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Breastfeeding Decision-Making and HIV/AIDS

Baby holding red HIV/AIDS ribbon

World AIDS Day reminds us that mothers and babies are living with, or at-risk of, HIV/AIDS.

This disease affects approximately 38 million people worldwide. It has caused more than 35 million deaths since it was first identified in 1984. In the US, in 2018, about 1 in 5 new HIV diagnoses were in women, most of whom were younger than 45 years old.

What is HIV/AIDS?

Human immunodeficiency virus (HIV) is the cause of AIDS (Auto-Immune Deficiency Syndrome). As the name suggests, it interferes with the body’s ability to fight infections.

The virus can be spread through contact with infected bodily fluids, including blood, semen, and vaginal fluids. Unquestionably, it can be spread through the mother’s milk. Yet, contrary to what you might expect, this doesn’t necessarily mean mothers with HIV can’t breastfeed.

Mothers with HIV can’t breastfeed … right?

Mothers in low-resource countries may need to breastfeed for several reasons. The AFASS criteria specify that breastfeeding is less risky than formula feeding unless formula feeding is

  • acceptable (meaning, acceptable in the family and the culture)
  • feasible (including the ability to understand how to mix the formula)
  • affordable (family has money for formula, heating fuel, and more)
  • sustainable (ability to continue, once started)
  • safe (including having clean water for mixing the formula)

In short, lack of ability to prepare, mix, or store infant formula, or lack of access to clean water, are major factors to discourage formula feeding. 

As always, public health authorities and experts based their recommendations on risks and benefits. Breastfeeding helps protect infants from malnutrition, and even death from causes other than HIV or AIDS.

Although it may seem counter-intuitive, mothers in low-risk countries are advised that the potential infant health risks from not breastfeeding may be higher than the infant’s risks of getting HIV due to breastfeeding.

At the same time, the advice from doctors to families in high-resource countries — including the U.S .— was that they not breastfeed their babies any amount, at any time. The milk of mothers with HIV could be said to be a danger to the baby.

As you review that AFASS criteria, you can see that why formula is considered less risky here in the US, and formula is readily available here. (Donor milk may even be available. For more about donor milk banking, see my previous posts.) And feeding the infant formula (or donor milk) eliminates the risk of mother-to-child transmission (MTCT) of HIV.

Lowering MTCT rates

Since indentification of the virus more than thirty years ago, the single biggest game-changer in HIV treatment is antiretroviral treatment (ART).

As it turns out, ART is good not just for treating HIV but also reducing the risk of MTCT via breastfeeding. This advancement has opened the door for these mothers to consider breastfeeding, under certain conditions.

Since 2012, the World Health Organization (WHO) has recommended that all pregnant and lactating mothers receive “lifelong ART.” This comprehensive approach helps to reduce the risk of non-feeding-related transmission from a woman to her infant, and to other children during future pregnancies.

Further, it also lowers the risk of transmission during breastfeeding, making this a possible option, for some mothers. The most recent guidance from American College of Obstetricians and Gynecologists (ACOG) recommends that physicians counsel patients with HIV about their status and breastfeeding decision-making.

A word of caution …

I’m not saying everyone should breastfeed, regardless of their HIV status.

What I am saying is that parents who want to weigh the risks and benefits should talk with their health care provider. They should also read recommendations from the public health authorities.

For more information on HIV and infant feeding, see these official statements:

The advice about breastfeeding and HIV has changed over the years. And, I fully expect there will be more changes forthcoming.  

What do you think about this tough decision of whether or not to breastfeed with HIV/AIDS? Tell us in the comments below!

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