Physicians caring for infants born to women infected with HIV are likely to be involved in providing guidance to HIV-infected mothers on appropriate infant feeding practices. It is critical that physicians are aware of the HIV transmission risk from human milk and the current recommendations for feeding HIV-exposed infants in the United States. Because 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.
Breastfeeding provides numerous health benefits to infants. In addition to providing optimal infant nutrition, human milk contains immune-modulating factors that protect against morbidity and mortality from infectious diseases, particularly those causing respiratory and gastrointestinal tract illnesses, which is especially important for infants living in resource-limited countries where infectious diseases are a major cause of infant mortality.1 The American Academy of Pediatrics (AAP) strongly supports exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.2
Given that each year, approximately 8700 HIV-infected women give birth in the United States,3 it is critical that physicians are aware of the HIV transmission risk from human milk and the current recommendations for feeding HIV-exposed infants in the United States. HIV can be transmitted from mother to child through human milk, with ongoing risk of infection throughout the breastfeeding period.4 In the absence of antiretroviral prophylaxis, postnatal infection risk appears to be highest in the first 4 to 6 weeks of life, ranging from 0.7% to 1% per week.5,–7 However, risk continues for the duration of breastfeeding; in 2 large studies, late postnatal transmission risk after 4 to 6 weeks of age was 8.9 infections per 100 child-years of breastfeeding (approximately 0.17%/week) and was constant throughout this period.4,8 Transmission risk is higher for women who acquire HIV infection (acute HIV infection) during lactation than for women with preexisting infection9; in 1 study, the cumulative risk of transmission of HIV via human milk was 14% from mothers with chronic HIV infection compared with 25% to 30% among mothers who acquired HIV during late pregnancy or lactation.8 Other factors associated with increased risk of HIV transmission via human milk include high maternal plasma and human milk viral load, low maternal CD4+ cell count, longer breastfeeding duration, breast abnormalities (eg, mastitis, nipple abnormalities), oral lesions in the infant, mixed breastfeeding and formula feeding in the first few months of life (compared with exclusive breastfeeding), and abrupt weaning.7
Recent studies in Africa have revealed that 6 months of antiretroviral prophylaxis, either daily infant nevirapine or a triple-drug antiretroviral regimen administered to the mother, significantly reduced postnatal transmission risk to 1% to 5%.10 On the basis of these data, the World Health Organization (WHO) published revised feeding guidelines for infants born to HIV-infected mothers living in resource-limited settings where infectious disease and malnutrition are major causes of infant mortality and replacement feeding is not feasible. In such settings, the WHO recommends exclusive breastfeeding for the first 6 months of life, followed by complementary foods and breastfeeding through 12 months of age, accompanied by postnatal infant or maternal antiretroviral prophylaxis to reduce HIV transmission during breastfeeding.11,12
However, neither infant nor maternal postpartum antiretroviral prophylaxis completely eliminates the risk of HIV transmission via human milk. In the United States, with current interventions, mother-to-child HIV transmission during pregnancy and labor is very low at under 1%.13 Breastfeeding transmission rates with antiretroviral prophylaxis administered to either the infant or the mother, although low, are still 1% to 5%, and transmission can occur despite undetectable maternal plasma RNA concentrations.14 Maternal prophylaxis with triple-drug regimens may be less effective if first started during the postpartum period or late in pregnancy, because it takes several weeks to months before full viral suppression in human milk is achieved.15,16 Antiretroviral drugs taken by the mother have differential penetration into human milk, with some drugs achieving concentrations much higher or lower than maternal plasma concentrations.10,17 Although clinical trials of maternal antiretroviral prophylaxis to prevent postnatal transmission in resource-limited countries have generally shown low infant toxicity, increased rates of severe infant anemia and development of multiclass antiretroviral drug resistance in infants infected despite prophylaxis have been reported.18,19 Therefore, in the United States, where there is access to clean water and affordable replacement feeding, the AAP continues to recommend complete avoidance of breastfeeding as the best and safest infant feeding option for HIV-infected mothers, regardless of maternal viral load and antiretroviral therapy.
An HIV-infected woman receiving effective antiretroviral therapy with repeatedly undetectable HIV viral loads in rare circumstances may choose to breastfeed despite intensive counseling.20 This rare circumstance (an HIV-infected mother on effective treatment and fully suppressed who chooses to breastfeed) generally does not constitute grounds for an automatic referral to Child Protective Services agencies. Although this approach is not recommended, 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 by nucleic acid (plasma HIV RNA or DNA) amplification testing throughout lactation and at 4 to 6 weeks and 3 and 6 months after weaning. Breastfeeding by an infected mother with detectable viral load or receiving no antiretroviral therapy despite intensive counseling represents a difficult ethical problem that requires consultation with a team of experts to engage the mother in a culturally effective manner that seeks to address both her health as well as her child’s.
The optimal strategy for management of breastfeeding women with suspected acute HIV infection is unknown. In such circumstances, the mother should undergo appropriate evaluation (ie, plasma HIV RNA test as well as an HIV antibody test, because the antibody test result may be negative in acute infection), and breastfeeding should be stopped until HIV infection is confirmed or ruled out. Mothers should be assisted to pump and store expressed milk until a confirmatory test result is available and supported with skin-to-skin care to maintain milk supply; if HIV infection is ruled out, breastfeeding can resume. If the mother is found to be HIV infected, the infant should undergo age-appropriate HIV diagnostic testing evaluation, with follow-up testing at 4 to 6 weeks and 3 and 6 months after breastfeeding cessation if the initial test result is negative.13
The use of antiretroviral postexposure prophylaxis (PEP) has not been studied in infants born to mothers with acute HIV infection. Infant PEP may be less effective in this circumstance compared with other nonoccupational exposures, because human milk exposure is likely to have occurred over a prolonged period rather than from a single exposure. A regimen of daily nevirapine given to breastfeeding infants born to women with chronic HIV infection significantly reduces postnatal infection.10 Whether a combination infant regimen would be more effective is unknown. In a study of infant prophylaxis in Malawi, the combination of daily nevirapine and zidovudine was not more effective in reducing transmission and was associated with more hematologic toxicity.21 Some experts recommend providing a combination 3-drug regimen to exposed infants that is effective for treatment in HIV-infected infants. The appropriate prophylaxis duration is unknown; 4 weeks is used for nonoccupational exposure PEP. Consultation with a pediatric HIV expert is recommended with regard to decisions about the use of PEP for infants of breastfeeding women diagnosed with acute HIV infection; the National Perinatal HIV Hotline (1-888-448-8765) is a federally funded service providing referrals and free clinical consultation to physicians providing care for HIV-infected women and their infants.
The use of expressed human milk for the nutrition of sick, preterm, and recuperating neonates in ICUs is common practice, and some mothers express milk for feeding their infants in child care settings. The potential for transmission of infectious agents, such as HIV, through donor milk requires appropriate selection and screening of donors and careful collection, processing, and storage of milk. Donor human milk banks that belong to the Human Milk Banking Association of North America (http://www.hmbana.org/) voluntarily follow guidelines of the Centers for Disease Control and Prevention (CDC), which include screening of donors for infectious transmissible agents as well as heat treatment of the milk. Holder pasteurization (ie, heating at 62.5°C for >30 minutes) is the only method that completely eradicates HIV in all human milk components and is the current standard in human donor milk banks in the United States. Flash-heat pasteurization (heating milk in a water bath to 100°C and removing it when water reaches a rolling boil, then allowing it to cool) has been recommended as a potential method for pasteurizing human milk in developing countries, because it is more feasible for caregivers and preserves more nutritive elements. However, although flash-heat pasteurization destroys cell-free HIV, it does not destroy cell-associated HIV in human milk22; therefore, in the United States, where there is access to clean water and affordable replacement feeding, infant feeding of expressed flash-heat–treated human milk from HIV-infected women is not recommended. Informal milk-sharing practices (ie, person-to-person or Internet sharing) are discouraged, because formal procedures for donor laboratory screening and pasteurization of milk cannot be guaranteed through such venues (http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/PediatricAdvisoryCommittee/UCM238627.pdf).23 Gloves are not recommended for the routine handling of expressed human milk but should be worn by health care workers in situations in which exposures to human milk might be frequent or prolonged, such as in human milk banking.
Recommendations for management of accidental exposure of an infant to human milk not obtained from his or her mother are available from the CDC (http://www.cdc.gov/breastfeeding). Risk of HIV transmission in the case of an infant consuming human milk from a woman other than the mother in the United States is low, because women with known HIV infection are advised not to breastfeed their infants, HIV screening of milk donors and heat treatment of human milk is performed by milk banks, and HIV transmission from a single human milk exposure has not been documented.
In 2009, the CDC reported late HIV transmission events in infancy among 3 HIV-infected children suspected to have acquired HIV infection as a result of consuming premasticated (prechewed) food given to them by their HIV-infected caregivers.24 Phylogenetic comparisons of virus from cases and suspected sources and supporting clinical history and investigations suggest that the feeding of premasticated foods to the infants was the route of transmission. Subsequent investigation has identified additional children with potential HIV acquisition through premastication.25 In a cross-sectional survey of primary caregivers of HIV-exposed infants 6 months of age or older from 9 pediatric clinics in the United States, 31% reported that the child had received premasticated food from either themselves, someone else, or both. Most primary caregivers were biological mothers and were HIV infected. Physicians should routinely inquire about this feeding practice and should instruct HIV-infected caregivers on potential risks, including premastication, as well as safer feeding options.
When making infant feeding recommendations, physicians should be aware of the potential for HIV transmission through human milk; knowledge of maternal HIV serostatus is essential to determine whether breastfeeding is appropriate. The WHO has developed recommendations for breastfeeding in resource-limited countries.11,12 The following recommendations are made by the AAP for the United States, where the risks of infectious diseases and malnutrition for infants who are not breastfed are outweighed by the risks of HIV transmission through human milk and where alternatives to breastfeeding are available. The CDC and the AAP recommend universal opt-out HIV screening of all pregnant women in the United States.26,27 Because 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 AAP recommends that HIV-infected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy.
Women and their physicians need to be aware of the potential risk of HIV transmission to infants during pregnancy, during labor and delivery, and from breastfeeding.
Documented routine, opt-out HIV antibody testing should be performed for all women seeking prenatal care in the United States. Knowledge of HIV infection status will facilitate implementation of measures to prevent the acquisition and transmission of HIV and can help to determine whether it is appropriate to breastfeed. Repeat testing may be considered for all HIV-seronegative women in the third trimester and is recommended for women receiving care in jurisdictions with high HIV prevalence (see http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm), for women delivering in health care facilities with an HIV infection prevalence of ≥1 per 1000 pregnant women, for women at increased risk of HIV acquisition, and for women with signs or symptoms of acute HIV infection.
For women in labor with undocumented HIV status during the current pregnancy, maternal HIV antibody testing with opt-out consent by using a rapid HIV test is recommended. Rapid antibody testing of the mother, by using either blood or saliva, is preferred over rapid testing of the infant; saliva HIV antibody testing should not be used for infant testing. A positive rapid test result should be confirmed by a standard HIV antibody test. Women with a positive HIV rapid antibody test result should promptly begin receiving antiretroviral prophylaxis to prevent intrapartum transmission (and their infants should receive prophylaxis), without waiting for results of the confirmatory test, and should be advised not to breastfeed. Mothers with a positive HIV rapid test result should be assisted to pump and store expressed human milk until a confirmatory test result is available and supported with skin-to-skin care to maintain milk supply; if HIV infection is ruled out, antiretroviral prophylaxis should be stopped and breastfeeding should be initiated. Women with a negative HIV rapid test result can initiate breastfeeding.
In the rare situation in which rapid HIV testing during labor is not immediately available, women with unknown HIV status should be counseled, with documentation in the medical record, regarding the potential high risk of HIV transmission through human milk should she be infected, and that an HIV test would be advised before initiation of breastfeeding.
In the United States, HIV-infected women should be counseled not to breastfeed or to provide their milk for the nutrition of their own or other infants, regardless of antiretroviral drug use or viral load; the discussion should be documented in the medical record. If financial resources are identified as a barrier to avoiding breastfeeding, physicians should assist in identifying appropriate financial support to access infant formula (eg, application to the Special Supplemental Nutrition Program for Women, Infants, and Children; http://www.fns.usda.gov/wic).
Women who are HIV seronegative should be strongly encouraged to exclusively breastfeed their infants.
Women who are HIV seronegative but who are at particularly high risk of seroconversion (eg, injection drug users or sexual partners of known HIV-infected persons or active drug users) should have repeat HIV testing and be provided education about HIV and the risk of transmission through human milk and should be provided an individualized recommendation concerning the appropriateness of breastfeeding.
In postpartum lactating women with suspected acute HIV infection, breastfeeding should be stopped until HIV infection is confirmed or ruled out. Pumping and temporarily discarding human milk can be recommended, and if HIV infection is ruled out, breastfeeding can resume. If maternal HIV infection is confirmed, the infant should undergo HIV testing. Consultation with a pediatric HIV expert is recommended regarding decisions about postexposure antiretroviral prophylaxis for the infant.
NICUs should develop polices for use of expressed milk for nutrition of neonates. Current standards of the Occupational Safety and Health Administration do not require gloves for routine handling of expressed human milk. However, gloves should be worn by health care workers in situations in which exposure to human milk might be frequent or prolonged (eg, human milk banking).
Human milk banks should follow guidelines developed by the US Public Health Service, which include donor screening for HIV infection and assessing risk factors that predispose to infection, as well as pasteurization of all human milk specimens.
Physicians should routinely inquire about premastication and prewarming feeding practices and instruct HIV-infected caregivers on safer feeding options.
Lynne M. Mofenson, MD
Committee on Pediatric AIDS, 2011–2012
Patricia M. Flynn, MD, Chairperson
Grace M. Aldrovandi, MD
Ellen Gould Chadwick, MD
Rana Chakraborty, MD
Ellen Rae Cooper, MD
Heidi Schwarzwald, MD
Jaime Martinez, MD
Russell B. Van Dyke, MD
Kenneth L. Dominguez, MD, MPH – Centers for Disease Control and Prevention
Lynne M. Mofenson, MD – National Institute of Child Health and Human Development
Gordon E. Schutze, MD
Anjie Emanuel, MPH
American Academy of Pediatrics
Centers for Disease Control and Prevention
World Health Organization
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Policy on Infant Feeding and Transmission of HIV Cites Outdated Information About Breastmilk Pasteurization
We read with great interest the Policy on Infant Feeding and Transmission of HIV in the United States published in the February 2013 issue of Pediatrics.(1)
Our major concern relates to the erroneous statement regarding flash- heat pasteurization not destroying cell-associated HIV in human milk. The committee wrote that 'Holder pasteurization (i.e. heating at 62.5 degrees C for > 30 minutes) is the only method that completely eradicates HIV in all human milk components and is the current standard in human donor milk banks in the United States. Flash-heat pasteurization (heating milk in a water bath to 100 degrees C [sic] and removing it when water reaches a rolling boil, then allowing it to cool) ... destroys cell-free HIV, [but] it does not destroy cell-associated HIV in human milk', citing a study by Orloff et al.(2)
First, it is important to note that the correct flash-heat procedure involves heating the water to 100 degrees C, not the milk. Further, Orloff et al. examined only temperatures of 56 degrees and 62.5 degrees C; this is known as low-temperature, long-time (LTLT) pasteurization. High- temperature short-time (HTST) methods, which typically utilize temperatures of 72 degrees C and are known commercially as flash pasteurization, were not tested by this group. Data suggest that HTST pasteurization, upon which flash-heat methodology is based, is effective at antimicrobial elimination while retaining breastmilk's protective elements.(3) Cost has historically prevented wide-scale use of flash- pasteurization. Given the current use of flash-heat in neonatal wards and milk banks in South Africa, as well as in homes in resource-poor settings elsewhere, we feel compelled to clarify that the inactivation of high- titer cell-associated virus has actually been demonstrated using flash- heat.(4,5) Indeed, flash-heated milk typically reaches 72 degrees C (the temperature used for commercial flash-pasteurization) or higher.
Further, the committee notes that in the unusual situation in which an HIV-infected mother in the U.S. who is on antiretroviral therapy and has undetectable viral load exclusively breastfeeds her infant against recommendations should be closely monitored but does not automatically indicate referral to Child Protective Services. We would like to point out that the small risk of transmission could be further reduced in this situation by the use of flash-heating expressed breastmilk.
Caroline J. Chantry MD Professor of Clinical Pediatrics University of California Davis Medical Center
Carl V. Hanson PhD Chief, Retroviral Disease Section, Viral and Rickettsial Disease Laboratory Center for Infectious Diseases California Department of Public Health
Kiersten Israel-Ballard, DrPH Technical Officer, Maternal and Child Health/Nutrition PATH
Sera L. Young PhD Research Scientist, Division of Nutritional Sciences Cornell University
1. Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics. 2013; 131:391-6.
2. Orloff SL, Wallingford JC, McDougal JS. Inactivation of human immunodeficiency virus type 1 in human milk: effects of intrinsic factors in human milk and of pasteurization. J Hum Lact. 1993;9(1):13-17.
3. Baro C, Giribaldi M, Arslanoglu S et al. Effect of two pasteurization methods on the protein content of human milk. Front Biosci (Elite Ed). 2011;1(3):818-29.
4. Volk ML, Hanson CV, Israel-Ballard K, Chantry CJ. Inactivation of cell-associated and cell-free HIV-1 by flash-heat treatment of breast milk. J Acquir Immune Defic Syndr. 2010;53(5):665-6.
5. Volk ML, Gesner M, Sheppard HW, Donovan R, Hanson CV, Abrams B, Israel-Ballard K, Chantry CJ. Flash-heat inactivation of HIV-1 in breastmilk. AIDS 2008 - XVII International AIDS Conference: Abstract no. MOPE0504. Accessed February 24, 2013.
Conflict of Interest:
Re:Re:Breastfeeding by HIV-infected women in the USA
Infant formula is not the safest feeding option; its use doubles the risk of SIDS (Vennemann 2009 Pediatrics), and plays a significant role in the development of obesity and diabetes.
Women deserve a full range of options. Our public health system should support the HIV+ mothers who want to breastfeed. From a life course perspective, a baby fed in the best way has the foundation for a healthy life.
It is odd to read about what the rest of the world is doing, and then have to say "except in the USA."
Conflict of Interest:
Re:Breastfeeding by HIV-infected women in the USA
To the Editor:
We would like to thank Dr. Greiner for his comments on the Committee on Pediatric AIDS Policy Statement on Infant Feeding and Transmission of Human Immunodeficiency Virus.
Dr. Greiner notes that in several studies of maternal triple antiretroviral prophylaxis of breast milk transmission, the transmissions that did occur were secondary to lack of maternal adherence to the regimen. While a number of studies of maternal triple antiretroviral prophylaxis have shown residual postnatal transmission rates ranging from <1% to 4% (1-3), we agree that adherence is a major issue. A recent meta-analysis of adherence to antiretroviral drugs during pregnancy involving 51 studies with 20,153 HIV-infected pregnant women defined "adequate adherence" as taking more than 80% of prescribed medication doses and reported adherence as only 73.5% (4). The estimated adherence was significantly lower during the postpartum period (53%, 95% confidence interval [CI] 32.8-72.7%) than antepartum period (75.7%, 95% confidence interval 71.5-79.7%). Therefore, achieving adequate adherence to antiretroviral therapy in pregnancy is a challenge, and becomes especially challenging in the postpartum period. Thus, lack of adherence is not an uncommon problem. Given the availability of safe replacement feeding in the United States, in the vast majority of situations the risk of potential transmission outweighs the potential benefits of breastfeeding in an HIV-infected women regardless of antiretroviral therapy. In the rare instance where a mother despite intensive counseling decides to breastfeed, careful attention to supporting maternal adherence and monitoring of viral load will be essential to prevent transmission to the infant.
1. Chasela CS, Hudgens MG, Jamieson DJ et al. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med 2010;362:2271-81.
2. Kesho Bora Study Group. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora Study): a randomised controlled trial. Lancet Infect Dis 2011;11:171-80.
3. Thomas TK, Masaba R, Borkowf CB, et al. Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding - the Kisumu Breastfeeding Study, Kenya: a clinical trial. PLos Med 2011;8:e1001015. 4. Nachega JB, Uthoman OA, Anderson J et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle- income and high-income countries: a systematic review and meta-analysis. AIDS 2012;26:2039-52.
Conflict of Interest:
Breastfeeding by HIV-infected women in the USA
In December 1998, a mother recently diagnosed as HIV-positive lost legal custody of her newborn to the State of Oregon because she wanted to breastfeed. (1) She was charged with Intent to Harm and, in order to retain physical custody, the mother had to agree not to breastfeed, nor to feed her baby any stored breastmilk.
Recent publication of the American Academy of Pediatrics' (AAP) policy document on HIV and infant feeding (2) may prevent such an eventuality from happening again, at least under certain conditions. While the guidance contains a clear recommendation, echoing national policy since 1985, that HIV-infected mothers should formula-feed, it also provides for some flexibility; an HIV-infected mother living in the United States, on effective treatment and with full viral suppression, may still wish to breastfeed, and this does not constitute automatic grounds for referral to child protective agencies.
Instead, a pediatric HIV expert should be consulted about how to minimize transmission risk, including through exclusive breastfeeding, careful monitoring of maternal viral load, adherence to maternal ART, prompt treatment of any clinical mastitis, and infant HIV-testing throughout lactation and at 4-6 weeks and 3-6 months after cessation of breastfeeding.
This wording reflects recent research outlined in current global HIV and infant feeding and antiretroviral (ART) recommendations. It has important implications for healthcare providers, who are to make a clear infant feeding recommendation to HIV-infected mothers, but ultimately support the mothers' choices.
We would point out that while the AAP statement cites a paper by Shapiro et al. (3) as evidence that postnatal transmission can occur even with full ART and undetectable viral load, these safeguards were not in place for the 2/709 mothers who transmitted postnatally in that study. One mother had medication adherence issues. The other had a baseline viral load of 171,000 copies/mL at recruitment at ~28 weeks of pregnancy, received antenatal HAART for <4 weeks before delivery at 32 weeks' gestation, and had a detectable HIV-1 plasma RNA of 257 copies/mL at commencement of breastfeeding.
Confirmatory results from a more recent pilot program involving 194 Zambian HIV-positive women and their infants (4) also showed that the only postnatal transmissions during not only 6 months exclusive breastfeeding but also 6 months of continued breastfeeding, occurred in women who were non-adherent to their medications.
The effectiveness of full ART in preventing vertical transmission is achieved by maternal adherence to antiretroviral regimens for at least 13 weeks prior to delivery. (5) Women on HAART for <4 weeks may have a 5.2 -fold increased odds of HIV transmission.
The AAP decision to accommodate the option of breastfeeding in the context of HIV will enable careful monitoring and documentation of outcomes in resource-rich settings. Since nearly all research on postnatal transmission of HIV to date has, of necessity, come from developing countries, such data are currently lacking. The new policy constitutes a far-reaching and enlightened revision for which the AAP can be congratulated.
1. Kent G. Tested in Court: The Right to Breastfeed. SCN News. 1999;18:89-90. 2. American Academy of Pediatrics, Infant feeding and transmission of HIV in the United States, Pediatrics, DOI: 10.1542/peds.2012-3543, 28 Jan 2013. Available at http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012- 3543.full.pdf+html. Accessed January 28, 2013 3. Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral Regimens in Pregnancy and Breast-Feeding in Botswana. New England Journal of Medicine 2010;362:2282-94. 4. Silverman MS. Interim Results of HIV Transmission Rates Using a Lopinavir/ritonavir based regimen and the New WHO Breast Feeding Guidelines for PMTCT of HIV [abstr. H1-1153] Presented at: International Congress of Antimicrobial Agents and Chemotherapy (ICAAC) Chicago IL, Sep19, 2011. 5. Chibwesha CJ, Giganti MJ, Putta N, et al. Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr. 2011;58(2):224-8. doi: 10.1097/QAI.0b013e318229147e.
Conflict of Interest: