Each time LaTonya looks at framed photos of herself breastfeeding her baby son for the first time, she swells with emotion.
As a mother living with HIV in Colorado, it was a moment she wanted to commemorate.
“That’s how important it was to me to be able to breastfeed,” LaTonya said about the photos. “So, I wanted to make sure we had that forever.”
For the first time, the American Academy of Pediatrics has changed its position to say people with HIV, the human immunodeficiency virus, can breastfeed their infants with “very low” risk if they follow certain guidelines with support from their medical care team.
Avoiding breastfeeding is the only option with zero risk for HIV transmission, but going forward, pediatricians should offer support and counseling for women who wish to breastfeed, who are receiving antiretroviral treatment, known as ART, as prescribed and who are maintaining an undetectable amount of virus in the body, according to a new clinical report from AAP that was published Monday in the journal Pediatrics.
Previously, the academy recommended that mothers with HIV in the United States not breastfeed their infants, regardless of their viral load and antiretroviral therapy use.
Recommendations against breastfeeding for people with HIV date to about 1985, when the US Centers for Disease Control and Prevention recommended that women with HIV infection avoid breastfeeding.
“The AAP recommends that for people with HIV in the United States, replacement feeding (with formula or certified, banked donor human milk) is the only option that is 100% certain to prevent postnatal transmission of HIV,” the new report says. “However, pediatric health care professionals should be prepared to provide infant feeding counseling and a family-centered, culturally sensitive, harm reduction approach for people with HIV on ART with sustained viral suppression who desire to breastfeed.”
HIV is a virus that attacks the body’s immune system, and if not treated, it can lead to acquired immunodeficiency syndrome or AIDS.
LaTonya has been living with HIV for about 20 years, she said, but as soon as she gave birth to her son, she knew that she wanted to breastfeed because of the health benefits breastfeeding has for infants, including being associated with a lower risk of asthma, obesity, type 1 diabetes and sudden infant death syndrome.
“Being a mom is absolutely amazing. I wouldn’t trade it for the world,” LaTonya said, adding that every parent desires to give their child “the best shot” at being the best person that they can be.
“I feel like breastfeeding was a step towards me being able to provide that for him,” she said of her son.
After she talked talking about her decision with her doctors, they developed a plan for her to breastfeed since her viral load is undetectable and she is taking antiretroviral medications.
“I think it’s essential for people to understand the science behind it,” she said. “If you’re undetectable, you cannot transmit it to your partner. It’s essential for people to understand that, as well as, if you’re adhering to your medication, that it’s not going to transfer through the breast milk to your child. And so therefore, why deprive your child of … having that benefit?”
‘This has been a long evolution’
Although HIV can be passed to infants through breastfeeding, research has shown that the use of antiretroviral drugs can significantly reduce the risk of HIV transmission, and these medicines are found to be safe during breastfeeding.
In the absence of the mother taking ART or the infant taking preventive antiretrovirals, the risk of HIV transmission through breast milk appears to be highest in the baby’s first four to six weeks of life, ranging between 5% and 6%, according to the AAP report.
But the risk is “estimated to be less than 1%” if the mother is taking antiretroviral medications and the virus is suppressed in her body, meaning there is no detectable viral load, the report said.
“What’s new is that the AAP for the first time is explicitly saying that pregnant people with HIV who are on treatment and undetectable can be supported to breastfeed,” said Dr. Lisa Abuogi, lead author of the report and a pediatrician in Colorado who works with people with HIV during their pregnancies.
“This has been a long evolution, and people living with HIV have been a part of advocating for this change,” Abuogi said. “Some women feel shame or distress or feel like they’re not fulfilling their role as a mother if they can’t breastfeed, and some are really worried that that discloses their HIV status in their community — if breastfeeding is the norm and you have to explain why you’re not doing it.”
It’s estimated that about 5,000 people with HIV give birth in the United States each year.
“So having the opportunity to offer women the choice, as all women have, and to support their decision is really empowering,” Abuogi said. “People living with HIV should have all of the same infant-feeding options as anyone else, and we’re really working to make that a safe decision for women.”
Last year, an advisory panel to the US Department of Health and Human Services made similar updates to its recommendations around infant-feeding, saying that “individuals with HIV who are on ART with a sustained undetectable viral load and who choose to breastfeed should be supported in this decision.”
The new AAP position now aligns with those updated recommendations from the HHS panel, said Dr. Rana Chakraborty, a pediatric infectious disease specialist and researcher at Mayo Clinic in Minnesota, who is a member of HHS’ Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission.
“This is something that’s been under discussion for a few years now. It began with the Department of Health and Human Services panel, and I think the authors of this report from the AAP have really summarized very nicely the current national guidelines in the US,” said Chakraborty, who was not involved in the new AAP report.
“A number of investigators, including many from the US working in relatively resource-limited settings, were previously able to demonstrate that breastfeeding could be undertaken safely if the mother is taking antiretroviral therapy and maintains undetectable HIV viral loads — in other words, the amount of virus in one drop of blood needs to be less than 50 copies per milliliter,” he said. “In the US, this is also doable. But breastfeeding during maternal HIV infection does need a supporting multidisciplinary team of providers to make sure that this can be done safely for both mom and baby.”
‘We’re seeing a consensus’
The AAP recommendations signal that there is now a consensus among leading medical groups that mothers living with HIV can be supported and counseled in safely breastfeeding their babies, said Dr. Elaine Abrams, professor of epidemiology and pediatrics at the Columbia University Medical Center in New York, who has treated people living with HIV during their pregnancies and postpartum but was not involved in the new AAP report.
“All of the bodies that provide guidelines to clinicians are now saying the same thing. We’re seeing a consensus, and the consensus also puts the mother right up-front central in the conversation and decision-making,” she said.
“It’s moved away from telling her what to do, to rather understanding what she wants to do, providing her with evidence and information and then supporting her in her decision,” Abrams added. “In the old days, that wasn’t necessarily the case.”
In the early 2000s, studies emerged showing that infants born to women with HIV in low-income countries had increased risks of illness and death when they were given formula — and that was found to be associated with the mothers not having safe drinking water to mix with the formula, according to the new AAP report. That prompted the World Health Organization to recommend that people with HIV should breastfeed their babies in places without safe drinking water and accessible formula.
As more mothers with HIV breastfed, more studies then found that when the mother took ART or the infant was given antiretrovirals preventively, that effectively reduced the risk of HIV transmission.
The new AAP report noted that there is no consensus on the optimal regimen of preventive antiretrovirals for infants during breastfeeding. Also, people who breastfeed are recommended to do so exclusively, because mixing breastfeeding and formula or solid foods has been associated with increased HIV transmission.
“This increased rate may be a result of disrupted infant gut integrity associated with consuming substances other than human milk, decreases in the amount of antiviral or anti-inflammatory substances typically consumed in human milk, or other mechanisms,” according to the AAP report.
LaTonya said that among the guidance that her medical team discussed with her for breastfeeding was to not incorporate formula but to breastfeed exclusively.
“One of the guidelines that we went over is, if we were going to breastfeed, that was the only thing that we could do,” LaTonya said. “We could not mix formula and breastfeeding.”
Along with supporting and counseling patients with HIV who wish to breastfeed, the AAP also recommended in the new report that pregnant people be routinely tested for HIV and those living with HIV or newly diagnosed should be linked to treatment.
LaTonya said that she hopes the new AAP recommendations encourage health-care providers to educate the public more about what an undetectable level of HIV means, how infections can be treated and how the virus can be suppressed.
“It’s something people live with, and it’s not something to be afraid of,” LaTonya said.
The time for doctors to have those types of educational discussions with their patients would be when someone has a routine HIV test, she said.
“They will talk to you about gonorrhea and chlamydia, but the HIV portion is missing. And so therefore, a lot of people are still stuck in the ‘80s with their mentality of HIV and AIDS,” LaTonya said. “I believe that is mostly due to lack of education.”
