Model of Breastfeeding Management Among People Living with HIV in the USA
by Anne Eglash MD, IBCLC, FABM
What are considerations in implementing lactation management for people living with HIV in the USA?
In February 2023, the US Centers for Disease Control updated their recommendations on infant feeding among mothers living with HIV, and no longer recommends advising against breastfeeding. They now recommend patient-centered, evidence-based counseling on infant feeding options, in line with some other high-income countries. They acknowledge that there is less than 1% risk of HIV transmission via breastfeeding for people living with HIV on anti-retroviral therapy with undetectable HIV viral loads. Although the CDC outlines management considerations, institutions are seeking standardized approaches to care for people living with HIV who want to breastfeed.
Authors at the Children’s Hospital of Colorado Immunodeficiency Program (CHIP) documented their experience developing and implementing an interdisciplinary approach to managing breastfeeding for people living with HIV and reported their patient outcomes. They reported on breastfeeding rates, and complications related to breastfeeding and infant antiretroviral treatment among 21 pregnant women who considered breastfeeding and 10 dyads who breastfed for a median of 62 days. They also discussed strategies to support pregnant individuals when making their infant feeding decisions, suggestions on prenatal lactation education topics, and interdisciplinary support for dyads. They discussed differing strategies for infant antiretroviral treatment from various institutions. Although there are no standardized approaches yet, there are some basic guidelines recommended by the CDC.
- If an individual living with HIV develops a detectable viral titer during lactation, they can be advised that it is safe to continue breastfeeding as long as the parent and infant remain on antiretroviral therapy.
- If a lactating individual living with HIV with an undetectable viral load develops mastitis, they may have a higher risk of transmitting HIV to their infant.
- It is recommended that lactating individuals living with HIV have their viral load monitored every 1-2 months.
- Lactating individuals are encouraged to wean slowly to minimize breast inflammation.
- It is recommended to avoid mixed feeding (formula supplementation) for breastfed infants of parents living with HIV.
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Women with HIV in high-income settings have increasingly expressed a desire to breastfeed their infants. While national guidelines now acknowledge this choice, detailed recommendations are not available. We describe the approach to managing care for breastfeeding women with HIV at a single large-volume site in the US.
We convened an interdisciplinary group of providers to establish a protocol intended to minimize the risk of vertical transmission during breastfeeding. Programmatic experience and challenges are described. A retrospective chart review was conducted to report the characteristics of women who desired to or who did breastfeed between 2015-2022 and their infants.
Our approach stresses the importance of early conversations about infant feeding, documentation of feeding decisions and management plans, and communication among the healthcare team. Mothers are encouraged to maintain excellent adherence to antiretroviral treatment, maintain an undetectable viral load, and breastfeed exclusively. Infants receive continuous single drug antiretroviral prophylaxis until four weeks after cessation of breastfeeding. From 2015-2022, we counseled 21 women interested in breastfeeding, of whom 10 women breastfed 13 infants for a median of 62 days (range, 1-309). Challenges included mastitis (N=3), need for supplementation (N=4), maternal plasma viral load elevation of 50 to 70 copies/mL (N=2), and difficulty weaning (N=3). Six infants experienced at least 1 adverse event, most of which were attributed to antiretroviral prophylaxis.
Many knowledge gaps remain in the management of breastfeeding among women with HIV in high-income settings, including approaches to infant prophylaxis. An interdisciplinary approach to minimizing risk is needed.
The CDC recommends that if a lactating parent’s HIV viral titer becomes detectable, to either feed previously stored milk, flash heat their milk, substitute with formula or donor milk, or wean. The non-weaning options can be done while there is an adjustment or improved compliance with antiretroviral therapy.
Exclusive breastfeeding in the first 6 months minimizes risk of HIV transmission as compared to mixed feeding, and/or feeding complementary foods before 6 months of age.
This paper is a good resource for institutions developing policies and protocols to support lactating individuals who are living with HIV. There are policy decisions that need to be made, such when it is safe to resume breastfeeding after mastitis, best methods for weaning, whether to allow breastfeeding during plugged ducts, what to do for cracked bleeding nipples, how often to screen infants for side effects from anti-retroviral therapy, etc. In addition, addressing the unique socioeconomic, mental health, language, and literacy needs of one’s patient/client population by including patient representatives in policy/protocol development would be key in providing optimal support and management of safe infant feeding.