Chestfeeding for Lactating People Living with HIV

To the Editor: A term infant born to a 24-year-old G1P1 birthing person living with human immunodeficiency virus (HIV) was rooming in on the postpartum unit. When discussing feeding preferences with nursing, the birthing person stated they are interested in chestfeeding, the gender-inclusive term for breastfeeding,¹ however both nursing staff and the birthing person are unsure if it is safe to do so when living with HIV. An initial decision was made to start exclusive formula feeding. When approached with the clinical question the following day, the physician discussed the evidence with the birthing person, explaining that the rates of transmission are low but not zero and professional society recommendations at the time recommended alternative feeding. Notably, the discussion did not include a review of the birthing person’s CD4 counts or whether they were prescribed and adherent to highly active antiretroviral therapy (HAART). Following this discussion, the birthing person opted to exclusively formula feed the infant.

This real-life case demonstrates the importance for family physicians to understand the evolving guidelines for chestfeeding infants born to birthing persons living with HIV. Chestfeeding is a personal and important decision for many birthing persons. Chestfeeding, in this context, refers to the use of human milk from people living with HIV both directly from the chest and indirectly using a supplemental feeding system.¹ The benefits that infants and lactating people receive from direct chestfeeding are well documented. Recent changes to professional society recommendations have opened the opportunity for lactating people living with HIV to chestfeed under certain circumstances. Presented below are the current guidelines regarding chestfeeding for lactating people living with HIV. Understanding these guidelines allows the opportunity for informed shared decision making in the best interest of the infant and their family.

Although professional societies report differing conclusions (Table 1), several support birthing persons living with HIV in chestfeeding when their viral load is undetectable on highly active antiretroviral therapy (HAART), and their infant also receives HAART. Family physicians are well suited to discuss these varying recommendations and guide families to make informed decisions.

The rates of HIV transmission are low with chestfeeding; however, they are not zero. This is the rationale behind the American Academy of Pediatrics (AAP) guidelines, which state that HIV infection is an absolute contraindication to chestfeeding.² The World Health Organization (WHO), however, released a statement in 2010 stating that persons with HIV on HAART may chestfeed,³ primarily to support nonaffluent developing nations where human milk can be a safer alternative to contaminated water supplies while also acknowledging that HIV transmission is low for lactating persons on HAART. The Academy of Breastfeeding Medicine (ABM) later endorsed the WHO statement, citing the substantial health benefits, for infants and lactating persons through exclusive chestfeeding.⁴ The WHO formalized this recommendation in their 2016 guideline.³ In January 2023, The United States Department of Health and Human Services (US HHS) also endorsed shared decision making between physicians and lactating persons with undetectable HIV viral loads on HAART regarding chestfeeding.⁵ This position is supported by research showing an exceptionally low transmission rate through exclusive chestfeeding when both the lactating person and the newborn are receiving adequate HAART.⁵

These guidelines’ differences warrant shared decision making with pregnant persons living with HIV regarding chestfeeding. Based on the most current evidence, family physicians may reasonably consider including chestfeeding as a feeding option for newborns of birthing persons living with HIV if the lactating person is on HAART with undetectable viral loads and the newborn is also on HAART.