HIV and Breastfeeding

Introduction to HIV and BreastfeedingI want to breastfeed but am so worried. I don’t want my baby to get HIVSome facts to help your decision process What if I have to be separated from my baby?What if I am unable to exclusively breastfeed for the first six months?What if I have cracked and bleeding nipples?What if my baby is also HIV-positive? Choosing not to breastfeed Heat Treating or Flash Heating of Expressed Breastmilk LLLI ResourcesReferences If you have tested positive for human immunodeficiency virus (HIV), you may wonder whether you can breastfeed your baby. Medical treatments for HIV have improved considerably, and the recommendations for infant feeding for babies of nursing parents with HIV have also changed. HIV infection is regarded now as a chronic condition, similar to diabetes or high blood pressure. When you take your HIV treatment as recommended, health authorities agree that you now have choices when it comes to feeding your baby. Having HIV does not necessarily mean that you cannot breastfeed.  (WHO, 2016,2021, 2023; South African Dept. of Health, 2019; WABA, n.d.;  Western Cape Gov’t Health, 2018; NIH 2023, 2024) According to the World Health Organization (WHO) breastfeeding is the recommended feeding option for all babies, including those who have mothers with HIV, as long as the mother takes antiretroviral treatment (ART, also referred to as ARV).  The WHO recommends exclusive breastfeeding for the first six months and continued breastfeeding for two years or longer. (WHO. 2016,2021, 2023;  South African Dept. of Health, 2019; Western Cape Gov’t Health, 2018) In the past, health agency recommendations in the USA and in Europe have been for HIV-positive mothers not to breastfeed. (Gross et al., 2019; European AIDS Clinical Society, 2020 ) Since 2010, British guidance has supported breastfeeding by individuals living with HIV who choose to do so. (Gilleece et al., 2022) The National Institutes of Health (NIH) in the USA has recently also updated its recommendations stating that people with HIV should receive evidence-based, patient-centered counseling about infant feeding. (NIH, 2023, 2024) It is true that HIV can be transmitted to a child during pregnancy, labor, and birth, and during breastfeeding. However, taking your ART medication as prescribed makes the risk of infecting your baby extremely low. (WHO. 2016;  South African Dept. of Health, 2019; WABA, n.d.; Western Cape Gov’t Health, 2018; NIH, 2023, 2024) A yearly HIV test is recommended for anyone at risk. (WHO, 2016; South African Dept. of Health, 2019; WABA. 2018; Western Cape Gov’t Health, 2018) Screening during early pregnancy helps to diagnose HIV infection in time for treatment to achieve an undetectable viral load before birth. The viral load is an indication of how much virus can be found in your blood. Viral loads of <50c/ml are regarded as being undetectable. (WHO, 2016; South African Dept. of Health, 2019) The 2023 NIH recommendations state that if a person is taking ART and has an undetectable viral load during at least the third trimester of pregnancy and childbirth, and continues to be ART adherent, the chances of the baby acquiring HIV are less than 1%. (NIH, 2023, 2024) It is very important that you continue your antiretroviral medication, go for regular health checks, and have your blood checked to monitor your viral load. The goal is for your viral load to be undetectable. Where possible, it is preferable to work with your healthcare provider when you are planning a pregnancy to get your viral load to an undetectable level before pregnancy. If this is not possible, you should aim to have your viral loads lowered to the undetectable range by the time your baby is born or earlier. (WHO. 2016; South African Dept. of Health, 2019; NIH, 2023, 2024; Chibwesha, 2011) First, please check on your own country’s guidelines. These do vary between countries. Medication availability and the feasibility of closely monitoring viral loads may also differ by location. Studies show that mothers who take their ARTs daily and have a suppressed viral load, have an extremely low (less than 1%) risk of transmission of HIV to their babies. (WHO. 2016;  South African Dept. of Health, 2019; WABA. 2018; Western Cape Gov’t Health, 2018;  NIH, 2023, 2024) Breastfeeding helps protect your baby from all sorts of infections, including diarrhea and pneumonia. These are two of the biggest reasons for babies getting seriously ill and sometimes dying.  (Chapman, 2016) Breastfeeding provides comfort, love and security to your baby. Breastfeeding is important for your own health and for your baby. Long -term breastfeeding offers protection to the nursing parent and to the baby from breast cancer, diabetes, hypertension and many other conditions. (Chapman, 2016) The most important benefit of exclusive breastfeeding is the reduction in the risk of HIV transmission and improved child survival. (Western Cape Gov’t Health, 2018) This means that on its own, exclusive breastfeeding reduces the risk to babies of HIV transmission, as well as giving the baby the best chance of good health and protection from many other infections. (WABA, n.d; Western Cape Gov’t Health, 2018) Exclusive breastfeeding for the first six months of a child’s life means that the baby gets nothing else to eat or drink other than breastmilk or medication. South Africa has the largest population of HIV-positive people in the world (around 8 million of its 60 million population in 2023). Some 20-25% are women in their child-bearing years. (Statistics South Africa, 2022)Over the five years (2017-2022), after the introduction of ART for all HIV-positive pregnant women, the risk of mother to child transmission was reduced to <1%. This means that 99% of all treated HIV-positive women did not pass on HIV to their babies. (Daniels et al, 2022; Haeri et al, 2023) The Centers for Disease Control (CDC) in the USA writes: “If a mother with HIV takes HIV medicine daily as prescribed throughout pregnancy and childbirth and gives HIV medicine to her baby for 4 to 6 weeks after giving birth, the risk of transmitting HIV to the baby can be less than 1%.” (CDC, 2024) The NIH concurs: “Achieving and maintaining viral suppression through antiretroviral treatment (ART) during pregnancy and postpartum decreases breastfeeding transmission risk to less than 1%.”  The NIH states that “Individuals with HIV who are on ART with a sustained undetectable viral load and who choose to breastfeed should be supported in this decision.” (NIH, 2023, 2024) The widespread recommendation for the baby to also receive some antiretroviral medication after birth acts as a further precaution regardless of whether you breastfeed or not. (WHO. 2016;  South African Dept. of Health, 2019; CDC, 2024; NIH 2023) A research review done in 2017 showed that if transmission occurred, most of these cases of transmission were mothers newly infected with HIV or who were not taking their ART medication as directed (UNAIDS, 2020). All across the world the number of babies acquiring HIV through breastfeeding is decreasing.  (Van de Perre, 2021) To summarize, all the studies so far show that the risk of postpartum transmission (through breastfeeding) can be reduced to almost zero if you: Sometimes breastfeeding is interrupted, due to returning to work or to school or hospitalization, for instance. The WHO says: “Mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practicing mixed feeding is not a reason to stop breastfeeding in the presence of ART drugs.” (WHO 2016;  South African Dept of Health, 2019; Western Cape Gov’t Health, 2018) Mixed feeding means that a baby receives both breastmilk and formula during the same period. If you are going to be separated from your baby, expressing, or pumping breastmilk, is an option that you could also consider. See our articles on Hand Expressing and Pumping Milk. The WHO states: “Mothers living with HIV and healthcare workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all” and “ART reduces the risk of postnatal HIV transmission in the context of mixed feeding.” (WHO 2016;  South African Dept of Health, 2019; Western Cape Gov’t Health, 2018) All La Leche League (LLL) Leaders have breastfed a baby for at least 12 months. Reach out to your local Leader to discuss your concerns. Options like expressing and storing breastmilk may be manageable with some planning and support. If unexpected separations like hospitalizations and other challenges occur, an LLL Leader can offer suggestions. The Leader can share examples of what has worked for other families. If you still feel unsure, speak to different breastfeeding helpers and your doctor to help you make an informed decision. (Adult Primary Care (APC) Guide 2019/2020 ) Getting breastfeeding off to a good start can help prevent the development of cracked and bleeding nipples. Holding your baby in skin-to-skin contact right after birth, for as long as possible, helps to get breastfeeding off to a good start. Skin-to-skin contact helps you both with your natural instincts to breastfeed. If your baby is latched on deeply and comfortably, there should be no pain, and less chance of getting cracked nipples. If you nevertheless get cracked or bleeding nipples, get help quickly from an experienced breastfeeding helper. If your viral load has been undetectable, and you are taking your antiretroviral medications as prescribed, there is an extremely low risk of transmission to your baby. If there is a concern about transmission, expressing milk and heat-treating it is another possible way of providing human milk. See below for instructions on how to heat-treat expressed breastmilk. Less than 1% of babies born to HIV-positive mothers become infected with HIV. (WHO. 2016;  South African Dept. of Health, 2019; CDC, 2024; NIH 2023) If your baby tests HIV-positive, there is absolutely no reason for you not to breastfeed. Breastfeeding takes care of feeding, drinking, comforting, teaching, protecting, brain development and growth – in one package and all without a price tag attached. Breastfeeding is better for an HIV-infected infant’s health, nutrition and survival. (WHO, 2016;  South African Dept. of Health, 2019; Western Cape Gov’t Health, 2018) Breastfeeding is recommended for two years and longer. It may help to know that babies, children and adults living with HIV can live a long healthy life if they take their ART treatment as prescribed and maintain a healthy lifestyle. If you are HIV-positive and decide not to breastfeed, make sure you understand and get information on: In circumstances where there is concern about transmission, expression and heat treatment of the expressed breastmilk is an option. 1.       Place expressed breastmilk in a (food grade) glass container. 2.       Place the glass jar inside a pot of water. The water level should be two finger widths higher than the milk. 3.       Place the pot onto a stove and quickly bring to the boil. 4.       Once the water is at a rapid, rolling boil, remove the pot from the stove immediately. 5.       Remove the jar from the pot (while protecting your hands from the heat). 6.       Allow the milk to cool down. July 2024 by Dr. Rahmat Bibi Bagus, Cape Town, South Africa Update on HIV and Breastfeeding, Pamela Morrison, 2019 Breastfeeding for HIV-Positive Mothers, Pamela Morrison, 2018 Bispo S, Chikhungu L, Rollins N, Siegfried N, Newell ML. (2017, Feb 22). Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. J Int AIDS Soc. 20(1):21251. doi: 10.7448/IAS.20.1.21251. PMID: 28362072; PMCID: PMC5467610. CDC. (2024, May 10). HIV and Breastfeeding. Breastfeeding Special Circumstances. https://www.cdc.gov/breastfeeding-special-circumstances/hcp/illnesses-con ditions/hiv.html Chantry CJ, Young SL, Rennie W, Ngonyani M, Mashio C, Israel-Ballard K, Peerson J, Nyambo M, Matee M, Ash D, Dewey K, Koniz-Booher P. (2012, May 1). Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 months of age in urban Tanzania, J.Acquir Immune Defic Syndr. 1;60(1):43-50. doi: 10.1097/QAI.0b013e31824fc06e. Chapman, S. (2016, Jan 29). Lancet Breastfeeding Series is a call to action. [Blog]. Cochrane UK. Chibwesha, Luoga E et al. (2018),Brief Report: No HIV Transmission From Virally Suppressed Mothers During Breastfeeding in Rural Tanzania. J Acquir Immune Defic Syndr, 2018;79(1):e17-e20, https://www.ncbi.nlm.nih.gov/pubmed/29781882 Chibwesha CJ, Giganti MJ, Putta N, Chintu N, Mulindwa J, Dorton BJ, Chi BH, Stringer JS, Stringer EM. (2011). Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr. 2011 Oct 1;58(2):224-8. doi: 10.1097/QAI.0b013e318229147e Daniels, B., Spooner, E., & Coutsoudis, A. (2022). Getting to under 1% vertical HIV transmission: lessons from a breastfeeding cohort in South Africa. BMJ Global Health, 7(9), e009927. https://doi.org/10.1136/bmjgh-2022-009927 European AIDS Clinical Society. (2020). Guidelines, version 10.1, https://www.eacsociety.org/files/guidelines-10.1_30032021_1.pdf Gilleece, Y., Byrne, L., Bamford, A., Lyall, H., Seery, P., & Tariq, S. (2022). Interim BHIVA position statement on HIV and mixed infant feeding. https://www.bhiva.org/file/639b0a86a19c7/BHIVA-position-statement-on-HI V-and-mixed-infant-feeding.pdf Gross, M. S., Taylor, H. A., Tomori, C., & Coleman, J. S. (2019). Breastfeeding with HIV: An Evidence-Based Case for New Policy. The Journal of Law, Medicine & Ethics, 47(1), 152–160. https://doi.org/10.1177/1073110519840495 Haeri, A. F., Murray, T. Y., Johnson, L. F., Ntloana, M., Tabisa Silere-Maqetseba, Guo, S., & Sherman, G. G., (2023). Eliminating Vertical Transmission of HIV in South Africa: Establishing a Baseline for the Global Alliance to End AIDS in Children. Diagnostics, 13(15), 2563–2563. https://doi.org/10.3390/diagnostics13152563 NIH, (2023), Infant Feeding for Individuals with HIV in the United States. Clinicalinfo.hiv.gov. NIH, (2024, January 31). Overview: Recommendations for Antiretroviral Drugs Use  During Pregnancy, Clinicalinfo.hiv.gov. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arv-dru gs-pregnancy-overview#:~:text=Overview South African National Department of Health, (2019). Guideline for the Prevention of Mother to Child Transmission of Communicable Infections. https://www.knowledgehub.org.za/system/files/elibdownloads/2019-10/PMT CT%20Guideline%2028%20October%20signed.pdf Adult Primary Care (APC) Guide (2019/2020) – Updated | Department of Health Knowledge Hub. Knowledgehub.health.gov.za, https://www.knowledgehub.org.za/elibrary/adult-primary-care-apc-guide-20 192020-updated Statistics South Africa. (2022) Mid-Year Population Estimates 2022, https://www.statssa.gov.za/publications/P0302/P03022022.pdf UNAIDS. (2020, Feb). How are babies becoming infected with HIV in Africa? https://www.unaids.org/en/resources/presscentre/featurestories/2020/febru ary/20200211_babies-becoming-infected-with-hiv-in-africa Van de Perre P, Goga A, Ngandu N, Nagot N, Moodley D, King R, Molès JP, Mosqueira B, Chirinda W, Scarlatti G, Tylleskär T, Dabis F, Gray G. (2021, April 3). Eliminating postnatal HIV transmission in high incidence areas: need for complementary biomedical interventions. Lancet.397(10281):1316-1324. doi: 10.1016/S0140-6736(21)00570-5. PMID: 33812490. Western Cape Government Health,(2018). Consolidated Guidelines for HIV Treatment. https://www.westerncape.gov.za/assets/departments/health/wc_hiv_consoli dated_guidelines_march_2018_0.pdf WABA. (n.d.), Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource. ( World Alliance for Breastfeeding Action. Retrieved June 26, 2024, from https://waba.org.my/understanding-international-policy-on-hiv-and-breastfe eding-a-comprehensive-resource/ WHO. (2016) Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. (n.d.). https://www.who.int/publications/i/item/9789241549707 WHO. (2021). HIV/AIDS: Infant feeding and nutrition. Www.who.int. https://www.who.int/news-room/q-a-detail/hiv-aids-infant-feeding-and-nutriti on WHO. (2023). Infant and young child feeding. World Health Organization.[Factsheet]