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

For decades, the organization recommended against breastfeeding or providing breast milk from mothers with HIV to prevent transmission of the virus to infants.

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

According to the authors, people with HIV who strongly wish to breastfeed should be able to if they meet the following criteria: ART was initiated early in or before pregnancy; the parent has sustained HIV viral suppression (viral load <50 copies/mL); the parent has continuous access to ART and consistently takes ART; and infant antiretroviral prophylaxis is given.

“There has been accumulating evidence over the last several years that really supports that breastfeeding in people on antiretroviral treatments with [an undetectable viral load] is really quite safe,” Abuogi told MedPage Today. “There’s a very low transmission risk, and so that’s what prompted this change.”

“The risk is not zero. There have been a few cases in research studies in which a baby acquired HIV and the mom’s viral load was undetectable,” she explained. “But it is really low — less than 1% — so we feel like it’s safe to offer this option.”

The new AAP recommendation now also aligns more closely with a recommendation from a joint CDC and HHS panel issued early last year that concluded it was safe for mothers with HIV to breastfeed if they wish to do so and are virally suppressed on ART.

The AAP report summarized the evidence used to support the new recommendation. Without ART or infant antiretroviral prophylaxis, the risk of HIV transmission to infants from breastfeeding is highest during the first 4 to 6 weeks of life and ranges from 5% to 6%, Abuogi and colleagues wrote. After that time, the risk decreases to about 0.9% per month during the period that breastfeeding continues.

ART and infant antiretroviral prophylaxis both reduce the risk of HIV transmission from breastfeeding, but do not completely eliminate the risk. Use of either reduces the risk of transmission to less than 5%. In mothers who are on ART with an undetectable viral load, that risk is less than 1%, the report detailed.

The report also defined further recommendations for counseling parents with HIV who wish to breastfeed, periodic HIV screening of breastfeeding infants, assessing infants for antiretroviral drug side effects, and other key recommendations for infant feeding for mothers with or at risk for HIV.

It remains to be seen, however, how quickly the new recommendation will translate into changes in clinical practice. “A lot of us were trained that breastfeeding was not allowed” for mothers with HIV, even if they were virally suppressed, Abuogi noted. “But people in the HIV community have been advocating for this.”

“Hopefully [the report] will reach a lot of pediatricians and pediatric providers so that they feel like they have the information about why this change is happening,” she said. The AAP will be offering educational webinars to try and get the new recommendations out to clinicians.

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

Some HIV-positive women in the U.S. are also from these 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’re in your home country,’ so I think hopefully this [report] harmonizes with global recommendations and it’s less confusing.”

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