AAP Updates Guidance on HIV Transmission via Breastfeeding

The way that people with HIV approach nursing their infants has undergone a paradigm shift. AAP guidelines advised against nursing or giving any breastmilk to newborns of individuals with HIV in the United States for decades after the HIV epidemic began in order to reduce the risk of HIV transmission. Nonetheless, a growing body of evidence indicates that, in cases when the nursing parent with HIV is on antiretroviral therapy (ART) and has an undetectable viral load, the risk of HIV transmission during breastfeeding is rather low. Simultaneously, the US is getting close to reaching its targets for eradicating HIV transmission during pregnancy.

The clinical report Infant Feeding for Persons Living With and at Risk for HIV in the United States has been updated by the American Academy of Pediatrics in response. The paper offers guidelines for pediatric healthcare providers who treat HIV-positive infants. These guidelines assist the elimination of perinatal transmission, guarantee the best possible health for both parents and infants, and advance health equity.

The function of pediatric healthcare providers

To properly advice on infant feeding, pediatric healthcare providers need to be aware of the pregnant person’s HIV status. As a result, every pregnant individual should have perinatal HIV testing, according to the clinical report. Individuals who are newly diagnosed or known to be HIV positive should be connected to therapy. Pre-exposure prophylaxis, or PrEP, should be given to those who are highly susceptible to contracting HIV.

The paper also provides recommendations for breastfeeding babies in cases where the mother’s HIV status is unknown or when testing is done at birth.

According to recent research, the risk of HIV transmission is less than 1% among nursing persons with HIV who are on continuous antiretroviral therapy (ART) or in infants who receive preventive medicine during breastfeeding. As a result, in some circumstances, the Department of Health and Human Services and the Centers for Disease Control and Prevention promote shared decision-making about newborn feeding in individuals with HIV.tHI

In a similar vein, the AAP has modified its suggestions. The only way to feed a baby without danger of HIV transmission is to avoid human milk, but if a person on antiretroviral therapy (ART) has undetectable viral loads and wants to breastfeed, the AAP suggests supporting them.

As a member of a multidisciplinary team, pediatric healthcare providers can use the clinical report’s helpful advice to give evidence-based infant feeding counseling and care to people with HIV who choose to breastfeed their babies.

Important steps for pediatric healthcare professionals

Be ready to offer advice to HIV-positive individuals who wish to breastfeed their child.
Provide assistance to HIV-positive individuals who desire to breastfeed provided they fulfill the following requirements: started antiretroviral therapy (ART) early in or before pregnancy; maintain viral suppression (HIV viral load <50 copies/milliliter); have continuous access to ART; and pledge to take ART consistently during breastfeeding.

To lower the risk of HIV transmission through breastfeeding, it is advised to implement the following strategies: gradual weaning over the course of two to four weeks; continuous antiretroviral therapy (ART) and regular viral load testing for the breastfeeding parent; and infant prophylaxis after consulting with a pediatric HIV specialist.

Inform expectant and new mothers about the possibility of HIV transmission to a child through human milk if HIV acquisition happens during breastfeeding. This includes pregnant and postpartum individuals who are at high risk of contracting HIV (such as drug injectors or those with sexual partners who are HIV positive but not virally suppressed). In addition, during pregnancy and lactation, provide PrEP and regular HIV testing (e.g., every three months).

For more information: Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report, American Academy of Pediatrics, https://doi.org/10.1542/peds.2024-066843