Please note: The British HIV Association (BHIVA) guidelines were updated in 2018. The current BHIVA guidelines (as well as patient information leaflets) are here: https://www.bhiva.org/pregnancy-guidelines
Summary of Key points
• The World Health Organisation recommends that replacement feeding for babies (avoiding breastfeeding) should only be used in areas where it is acceptable, feasible, affordable, sustainable and safe.1
• Current guidelines from the British HIV Association (BHIVA) state that HIV positive mothers should be advised to formula feed exclusively from birth.
• Because of the very low risk of mother-to-child HIV infection, BHIVA guidelines advise that mothers who choose to breastfeed should be supported to do so. The conditions are that mothers follow the antiretroviral therapy (ART) strictly, and that standard HIV tests show consistently undetectable levels of the virus in the mother.
• If a mother who is on effective cART (combined antiretroviral therapy), and whose levels of virus are consistently undetectable, chooses to breastfeed, this does NOT constitute a child protection concern.
• Breastfeeding while not on cART, or with detectable levels of virus even if the mother is on cART, constitutes a potential child protection concern.
• If a mother chooses to breastfeed, exclusive breastfeeding should be encouraged for the first 6 months. Mixed feeding for babies under 6 months is associated with a greater risk of transmission.
• Mastitis, cracked nipples and other causes of breast inflammation are associated with an increased risk of HIV-transmission, so good breastfeeding support is crucial. Sores in the baby’s mouth can make it easier for the virus to infect the baby, so it is important to treat sores or thrush promptly.
• Current BHIVA guidelines recommend that breastfeeding should stop at around 6 months, once solids are introduced. However, research suggests that the risk of HIV transmission from mother to baby declines significantly as the child becomes older. The WHO recommendation is that “mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breast feeding for the first 12 months of life”. WHO guidelines state that, if appropriate animal milk and other food is available for the baby, mothers should be counselled to stop breastfeeding at 12 months.
Background information
A significant body of research has focused on how mothers with HIV might feed their babies and how health professionals can better support these mothers. An article by Pamela Morrison (Morrison, 2014) provides a very useful overview of the issues surrounding breastfeeding and HIV, and summarises our current understanding of the topic. The WHO website has a section on questions and answers about infant feeding and HIV transmission which cover most common questions from healthcare professionals and mothers. The UNICEF website has some key points on how to minimise mother-to-child transmission of the HIV virus.
The WHO (2010) recommends that replacement feeding (avoiding breastfeeding) should only be used in areas where it is acceptable, feasible, affordable, sustainable and safe. In the UK, guidelines from the British HIV Association (BHIVA) state that HIV positive mothers should be advised to formula feed exclusively from birth (BHIVA 2014). However, several research studies have shown that a combination of exclusive breastfeeding and the use of antiretroviral therapy (ART) can reduce mother-to-child transmission of HIV through breast milk to negligible levels (White et al, 2014; Kuhn et al, 2007). In addition, a baby who is not breastfed is more likely to suffer from illnesses, both as a child and later as an adult (LLLGB, 2016 ). For those reasons, mothers with HIV may take the decision that breastfeeding is the best option for their babies.
BHIVA guidelines recognise that mothers with HIV who choose to breastfeed should be supported to do so, providing they adhere strictly to ART, and their viral loads are repeatedly undetectable. BHIVA recommends careful monitoring of maternal adherence to ART, as well as regular monitoring of the mother’s viral load, and diagnostic testing of the baby for HIV. Mastitis, cracked nipples and other causes of breast inflammation are associated with an increased risk of HIV-transmission, so good breastfeeding support is crucial to avoid any of these happening. Sores in the baby’s mouth can make it easier for the virus to infect the baby, so it is important to treat sores or thrush promptly (UNICEF website)
The review by White el at (2014) includes both ART given to the mother, and long term ART given as a preventive measure to the baby while breastfeeding. None of the studies included in the review reported serious adverse effects on the babies given ART therapy. However, due to the lack of safety data in the long term use of ART in individuals not infected with HIV, BHIVA does not recommend prophylactic ART use for the baby for longer than 2-4 weeks (BHIVA, 2014).
Mixed feeding for babies under 6 months should be avoided, since it is associated with a greater risk of transmission. It has been suggested that early introduction of liquids and/or solids in the immature gut of the baby can create small lesions in the gut wall, which may allow the virus to cross the intestinal walls and enter the blood stream (Morrison, 2014). Kuhn et al (2007) suggest there may be additional factors, such as increased viral load in breast milk as a result of milk stasis (due to missing feeds or decreased frequency of infant suckling).
Current BHIVA guidelines recommend that breastfeeding should stop once solids are introduced (BHIVA 2014). However, WHO recommends that “mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breast feeding for the first 12 months of life”. According to Kuhn et al (2007) “the risk of post-natal HIV transmission occurring during non-EBF [Exclusive Breastfeeding] is greater in the first 4 months of life and declines as the child becomes older. Non-EBF i.e. continuing breastfeeding with complementary foods, is developmentally-appropriate at older ages and conveys less of a risk of HIV transmission than non-EBF in the first few months of life.” UNICEF states that breastfeeding for 6 months has about one third of the risk of breastfeeding for 2 years.
If the child is known to be already HIV-infected, WHO recommends that mothers follow the guidelines for the general population: exclusive breastfeeding for the first six months of life and continue breastfeeding with complementary foods up to two years or beyond (WHO, 2010).
1 The WHO previously referred to these ideas as AFASS, this acronym isn’t used anymore.
