Pamela Morrison IBCLC
Originally published November 2014, updated and republished with the express permission of the author.
Recommendations from global health authorities endorse exclusive breastfeeding for all babies for the first six months of life and continued partial breastfeeding for up to two years or beyond. (1) Yet it is commonly believed that the one exception to this recommendation is the baby of a mother who has been diagnosed as HIV-infected, due to the fear that the mother may pass the virus to her baby in her milk. (2)
Most HIV-exposed babies are born in places where breastfeeding is the cultural norm and where formula-feeding is particularly unwelcome, unnatural and stigmatising. (3)
Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first six months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival. (4) In other words, recent research suggests that formula-feeding is more risky than breastfeeding with HIV. As more is known, an increasing number of HIV-positive mothers in industrialized countries are questioning whether the risk of HIV transmission through breastfeeding is as high as they have been led to believe and, if it is not, they are asking if they, too, can breastfeed.
What information will help these mothers to make an informed decision about whether breastfeeding will be safe for their babies? What research can they discuss with their doctors and HIV clinicians as they express their ambitions and ask for support?
How is the risk of breastfeeding-associated HIV transmission measured?
Firstly, it needs to be remembered that since 1985 breastfeeding in the context of HIV has received very bad press. Fears about early high-risk estimates of HIV transmission persist. But there is a great difference in transmission risk between a mother receiving effective antiretroviral therapy (ART) in 2014 (5) and the unfortunate mother of several decades ago for whom no drug therapy was available and the risk of postnatal transmission through any breastfeeding was estimated to be 15–30% higher than that of no breastfeeding. (6)
The transforming effect of effective antiretroviral therapy (ART)
A growing body of research shows that effective ART can not only improve the health of an infected individual so that he or she can enjoy a normal life-span, (7) but that treatment also constitutes an effective form of prevention between infected and uninfected members of a couple, and between an infected mother and her infant during pregnancy, birth or breastfeeding.
No cases of transmission of HIV were found during two years of follow-up of sero-discordant couples when the HIV-infected partner received and took antiretroviral medications. (8) Up-to-date World Health Organization guidance recommends that all women diagnosed as HIV-infected should receive immediate ART, which should be continued for life.5 HIV-infected expectant mothers who are diagnosed as HIV-positive during early pregnancy can receive a long enough course of ART to ensure that the number of viral copies in their blood becomes undetectable by their due date, posing a negligible risk of transmission of the virus during labor and delivery, and allowing them to have a normal vaginal birth. (9) The duration of treatment is important: a study published in 2011 (10) showed that ART needs to be taken for approximately 13 weeks to reduce the number of viral copies to levels that are no longer detectable on a standard HIV test; mothers who received ART for less than four weeks had a five-fold increased risk of HIV transmission to their babies.
The importance of exclusive breastfeeding in reducing the risk of postnatal HIV transmission was first established in a South African study published in 1999, (11) and subsequently confirmed amongst Zimbabwean infants in 2005. (12) In the latter study, compared with early mixed feeding (breast milk and other foods and liquids), exclusive breastfeeding (feeding only breast milk) reduced transmission by 75% in babies tested at six months. It was hypothesized that too-early feeding with other foods and liquids besides breast milk may disturb the normal infant gastrointestinal flora. (13) When babies are mixed fed, pathogens and dietary antigens in formula can cause small sites of damage and inflammation to the baby’s intestinal mucosa. Once the integrity of the baby’s gut has been compromised, it is easier for HIV in breast milk to cross the mucous membranes and to make contact with the baby’s bloodstream. On the other hand, protective components in mother’s milk, for example epidermal growth factor, can help the intestinal epithelial barrier to mature, thus helping to protect against infection with HIV.
When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding.
Normal mixed feeding after six months
As a result of the findings about the protective effects of exclusive breastfeeding during the first six months, concern was expressed about the possible dangers of HIV-transmission during normal mixed feeding after six months. As a result, HIV-positive mothers who elected to breastfeed were advised to practice what was called “early cessation of breastfeeding,” or premature weaning, as soon as practicable. (14, 15)
Subsequent studies have confirmed that after the recommended period of six months’ exclusive breastfeeding, continued partial breastfeeding with the addition of other foods and liquids, as recommended for babies outside the context of HIV, resulted in an extremely low risk of transmission in the 6–12 month period. (16, 17) Further studies from Zambia where maternal ART was initiated in early pregnancy and continued to 12 months postpartum, while infants were exclusively breastfed to six months and continued breastfeeding with complementary feeding from 6–12 months, resulted in postpartum HIV transmission rates of 1–2% at 12 months. (17, 18, 19) Confirmatory results showed that the only postnatal transmissions occurred in one infant at two weeks postpartum (19), which most likely occurred in utero, or in women who were non-adherent to their medications. (20)
What is the risk of not breastfeeding?
In spite of these excellent results, there remains a common assumption that because mothers living with HIV in industrialized countries such as Europe, North America and Australia have access to clean water and safe infant feeding alternatives, breastfeeding avoidance is free from risk. This may in part stem from misleading reporting of research (21) results but in fact, formula-fed babies experience higher rates of morbidity and mortality than their breastfed counterparts, even in industrialized countries. (22, 23, 24, 25, 26, 27, 28)
Current guidance in developed countries
In the industrialized countries of UK, Europe, Australia and Canada, a high percentage of mothers diagnosed as HIV-positive are immigrants from countries of high HIV-prevalence, particularly those in Eastern and Southern Africa. In recognition that their guidance needed to fit the population it was designed to assist, and following extensive consultation, the British HIV Association (BHIVA) published a revised position paper in 2011 stating that although formula-feeding remains the first recommendation for infant feeding in the context of HIV, when an HIV- positive mother with an undetectable viral load wishes to breastfeed, then she should be supported to do so. (29) BHIVA recommends that mothers who choose this option should practice exclusive breastfeeding for the first six months of life while receiving regular monitoring of maternal viral load and infant HIV status.
A similar relaxation of a formerly absolute prohibition of breastfeeding, and accompanying threats of imposition of child safe-guarding measures against mothers who did not comply, has also occurred in the USA. In early 2013, the American Academy of Pediatrics published revised recommendations to support breastfeeding by HIV-positive mothers when mothers are adherent to ART, achieve an undetectable viral load, and practice exclusive breastfeeding for the first six months, and the health of mother and baby are closely monitored and optimised. (30)
Supporting breastfeeding, even in the context of HIV?
Breastfeeding in the context of HIV is best planned meticulously. Antenatally, HIV-positive mothers need to be in touch with their physicians and HIV clinicians. They should discuss with them what they know of up-to-date research findings, including the risks and benefits of different feeding methods, the importance of ART, the duration of therapy, undetectable viral load, and ongoing adherence to their medications. They might also be advised to inform themselves about local and/or national HIV and infant feeding policy and to seek legal representation if there are likely to be any safe-guarding concerns or any threat of coercion to bottle-feed, as is occasionally reported. (31)
If the decision is made to breastfeed, HIV-positive mothers should receive competent and well-informed breastfeeding assistance from a recognized breastfeeding support organization or an International Board Certified Lactation Consultant (IBCLC) before and after birth. Mothers will need practical assistance with latching their baby comfortably to the breast, and ensuring effective breastfeeding. They may need advice and ongoing follow-up to avoid, minimize and quickly resolve any postpartum breast or nipple problems, such as sore nipples, breast engorgement, or symptoms of mastitis. It is important to prevent or treat these kinds of difficulties promptly should they occur, not only to avoid increasing the risk of transmission of postpartum HIV but also so that exclusive breastfeeding can easily be initiated and maintained for the full first six months of their infant’s life. The baby’s HIV status should be tested at birth, and at monthly intervals until three months after breastfeeding ends. (29, 30)
Finally, it is not possible to overstate the need for breastfeeding counselors or IBCLCs to liaise with and be guided by the mother’s and baby’s primary healthcare providers so that all parties can work together as a team for the best health outcomes for both mother and baby.
Hope for the future
When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV-positive women to give up all hope of breastfeeding. Up-to-date evidence-based research suggests that when HIV-positive women receive adequate ART, they can safely embark upon a pregnancy and deliver their children vaginally. Research also shows that improved health outcomes can be achieved with breastfeeding compared to not breastfeeding. There are only two provisos:
1) mothers must be meticulously adherent to their medication, and
2) breastfeeding should be practiced exclusively during the first six months of life.
When these two preconditions are met, the risk of mother-to-child transmission of HIV through breastfeeding can be reduced to negligible levels. The World Health Organization describes these findings as “transforming,” and it follows that there should thus be no need to discourage breastfeeding, both within and outside the context of HIV.
2 Horvath, T, Madi, B, Iuppa, I. et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database of Systematic Reviews (1) doi: 10.1002/14651858.CD006734.pub2.
6 Dunn, DT, Newell, ML, Ades, AE et al. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet Sep 5, 1992;340:585-88.
8 Rodger A, Bruun T, Cambiano Vet al HIV. Transmission Risk Through Condomless Sex If HIV+ Partner On Suppressive ART: PARTNER Study. Paper presented at 21st Conference on Retroviruses and Opportunistic Infections, Boston. 2014.
10 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.
11 Coutsoudis A, Pillay K, Spooner E et al. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet 1999 Aug 7;354(9177):471-6.
14 Ekpini ER, Wiktor SZ, Satten GA et al. Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Côte d’Ivoire. Lancet 1997;349: 1054–1059.
17 Ngoma M, Raha A, Elong A, et al. Interim Results of HIV Transmission Rates Using a Lopinavir/ritonavir based regimen and the New WHO Breast Feeding Guidelines for PMTCT of HIV. International Congress of Antimicrobial Agents and Chemotherapy (ICAAC) Chicago Il, Sep19,2011. H1-1153.
18 Silverman MS. (Powerpoint Presentation): 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.
19 Gartland MG, Chintu NT, Li MS et al, Field effectiveness of combination antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission in rural Zambia. AIDS 2013 May 15; 27(8): doi:10.1097/ QAD.0b013e32835e3937.
20 Silverman, M. Personal communication, 2 Oct 2011.
21 Smith J, Dunstone M, & Elliott-Rudder M. (2009) Health Professional Knowledge of Breastfeeding: Are the Health Risks of Infant Formula Feeding Accurately Conveyed by the Titles and Abstracts of Journal Articles? Journal of Human Lactation, 2009;25(3): 350-358.
22 Bachrach VR, Schwarz E & Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Archives of Pediatrics & Adolescent Medicine2003;157(3): 237-243.
23 Bartick M, & Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010; 125(5): e1048-1056.
24 Chen A & Rogan W J. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004; 113(5): e435-e439.
25 Duijts L, Jaddoe VW, Hofman A et al. Prolonged and exclusive breastfeeding reduces the Risk of infectious diseases in infancy. Pediatrics 2010;126(1), e18-25.
26 Glass RI, Lew JF, Gangarosa RE et al. Estimates of morbidity and mortality-Rates for diarrheal diseases in American children Journal of Pediatrics 1991;118(4),S27-S33.
27 Ip S, Chung M, Raman G et al. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeeding Medicine2009; 4(Suppl 1):S17-30.
28 Quigley MA, Kelly YJ, & Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics 2007;119(4), E837-E842. doi:10.1542/peds.2006- 2256.
29 Taylor GP, Anderson J, Clayden P et al. For the BHIVA/ CHIVA Guidelines Writing Group. British HIV Association and Children’s HIV Association position statement on infant feeding in the UK, 21 March, 2011.
30 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.
31 Walls T, Palasanthiran, Studdert J et al. Breastfeeding in mothers with HIV. Journal of Pediatrics and Child Health 2010 Jun;46(6):349–352, doi:10.1111/j.1440- 1754.2010.01791.x.
Pamela Morrison is the mother of three adult sons, including twins, who were all breastfed. She became a La Leche League Leader in Zimbabwe and then certified as the first IBCLC in the country where she practiced until 2003. Now living in England, Pamela enjoys working to assist mothers who wish to maximize their milk supply in challenging circumstances, for example those wishing to induce lactation or to relactate for adopted, surrogate, sick babies, or those whose babies experience inadequate weight gain or failure to thrive.