Shared Decision-Making Regarding Lactation for People Living with the Human Immunodeficiency Virus (HIV)
by Anne Eglash MD, IBCLC, FABM
Perinatal HIV transmission is the #1 cause of childhood HIV infection. Perinatal spread is most likely to occur during the antepartum and intrapartum periods, but can occur postpartum via human milk. Without any anti-retroviral therapy (ART), a pregnant individual has a 15-45% risk of transmitting HIV to their child. Use of ART during pregnancy has markedly reduced the risk of perinatal transmission of HIV to less than 1%.
The article for this week, written by physicians in the departments of OB/Gyn at University of North Carolina at Chapel Hill and Baylor College of Medicine in Houston Texas, is a clinical expert summary addressing shared decision making for people living with HIV (PLHV), who are deciding on infant feeding. The provision of human milk by PLHV is associated with a risk of HIV transmission, which is not completely prevented by ART. PLHV who have an undetectable viral load are considered noninfectious via sexual contact. However, the same principle may not be true for lactation, since there may be HIV DNA within the cellular components of human milk that ART cannot suppress. The theory is that HIV DNA can be transmitted and reactivated in the infant to produce infectious HIV RNA.
There is also a concern that mammary inflammation such as mastitis, engorgement, or abscess might lead to cell-associated HIV DNA activation.
Because of these risks, the World Health Organization has recommended not breastfeeding in countries with safe and accessible human milk substitutes. In countries where families cannot access safe, clean water or sufficient appropriate human milk substitutes, it is recommended that lactating individuals breast/chestfeed exclusively, as mixed feeding is associated with increased HIV transmission to the infant.
The authors of this clinical expert summary discuss management strategies for PLHV in the USA who choose to breast/chestfeed. They recommend discussing risks/benefits of lactation, along with feeding options such as donor milk, a lactational surrogate, or formula. Individuals making this decision should be counseled on the importance of exclusive breast/chestfeeding rather than mixed feeding, and to be aware of signs of mastitis or infant thrush, both of which may increase the risk of HIV transmission.
- PLHV should be advised to strictly adhere to their ART regimen during lactation.
- Infant treatment with ART throughout lactation has been shown unequivocally to be an effective strategy to prevent HIV transmission.
- Monitor the lactating individual’s viral load every 1-2 months. If it becomes detectable, counsel on the increased risk of transmission via their milk, and consider weaning.
- Test the infant for HIV every 3 months during lactation.
See the Answer
Considerable strides have been made in reducing the rate of perinatal human immunodeficiency virus (HIV) transmission within the United States and around the globe. Despite this progress, preventable perinatal HIV transmission continues to occur. Adherence to HIV screening and treatment recommendations preconception and during pregnancy can greatly reduce the risk of perinatal HIV transmission. Early and consistent usage of highly active antiretroviral therapy (ART) can greatly lower the HIV viral load, thus minimizing HIV transmission risk. Additional intrapartum interventions can further reduce the risk of HIV transmission. Although the current standard is to recommend abstinence from breastfeeding for individuals living with HIV in settings where there is safe access to breast milk alternatives (such as in the United States), there is guidance available on counseling and risk-reduction strategies for individuals on ART with an undetectable viral load who elect to breastfeed.
Infants born to PLHV are routinely treated with ART prophylaxis for the first 4 weeks of life. There is insufficient evidence to demonstrate that longer duration of ART prevention for a breast/chestfeeding infant further reduces the risk of HIV transmission.
The reason for this expert summary is that pregnant people living with HIV have asked their HIV healthcare team if they can breast/chestfeed. There are several considerations when advising on infant feeding, and simply saying ‘no’ to breast/chestfeeding does not allow for autonomy and beneficence. The authors make the point that the healthcare provider’s role is to educate their patients. Despite the very low risk of HIV transmission, PLHV have the right to make their own infant feeding decisions.