US guidelines recommending that HIV-positive women feed their infants formula milk instead of breast milk create unique challenges for patients and healthcare providers alike, according to a mixed-methods study recently published in the Journal of the International AIDS Society. This research was led by Dr Emily Tuthill at the University of California San Francisco and found that over three-quarters of healthcare providers had patients asking if they could breastfeed their infants, and nearly a third had cared for patients who decided to breastfeed despite the recommendations.
Patients expressed concerns over multiple forms of stigma, their babies missing out on the health benefits of breastfeeding and having to reveal their HIV status when probed about not breastfeeding. Providers were most concerned about patients’ adherence to treatment and maintaining an undetectable viral load.
Until recently, both the American Academy of Pediatrics and the US Department of Health and Human Services (DHHS) recommended that women with HIV should exclusively feed their infants formula milk due to the risk of transmission associated with breastfeeding. This recommendation is common in high-resource settings. A recent update to the DHHS' Perinatal Guidelines contains some guidance for providers who have patients wanting to breastfeed, including harm-reduction strategies. Nonetheless, the updated guidelines advise against breastfeeding and encourage exclusive formula feeding for HIV-positive mothers.
This is in contrast to the World Health Organization guidelines for resource-limited settings, which recommend exclusive breastfeeding for six months and continued breastfeeding up to 24 months if both the mother and infant are on antiretroviral treatment (ART). Studies from low-resource settings have shown that the chances of HIV transmission are low (0-3%) if ART is maintained before and during breastfeeding as well as a reduced risk of infant death from other causes.
Further conflict is created for mothers in high-resource settings when breastfeeding is heavily recommended for HIV-negative mothers by public health officials, due to the health benefits of early breastfeeding.