Pamela Morrison, IBCLC, West Sussex, England
La Leche League Leaders occasionally receive requests for information about whether mothers who have tested positive for the Human Immunodeficiency Virus (HIV) can breastfeed their babies.
Although the discovery that the virus can be passed from mothers to babies during breastfeeding was made in 1985, the original international advice from the World Health Organization (WHO) was that breastfeeding should continue, since the risk of death from acquisition of the virus through mother’s milk was less than the risk to babies when breastfeeding was withheld. It was not until 1997 that this recommendation changed to suggest that when formula feeding could be made acceptable, affordable, feasible, sustainable and safe, then there was less risk to babies when breastfeeding was withheld.
By 2010 WHO and UNICEF (United Nations International Children’s Emergency Fund) issued new recommendations on breastfeeding with HIV which were seen as “transformational.” All mothers who tested HIV-positive (HIV+) should receive effective antiretroviral treatment (ART) from the time of diagnosis, whenever that occurred, and such treatment should continue for life, enabling mothers to protect their own health and live a normal life span. Underpinning the new 2010 guidance was research demonstrating that when mothers received effective ART, the level of virus in their blood (their viral load) could be suppressed to undetectable levels. This meant that the risk of transmission of HIV during a vaginal birth could be reduced to <1%. Importantly, with maternal ART and six months exclusive breastfeeding (meaning that the baby receives no foods and liquids except breast milk, not even water) the risk of postpartum transmission of the virus could also be reduced to virtually zero. This was in line with global breastfeeding recommendations outside the context of HIV. Thereafter breastfeeding should continue with the addition of household weaning foods for up to 12 months. In 2016, WHO extended the recommended duration of breastfeeding for HIV+ mothers to 24 months.
In spite of this guidance, it is often believed that a diagnosis of HIV precludes breastfeeding. It needs to be acknowledged that in the era of effective antiretroviral treatment, fears of transmission through breastfeeding are often exaggerated, while the risks of formula-feeding are down played.
The British HIV Association (BHIVA) issued guidance on HIV and infant feeding in 2011, suggesting that while the usual advice was formula-feeding, if HIV+ mothers chose to breastfeed then they should be supported to do so. This guidance was revisited in 2014 and 2017, and at the end of 2018, after being under consultation for over a year, the British HIV Association issued two final guidance documents.   BHIVA is clear in its latest update that while formula-feeding is the usual advice, it is certainly envisaged that mothers living with HIV in the United Kingdom may want to breastfeed and—if they do—then there are fairly detailed recommendations on how to support them.
In 2013 the American Academy of Pediatrics issued recommendations outlining that support should be given to HIV+ mothers who wanted to breastfeed.  While formula-feeding is described as the initial option, later in the document, specific strategies for support and care of breastfeeding mothers and their babies are clearly outlined.
Current recommendations from the US Centers for Disease Control and Prevention (CDC) specify:
“In the United States, to prevent HIV transmission, HIV-infected mothers should not breastfeed their infants. The best way to prevent transmission of HIV to an infant through breast milk is to not breastfeed. In the United States, where mothers have access to clean water and affordable replacement feeding (infant formula), CDC and the American Academy of Pediatrics recommend that HIV-infected mothers completely avoid breastfeeding their infants, regardless of ART and maternal viral load. Healthcare providers should be aware that some mothers with HIV may experience social or cultural pressure to breastfeed. These mothers may need ongoing feeding guidance and/or emotional support.” 
For those who would like a more in-depth exploration of breastfeeding in the context of HIV, in July 2018 the World Alliance for Breastfeeding Action (WABA), published an update of their HIV Kit, originally issued in 2012, which contains a wealth of information from many angles. 
In early December 2018, the Thousand Days project also published a piece outlining five things you need to know about breastfeeding and HIV.
Finally, reminding us that this is a breastfeeding situation which is still current and in need of continuing clarification, in late 2018 the Global Breastfeeding Collective published a new call to action on HIV and breastfeeding. Led by UNICEF and WHO, the Global Breastfeeding Collective is a partnership of more than 20 prominent international agencies calling on donors, policy makers, philanthropists and civil society to increase investment in breastfeeding worldwide. The Collective’s vision is a world in which all mothers have the technical, financial, emotional and public support they need to breastfeed.
The Global Breastfeeding Collective HIV and Breastfeeding Advocacy Brief outlines key messages and key facts that can be used when sharing information with parents and their health care providers:
“Mothers living with HIV can breastfeed without negative consequences for their own health and the health of their children. When these mothers take antiretroviral medicine consistently throughout the breastfeeding period, the risk of transmitting HIV to their children is extremely low.
“WHO and UNICEF’s 2016 revised guidelines on infant feeding and HIV clarify that antiretroviral therapy (ART) is effective at vastly reducing virus transmission during pregnancy and breastfeeding. It is strongly recommended that pregnant and breastfeeding women living with HIV enroll in care and initiate ART to protect their own health and reduce the risk of HIV transmission to their babies.
“. . . In settings where breastfeeding with ART is recommended, the WHO/UNICEF guidelines for optimal breastfeeding are the same as those for all mothers and babies: breastfeeding initiated within the first hour after birth, exclusive breastfeeding for the first 6 months and continued breastfeeding for 2 years or longer.”
What does this mean for LLL Leaders? Leaders helping mothers with questions about HIV and breastfeeding can refer them to the most up-to-date recommendations for the country in which they live. Mothers, in turn, should seek the help, support and advice of their HIV clinicians, doctors, obstetricians and pediatricians.
In the light of new data, child protection measures are no longer recommended. To reduce her viral levels to undetectable, thereby rendering her infectivity to her baby as untransmissable, the mother with HIV needs to receive full antiretroviral therapy for approximately three months before delivery of her baby, and to adhere to her medication with no breaks. If she will be breastfeeding, she should seek help to exclusively breastfeed her baby for the first six months of life, with frequent follow-up and prompt treatment of any breastfeeding or breast problems and she should wean gradually when she is ready. Her baby should receive four to six weeks of antiretroviral prophylaxis after birth, and frequent monitoring of his HIV status, e.g., as a minimum, at birth, at four weeks of age and three months after weaning.
It is a great privilege to help a mother to achieve her breastfeeding goals, and nowhere is this more apparent than when working with mothers who have HIV. Thanks to current national and international guidance, HIV is no longer an automatic contraindication to breastfeeding, but we still have a little work to do in disseminating up-to-date recommendations.
How Leaders Can Help HIV+ Mothers Breastfeed
- Leaders helping mothers with questions about HIV and breastfeeding can refer them to the most up-to-date recommendations for the country in which they live. Working with a mother who is HIV+ in a decision making capacity about breastfeeding is usually beyond a Leaders’ primary role.
- Be sure the mother knows the importance of maintaining her treatment, both for herself and for the health of her baby. Encourage her to stay in close contact with her doctor.
- Emphasize the importance of exclusive breastfeeding for the first six months. Mixed feeding (with both breast milk and formula) is known to increase the risk of transmission of the virus to the breastfed baby. Exposure of the immature infant gut to foreign proteins in formula may cause inflammation and damage, thus increasing the risk of contact of any virus in the breast milk with the baby’s bloodstream.
- Provide information around the normal course of breastfeeding, including the principles of good positioning and attachment to avoid bleeding or damaged nipples, and how to protect a milk supply so that HIV+ mothers can produce sufficient breast milk to exclusively breastfeed for the first six months of life.
- Make sure the mother knows to watch the baby for hunger cues, not the clock. Skin-to-skin and frequent nursing can help assure a robust milk supply so supplements are not needed.
- Help the mother with any other breastfeeding concerns and provide emotional support.
- For support beyond encouragement and information about the normal course of breastfeeding the Leader can refer the mother to her health care professionals and a local International Board Certified Lactation Consultant (IBCLC) in her area.
In 1990 Pamela Morrison was certified as the first International Board Certified Lactation Consultant (IBCLC) in Zimbabwe where HIV-prevalence amongst pregnant women reached more than 30%. Pamela has been speaking and writing about breastfeeding in the context of HIV since 1995. She also served as a member of the Zimbabwe National Multi-sectoral Breastfeeding Committee, as a Baby Friendly Hospital Initiative trainer and assessor, and assisted with development of national World Health Organisation (WHO) Code legislation and HIV and Breastfeeding policy. She emigrated to Australia in 2003, moved to England in 2005 and worked for WABA for several years. She authored the 2012 WABA HIV and Breastfeeding Kit and co-authored the 2018 update.
 World Health Organization, Special Programme on AIDS statement, Breast-feeding/Breast milk and Human Immunodeficiency Virus (HIV) WHO/SPA/INF/87.8.
http://apps.who.int/iris/bitstream/handle/10665/60788/WHO_SPA_INF_87.8.pdf (accessed 24 November 2018)
 UNAIDS UNICEF WHO Policy Statement on HIV and Infant Feeding, Geneva 1997 (reproduced in Breastfeeding Review, 1999) https://www.ncbi.nlm.nih.gov/pubmed/10453706
 WHO 2010. Guidelines on HIV and Infant Feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. 1.Breast feeding 2.Infant nutrition 3.HIV infections – in infancy and childhood. 4.HIV infections – transmission. 5.Disease transmission, Vertical – prevention and control. 6.Infant formula. 7.Guidelines. I.World Health Organization. ISBN 978 92 4 159953 5. http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf
 WHO-UNICEF 2016, Guideline: Updates on HIV and Infant Feeding, http://apps.who.int/iris/bitstream/10665/246260/1/9789241549707-eng.pdf
 BHIVA 2018, British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (see page 84 onwards for section on infant feeding) https://www.bhiva.org/file/5bfd30be95deb/BHIVA-guidelines-for-the-management-of-HIV-in-pregnancy.pdf
 BHIVA 2018, General information on infant feeding for women living with HIV
 American Academy of Pediatrics, Committee on Pediatric AIDS, Infant feeding and transmission of HIV in the United States, COMMITTEE ON PEDIATRIC AIDS, Pediatrics 2013; 131:2 391-396; published ahead of print January 28, 2013, doi:10.1542/peds.2012-3543, Available at http://pediatrics.aappublications.org/content/131/2/391
 CDC, HIV and breastfeeding, https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hiv.html
 WABA, Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource, Second edition, published 14 July 2018,
http://waba.org.my/understanding-international-policy-on-hiv-and-breastfeeding-a-comprehensive-resource/ and at www.hivbreastfeeding.org
 Thousand Days, 5 things you need to know about breastfeeding and HIV, December 2018 https://thousanddays.org/5-things-you-need-to-know-about-breastfeeding-and-hiv/ (accessed 4 December 2018. )
 Global Breastfeeding Collective, ADVOCACY BRIEF, Breastfeeding and HIV https://www.unicef.org/nutrition/files/Global_Breastfeeding_Collective_Advocacy_Brief_Breastfeeding_and_HIV.pdf (accessed 4 December 2018)