Breastfeeding with HIV: Health advice for new and prospective mothers

The science of HIV transmission shows that people on effective HIV treatment cannot pass on HIV to their sexual partner. But what about breastfeeding?

For new and prospective mothers living with HIV, the health benefits of breastfeeding must be weighed up against the possible risks of passing on HIV through breast milk. Research suggests that with an undetectable viral load and engagement with ongoing clinical care, risk is minimal and can be considered alongside the health benefits of breast milk. Unfortunately, the waters are muddied by stigma, misconceptions, the limitations of research, and in some countries, criminalisation.

Why breastfeed?

According to the World Health Organisation (WHO), breastmilk is the ideal food for infants. It contains antibodies which help protect against many common childhood illnesses. For women in regions of the world where sanitation is an issue, the only water available to mix with baby formula can carry disease, pathogens or parasites, whereas breastmilk is clean and safe. Breastmilk provides all the energy and nutrients that the infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs for the first year of life. There is very strong research evidence showing that breastfeeding has many cognitive, functional and health benefits for the infant. The health benefits for mothers are also significant – women who breastfeed  recover more quickly post-pregnancy and have a reduced risk of breast and ovarian cancers.

Research into breastfeeding with HIV

Since 1991, there have been around 26 studies researching HIV transmission to babies through pregnancy and breastfeeding. These studies have included nearly 20,000 mothers with HIV and their babies. Not all mothers in these studies had undetectable virus while taking HIV medications. There are no Australian studies looking at HIV transmission rates through breastfeeding, largely because the number of women living with HIV and having babies in Australia at any given time is very small.

We now know that the risk of transmitting HIV through breastfeeding to your baby is extremely low when:

1. You are taking your HIV medication on time and as prescribed;
2. Your viral load has been undetectable during your pregnancy and remains undetectable while you are breastfeeding;
3. You are receiving regular medical care; and
4. You breastfeed for no more than six months.

A global context

For women in low and middle-income countries, where formula can be unaffordable and/or poor sanitation severely increases the risk of formula feeding, the benefits of breastfeeding can far outweigh the risks. In resource-limited settings, such as some parts of Africa, WHO recommends that mothers living with HIV breastfeed exclusively for the first six months of life and continue breastfeeding for at least 12 months, with the addition of complementary foods. Despite this, women living with HIV have faced prosecution for breastfeeding in many countries around the world, including in those countries where WHO actively recommends breastfeeding. In these circumstances, the weight of evidence has not been translated into gains for women’s rights and children’s wellbeing.

Breastfeeding with HIV in Australia

“Although medical and health experts agree that formula feeding is still the safest option, breastfeeding is increasingly being recognised as an option that may be open to some women.”

– NAPWHA, ‘Breastfeeding for women living with HIV in Australia’

In Australia, affordability and sanitation are unlikely to be concerns for breastfeeding mothers with HIV, but there is a growing case for informed choice due to the low risk of transmission and the established health benefits of breastfeeding for both mothers and infants. While there is a degree of risk to be considered, there are many women living with HIV in Australia and overseas who have safely breastfed their babies  in consultation with doctors and health professionals.

NAPWHA’s 2021 resource, Breastfeeding for women living with HIV in Australia, offers a snapshot of the risks and benefits of breastfeeding with HIV, as well as a decision making guide for women with HIV who are pregnant or thinking about having a child.  We also now have Australian guidance for health care providers that supports them to work with people with HIV to make shared decisions about breastfeeding. This guidance also contains a summary of research studies and other reference materials about HIV and breastfeeding that are relevant to the Australian context.

Health advice from peak HIV organisations

What does all this mean in simple terms for women in Victoria who are considering breastfeeding as an option? Living Positive Victoria and other organisations representing people living with HIV in Australia, including Positive Women Victoria and NAPWHA (National Association of People with HIV Australia), hold the position that:

1. Women living with HIV who are taking HIV medications (combination antiretroviral treatment), who have a suppressed HIV viral load (<50 copies) throughout pregnancy, and are under the care of a supportive, knowledgeable health practitioner, should be supported to consider the option of breastfeeding for up to six months
2. Breastfeeding is safest when women are supported by a strong healthcare team and have received clear information and counselling about strategies to prevent transmission of HIV through breastmilk in a way that is understandable to and culturally appropriate for the woman
3. Women living with HIV should be supported to make the decision about how to feed their baby without coercion or judgement, or legal interventions.

 

This article was written to mark World AIDS Day 2022, which shone a light on the particular experiences and issues facing women living with HIV. We are proud to support women with HIV to make informed choices about breastfeeding and live boldly positive.