AAP allows breastfeeding for some HIV-positive mothers on ART

Some HIV-positive mothers on antiretroviral therapy (ART) with an undetectable viral load can safely breastfeed their infants, according to a clinical report from the American Academy of Pediatrics (AAP).

For decades, the organization has advised against breastfeeding or giving breast milk to HIV-positive mothers to prevent transmission of the virus to infants.

The change in the AAP’s approach reflects the most recent evidence indicating a very low risk of HIV transmission to infants during breastfeeding for mothers on ART with undetectable viral loads, wrote Lisa Abuogi, MD, MS , of the University of Colorado School of Medicine in Aurora, and colleagues at Pediatrics.

According to the authors, HIV-positive people who strongly desire to breastfeed should be able to do so if they meet the following criteria: ART was initiated at the beginning of or before pregnancy; the parent has undergone HIV viral suppression (viral load

“Evidence accumulated over the past several years really supports that breastfeeding among people on antiretroviral therapy with (undetectable viral load) is really quite safe,” Abuogi said. Page Med today. “There is a very low risk of transmission, and that’s what prompted this change.”

“The risk is not zero. There have been a few cases in research studies where a baby contracted HIV and the mother’s viral load was undetectable,” she explained. “But it’s really low – less than 1% – so we think it’s prudent to offer this option.”

The new AAP recommendation now aligns more closely with a recommendation from a joint CDC and HHS panel issued early last year, which concluded that it was safe for HIV-positive mothers to breastfeed if they wish and if their viral load is suppressed on ART.

The AAP report summarized the evidence used to support the new recommendation. Without antiretroviral therapy or antiretroviral prophylaxis for infants, the risk of HIV transmission to infants through breastfeeding is highest during the first 4 to 6 weeks of life and ranges from 5 to 6 percent, Abuogi and colleagues wrote. After this time, the risk decreases to approximately 0.9% per month for the duration of breastfeeding.

Both ART and infant antiretroviral prophylaxis reduce the risk of HIV transmission through breastfeeding, but do not completely eliminate the risk. Using either reduces the risk of transmission to less than 5%. In mothers on ART with an undetectable viral load, this risk is less than 1%, the report details.

The report also sets out other recommendations regarding counseling HIV-positive parents who wish to breastfeed, periodic HIV testing of breastfed infants, assessment of infants for side effects of antiretroviral drugs and other key recommendations on infant feeding for HIV-positive or at-risk mothers.

However, it remains to be seen how quickly the new recommendation will translate into changes in clinical practice. “Many of us were taught that breastfeeding was not allowed” for HIV-positive mothers, even if their viral load was suppressed, Abuogi noted. “But members of the HIV community have advocated for this.”

“I hope (the report) reaches a lot of pediatricians and pediatric providers so that they feel like they have information about why this change is happening,” she said. The AAP will offer educational webinars to attempt to convey the new recommendations to clinicians.

Globally, recommendations on whether HIV-positive women should breastfeed have varied. Since 2016, the World Health Organization (WHO) has recommended breastfeeding for infants of HIV-positive mothers, ideally in combination with ART and infant antiretroviral prophylaxis, in low- and middle-income countries where infant formula Affordable infants and clean water are often not accessible. The WHO recommendation was based on the increased risk of infant death from malnutrition, diarrhea and pneumonia in HIV-exposed infants who received replacement formula instead of breast milk.

Some HIV-positive women in the United States also come from countries where breastfeeding among HIV-positive parents is the norm, Abuogi pointed out. “It was more confusing for them to come to us and for us to say ‘no, not here’, but ‘yes, when you are in your home country’, so I hope this (report) will align with global recommendations and is less confusing.