Originally published by our sister publication Infectious Disease Special Edition

Accumulating evidence demonstrates that HIV transmission is rare if the parent is on antiretroviral therapy (ART). Therefore, the American Academy of Pediatrics changed its recommendations for infant feeding among people with HIV for the first time since the start of the HIV epidemic (Pediatrics 2024 May 20 June).

The clinical report is a critical evidence-based update marking a reversal after decades of recommending against breastfeeding or providing breast milk to infants of people with HIV, and is aligned with CDC recommendations.

“Research now shows that the risk for HIV transmission through breastfeeding is quite low when the lactating parent is on antiretroviral treatment and has no detectable viral load,” said Lisa L. Abuogi, MD, MSc, FAAP, the lead author of the clinical report, written by the AAP Committee on Pediatric and Adolescent HIV and Section on Breastfeeding. “While avoiding breastfeeding is the only option to guarantee that the virus is not transmitted, pediatricians should be ready to offer family-centered and nonjudgmental support for people who desire to breastfeed.”

The report includes recommendations for pediatric health professionals caring for infants of people with HIV that support minimizing perinatal transmission while ensuring the optimal health of parents and infants and promoting health equity.

Nearly 5,000 people with HIV in the United States give birth every year. Without treatment, pregnant people with HIV can pass on the virus to their infants during pregnancy, delivery or breastfeeding. However, today’s ART, if taken as directed, can keep people with HIV healthy and significantly reduce the risk for transmission.

Research has found that the risk for HIV transmission via breastfeeding from a parent who is receiving ART and is virally suppressed is estimated to be less than 1%. This small risk should be weighed against the numerous health, psychosocial and financial benefits of breastfeeding, the AAP said.

The CDC, which starting in 1985 recommended against breastfeeding for people with HIV, has updated its position and now supports shared decision making regarding infant feeding for people with HIV who want to breastfeed. The AAP has strongly supported breastfeeding for decades, and now supports this infant feeding choice for people with HIV who are on successful treatment.

The AAP recommends that pediatric health professionals:

Know the HIV status of the pregnant individual to provide appropriate infant feeding counseling and encourage perinatal HIV testing. Those who are known to be living with HIV or who are newly diagnosed should be linked to treatment.

Be prepared to support people with HIV who want to breastfeed if they meet all the following criteria: They initiated ART early in or before pregnancy; they maintain viral suppression; have continuous access to ART; and are committed to continuing treatment consistently through breastfeeding.

Counsel pregnant and postpartum people who are at increased risk for acquiring HIV, including people who inject drugs or who have sexual partners living with HIV who are not virally suppressed, regarding the potential risk for HIV transmission to an infant through human milk if HIV acquisition were to occur while breastfeeding, and refer for pre-exposure prophylaxis (PrEP) medications.

“Healthcare professionals, researchers and people with HIV have made amazing strides over the past few decades toward eliminating perinatal transmission of HIV in the United States,” Dr. Abuogi said. “We encourage families to share information with their pediatricians about HIV and discuss what will work best for them when it comes to feeding their baby.”

Policy statements and technical reports created by AAP are written by medical experts, reflect the latest evidence in the field, and go through several rounds of peer review before being approved by the AAP board of directors and published in Pediatrics.