babies experience higher rates of illness and mortality. A recent study shows that the improved immunological and nutrition status enjoyed by breastfed, HIV-exposed infants is especially protective against pneumonia, diarrhoea and sepsis, leading to reduced hospitalisation during the first year of life. Two studies have also shown that when these babies have been exclusively breastfed for 6 months and continue to be breastfed while their mothers adhere to their ART, there is no increased risk of transmission up to 12 months
World Health Organisation guidance on HIV and breastfeeding
The latest guidance on HIV and breastfeeding is from the World Health Organisation (WHO) and UNICEF (United Nations Children’s Fund) from 2010 (updated 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 4.
HIV and breastfeeding guidelines 2010
The World Health Organisation states that in areas where antiretroviral drugs (ARV) are promoted from the time of diagnosis, mothers known to have HIV are recommended to breastfeed their babies for at least 12 months unless replacement feeding is is acceptable, feasible, affordable, sustainable and safe (AFASS).
When the mother is HIV negative OR her status is unknown
- Exclusive breastfeeding for 6 months
- From 6 months introduce complementary feeding while continuing to breastfeed for a minimum of two years and beyond.
When mothers are HIV positive
- HIV+ mothers to receive ARVs from the time of diagnosis which is to be continued for life.
- Exclusive breastfeeding (with maternal ARVs) is recommended for the first 6 months of life, unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable, AND Safe and the current 2010 WHO guidance spells out what those criteria really mean.
- From 6-12 months continue breastfeeding (if replacement feeding still does not meet the AFASS criteria) with additional complementary foods.
- Continue breastfeeding with complementary foods beyond 12 months unless there are safe conditions for weaning (as outlined above).
HIV and breastfeeding guidelines 2016
The feeding guidelines above have been reviewed in 2016. Most of the 2010 guidelines remain valid with a few additions, see the 2016 document for further information and excerpts below:
[Q] For how long should a mother living with HIV breastfeed if she is receiving ART and there is no evidence of clinical, immune or viral failure?
Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence
[Q] If a mother living with HIV plans to return to work or school, is a shorter duration of planned breastfeeding with ART better than no breastfeeding at all?
Mothers living with HIV and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.
Further guidance on HIV and breastfeeding
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 another 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 the correct antiretroviral therapy approach, the risk of mother to child transmission of HIV during pregnancy and childbirth is reduced substantially to negligible levels. Continuing to take these medications during lactation while under medical supervision, can also virtually eliminate HIV transmission by breast milk 5. However, in many developed countries, where formula feeding is assumed to be safer, general advice is still not to breastfeed—examples from UK and USA are given below:
Advice in the United Kingdom
National Health Service (NHS)
The UK’s National Health Services website advises taking antiretroviral drugs during pregnancy to reduce the risk of passing HIV mother to baby during pregnancy. And they recommend bottle-feeding instead of breastfeeding to avoid the risk of transmitting the virus via breast milk 6.
The British HIV Association (BHIVA)
Recently published BHIVA Guidelines on the Management of HIV in Pregnancy and Postpartum 2018 recommend formula feeding for mothers living with HIV in the UK—regardless of their ART status. It states however 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 also advocate replacement feeding (artificial formula milk) where appropriate—see first excerpt below. However they also 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
Replacement feeding must be safe
The World Health Organisation 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.
Although HIV can be transmitted mother to child during pregnancy, birth and via breast milk, the situation is not as straightforward as advising mothers not to breastfeed. Replacement feeding by formula, once thought to be the answer, is not without risks for the baby, particularly in undeveloped countries where HIV rates tend to be the highest. Research has indicated a greater risk of infant deaths from babies receiving formula in these areas because they are deprived of the many heath benefits and support to the immune system that breast milk provides. In addition alternatives to breast milk are not safe where parents do not have appropriate sterilising facilities, have unclean water, or cannot afford to buy the breast milk substitutes they need. Research also shows that appropriate medical care in the form of antiretroviral therapy (ART) can significantly reduce the risks of mother to child transmission by reducing the mother’s viral load to virtually zero. And research shows 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 her medications.