A paradigm shift has occurred in the approach to infant feeding among people with HIV.
For decades following the start of the HIV epidemic, AAP guidelines have recommended against breastfeeding or providing any breastmilk to infants of people with HIV in the United States to avoid any risk of HIV transmission. However, accumulating research has shown that the risk of HIV transmission through breastfeeding is quite low when the lactating parent with HIV is on antiretroviral treatment (ART) and has an undetectable viral load. At the same time, the United States is on the threshold of meeting goals to eliminate perinatal transmission of HIV.
The AAP has responded by updating its guidance in the clinical report Infant Feeding for Persons Living With and at Risk for HIV in the United States. The report includes recommendations for pediatric health care professionals caring for infants of people with HIV that support eliminating perinatal transmission, ensure optimal health of parents and infants, and promote health equity.
The clinical report, from the AAP Committee on Pediatric and Adolescent HIV and Section on Breastfeeding, is available at https://doi.org/10.1542/peds.2024-066843 and will be published in the June issue of Pediatrics.
Role of pediatric health care professionals
Pediatric health care professionals must know the HIV status of the pregnant individual to provide appropriate infant feeding counseling. Therefore, the clinical report emphasizes the need to ensure perinatal HIV testing for every pregnant person. Those who are known to be living with HIV or who are newly diagnosed should be linked to treatment. Those at high risk of acquiring HIV should be provided pre-exposure prophylaxis (PrEP) medications.
The report also outlines guidance on infant feeding when the HIV status of the pregnant person is unknown or testing is done at delivery.
Recent studies have shown that when breastfeeding individuals with HIV are on continuous ART or when the infant receives preventive medications throughout breastfeeding, the risk of HIV transmission is less than 1%. As a result, the Centers for Disease Control and Prevention and the Department of Health and Human Services support shared decision-making regarding infant feeding in people with HIV in certain situations.
Similarly, the AAP has updated its recommendations. While avoiding human milk is the only infant feeding method that has zero risk of HIV transmission, the AAP recommends supporting individuals on ART with undetectable viral loads who want to breastfeed.
The clinical report provides practical guidance for pediatric health care professionals, as part of a multidisciplinary team, in providing evidence-based infant feeding counseling and care for people with HIV who choose to breastfeed and their infants.
Key actions for pediatric providers
- Be prepared to counsel people with HIV who express a desire to breastfeed their infant.
- Support people with HIV who want to breastfeed if they meet all of the following criteria:
- initiated ART early in or prior to pregnancy,
- maintain viral suppression (HIV viral load <50 copies/milliliter),
- have continuous ART access and
- are committed to taking ART consistently throughout breastfeeding.
- Recommend exclusive breastfeeding through the first six months, continuous ART and regular viral load testing for the breastfeeding parent, gradual weaning over two to four weeks, and infant prophylaxis in consultation with a pediatric HIV expert to reduce the risk of HIV transmission via breastfeeding.
- Counsel pregnant and postpartum people who are at high risk of acquiring HIV (e.g., people who inject drugs or who have sexual partners living with HIV who are not virally suppressed) regarding the potential risk of HIV transmission to an infant through human milk if HIV acquisition were to occur while breastfeeding. Additionally, offer PrEP and frequent HIV testing (e.g., every three months) throughout pregnancy and breastfeeding.
Dr. Abuogi is the lead author of the clinical report and a member of the AAP Committee on Pediatric and Adolescent HIV.
Resources
- The clinical report at https://doi.org/10.1542/peds.2024-066843 includes links to resources and additional U.S. guidelines on infant feeding and HIV.
- Health care professionals can consult with a perinatal HIV expert by calling the National Clinical Consultation Center at 1-888-448-8765.
