Infant Feeding for Persons Living With and at Risk for HIV in the United States
Summary of Recommendations
- Perform HIV testing as soon as possible, unless the person declines.
- If HIV rapid test results are positive:
- Infant feeding options should be discussed. If the person desires to breastfeed, human milk should be expressed and stored until a confirmatory HIV test result is available. The infant should receive formula or certified, banked donor human milk while awaiting confirmatory test results. Skin-to-skin care can be initiated to maintain milk supply.
- Consultation with a pediatric HIV expert (ie, National Perinatal Hotline, 1-888-448-8765) is recommended to determine whether infant ARV prophylaxis is indicated. Infant prophylaxis should ideally be initiated within 6 hours of birth.
- If HIV infection is ruled out with confirmatory testing, breastfeeding can safely be initiated.
- If acute HIV infection is suspected, an HIV RNA polymerase chain reaction test (eg, HIV viral load test) should be obtained as part of confirmatory testing before breastfeeding is initiated.
- If HIV rapid test results are negative, breastfeeding can be initiated.
- If rapid HIV testing during labor is not available or the pregnant person declines testing, providers should consider potential risk factors for HIV acquisition (eg, intravenous drug use or high-risk sexual exposures) versus the benefits of initiating early breastfeeding.
- Health care professionals should advise parents with HIV that the only method of infant feeding that eliminates the risk of postnatal HIV transmission to the infant is complete avoidance of breastfeeding.
- Health care professionals should explore and address barriers to replacement feeding (with infant formula or certified, banked donor human milk), including the need for financial support.
- Health care professionals should be prepared to counsel people with HIV who express a desire to breastfeed their infant. Counseling should include the following:
- Explore reasons for wanting to breastfeed and provide guidance to address parental goals where possible (eg, alternative ways of bonding with the infant, approaches to avoiding HIV infection status disclosure, validating parental role regardless of infant feeding approach);
- Educate parents regarding the potential risk of HIV transmission throughout the duration of breastfeeding and inform parents that ART and infant ARV prophylaxis significantly reduce, but do not eliminate, this risk.
- Breastfeeding should be supported for people with HIV who strongly desire to breastfeed after comprehensive counseling if all of the following criteria are met:
- ART was initiated early in or before pregnancy;
- There is evidence of sustained viral suppression in the parent (HIV viral load <50 copies per mL);
- The parent demonstrates a commitment to consistently taking their own ART and to giving infant ARV prophylaxis;
- The parent has continuous ART access.
- Involvement of a multidisciplinary team in the counseling and management of a breastfeeding parent with HIV is recommended. For example, this team might include the pediatric providers who will care for the infant, the breastfeeding parent’s HIV care and obstetric providers, lactation consultants, and a pediatric HIV expert.
- Providers should recommend the following strategies to reduce the risk of HIV transmission via breastfeeding:
- Exclusive breastfeeding (no formula or other foods) through the first 6 months;
- Continuous ART for the breastfeeding parent with sustained undetectable viral load throughout the duration of breastfeeding;
- Regular assessment of viral load in the breastfeeding parent (eg, every 1–2 months);
- Infant ARV prophylaxis in consultation with a pediatric HIV expert;
- Gradual weaning over 2 to 4 weeks, rather than abruptly.
- Breastfeeding infants should be screened for HIV using nucleic acid testing (eg, plasma HIV RNA or DNA polymerase chain reaction) at 14 to 21 days, 1 to 2 months, and 4 to 6 months of life and then every 2 months throughout lactation and at 4 to 6 weeks and 3 and 6 months after weaning.
- Breastfeeding infants who receive extended ARV prophylaxis beyond 4 to 6 weeks of life should periodically be screened for hematologic and liver toxicity, as these complications can be associated with ARV drugs that are commonly used for infant prophylaxis (eg, a baseline complete blood count and liver enzymes can be obtained at the onset of infant prophylaxis and repeated after 2 to 4 weeks, then repeated only if abnormal or if clinically indicated).
- A decision to breastfeed by a person with HIV who is on ART and virally suppressed should not constitute grounds for a referral to child protective services agencies.
- Breastfeeding is not recommended for people with HIV who are not on ART or who do not take ART consistently, people without a sustained undetectable HIV viral load, or people newly diagnosed with HIV infection in pregnancy or postpartum. Those who choose to breastfeed despite this recommendation should receive ongoing intensive counseling and consultation with a team of experts (eg, pediatric HIV expert, social worker, ethicist, etc) to engage the person with HIV in a culturally effective manner that seeks to address both their health as well as the child’s.
- Parents with HIV who are not virally suppressed on ART should avoid premastication of food for infants. This recommendation should be discussed in a culturally sensitive and nonjudgmental manner.
- Counseling should be provided regarding the potential risk of HIV transmission to an infant through human milk if HIV acquisition were to occur while breastfeeding.
- Frequent HIV testing should be performed during pregnancy and breastfeeding (eg, every 3 months).
- Education about HIV prevention should be provided and HIV preexposure prophylaxis (PrEP) should be offered.
- The infant should not consume human milk from that person until HIV infection is confirmed or ruled out. Human milk can be expressed and stored until a confirmatory HIV test result is available. The infant should receive formula or certified banked donor breast milk while awaiting confirmatory test results. Skin-to-skin care can be initiated to maintain milk supply.
- If HIV infection is ruled out, breastfeeding can resume.
- If HIV infection is confirmed:
- Breastfeeding should be discontinued;
- The infant should undergo HIV testing, with follow-up testing at 4 to 6 weeks and 3 and 6 months after breastfeeding cessation if the initial test result is negative;
- Consultation with a pediatric HIV expert (ie, National Perinatal Hotline, 1-888-448-8765) is recommended regarding decisions about postexposure ARV prophylaxis for the infant;
- The breastfeeding parent with HIV should be promptly linked to care and receive ART, psychosocial support, and counseling on breastfeeding cessation.
Recommendation Grading
Disclaimer
Overview
Title
Infant Feeding for Persons Living With and at Risk for HIV in the United States
Authoring Organization
American Academy of Pediatrics
Publication Month/Year
May 20, 2024
Last Updated Month/Year
June 17, 2024
Document Type
Consensus
Country of Publication
US
Document Objectives
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
Target Patient Population
Infants and mothers with, or at risk of HIV/AIDS
Target Provider Population
Pediatricians and allied providers caring for infants and/or mothers with, or at risk of HIV/AIDS
Inclusion Criteria
Female, Adult, Infant
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D001942 - Breast Feeding, D006678 - HIV
Keywords
human immunodeficiency virus (HIV), Breastfeeding, HIV/AIDS, HIV, aids
Source Citation
Abuogi L, Noble L, Smith C; COMMITTEE ON PEDIATRIC AND ADOLESCENT HIV; SECTION ON BREASTFEEDING. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics. 2024 Jun 1;153(6):e2024066843. doi: 10.1542/peds.2024-066843. PMID: 38766700