By Pamela Morrison, IBCLC
Photo by DFID – UK Department for International Development via Flickr Creative Commons
Have you gained the impression that maternal infection with the Human Immunodeficiency Virus (HIV) automatically rules out breastfeeding? Or that formula-feeding by HIV-positive mothers, whenever possible, is always recommended? If you have had access to different global World Health Organization (WHO) HIV and infant feeding recommendations over the years, do you find them confusing? If the answer to any one of these questions is Yes, then you are not alone.
Based on the huge amount of research conducted since the 1985 discovery that HIV could be transmitted in mothers’ milk, global guidance about breastfeeding in the context of HIV has been changing every few years. One of the spillover effects has been that IBCLCs and others who work with mothers and babies have frequently been exposed to outdated and/or myth-information.
However, IBCLCs can now feel more confident than ever before in supporting HIV-positive clients who express a desire to breastfeed. With certain safe-guards, including maternal adherence to antiretroviral (ARV) regimens which are mandatory in developed countries, the risk of transmission of HIV through breastfeeding can be reduced to virtually zero.
Originally conceived as a joint ILCA-WABA collaborative project, with a gestation period of over seven years, WABA marked World AIDS Day this December with the easy delivery of a new Comprehensive Resource entitled “Understanding International Policy on HIV and Breastfeeding” which can be downloaded HERE.
Intended for use by policy-makers, national breastfeeding committees, breastfeeding advocates, women’s health activists and others working for public health in the community, the Resource sets out why breastfeeding in the context of HIV has never been as safe as it is today. Recent research shows that HIV-positive mothers who receive effective ARVs, protecting their own health sufficiently to result in a near-normal life-span, can also expect that the risk of transmission of HIV to their babies during pregnancy, birth, and throughout the recommended period of breastfeeding, can be close to zero. As a consequence, today’s HIV-positive mothers are enabled to avoid both the stigma and the risks of formula-feeding because current HIV and infant feeding guidance is once again more closely aligned to WHO recommendations for their uninfected counterparts, in place over the last decade: exclusive breastfeeding for 6 months and continued breastfeeding with the introduction of age-appropriate complementary feeding for up to 2 years or beyond.
Building on current research, the 2010 global HIV and infant feeding guidelines and ARV recommendations for prevention of transmission of vertical HIV show that, for the first time, there is enough evidence to recommend ARVs while breastfeeding. Where ARVs are available, it is recommended that HIV-positive mothers breastfeed until their babies are 12 months of age. Furthermore, updated WHO programmatic advice issued earlier this year for ARVs for pregnant women and prevention of HIV infection in their infants has gone a long way towards clarifying many previously perceived ambiguities. Rather than different ARV regimens being decided on the basis of an individual HIV-positive mother’s disease progression, a clear recommendation is now made for provision of ARVs to all HIV positive pregnant women from the time that they are first diagnosed with HIV and continued for life.
With proper treatment, an infected mother’s viral load becomes undetectable, not only protecting her own health and survival, but also reducing to virtually zero the risk of her baby acquiring HIV through her breastmilk.
Thus, current guidance has enabled countries as diverse as South Africa and the United Kingdom to develop national recommendations which once again effectively support breastfeeding for all babies. The up-to-date guidelines simultaneously free health workers from having to tailor infant feeding advice to the HIV-status of their clients and lift from HIV-positive mothers the stigma attached to previous advice about formula-feeding. Most importantly, current guidance ensures the greatest likelihood of HIV-free survival for babies exposed to the virus.
Fully referenced throughout, the Resource’s six sections clarify many past misconceptions by helping to explain how they came about. They track the impact of HIV on women and their infants, review past and current research on transmission of the virus through breastfeeding, trace the evolution of past guidance, outline current policy and counselling recommendations and list easily accessed informational and training materials.
The Resource clarifies how, in a situation of competing infant feeding risks, breastfeeding can now be safely promoted and supported. It is hoped that this tool will enable all who work with HIV-positive mothers to confidently endorse current HIV and breastfeeding recommendations so that each individual child’s chance to survive and thrive can be maximized.
We hope that this document impacts practice and helps to support mothers with HIV all over the world. Please download your own copy of “Understanding International Policy on HIV and Breastfeeding” HERE.
Pamela Morrison’s interest in HIV and breastfeeding arose from having worked as a private practice IBCLC in a country where HIV-prevalence amongst pregnant women reached 25%, yet breastfeeding was both the cultural norm and a cornerstone of child survival. While in Zimbabwe, Pamela also worked as a BFHI Facilitator and Assessor, as well as serving on the Zimbabwe National Multi-sectoral Breastfeeding Committee and the national BFHI Task Force. She has also served on the World Alliance for Breastfeeding Action (WABA) Task Forces for Children’s Nutrition Rights, and for HIV and Infant Feeding, and the ILCA Ethics & Code Committee. After moving to England in 2005, she was employed until 2009 as a Consultant to WABA. She is currently the ILCA media representative on HIV, and continues to do volunteer work for WABA.
Thank you for the link to this fantastic resource guide from WABA, and for putting into “plain language” these important evidence-based practice guidelines. As IBCLCs we advocate for mothers, babies and the breastfeeding relationship. This document offers an important new perspective, with science to back it up, that we can use to offer evidence-based information and support to the HIV+ mother who wants to breastfeed.
I contacted our ID physician who works with HIV+ mothers. She stated that unfortunately ARV regimens are NOT mandatory in the U.S., and she sees many mothers that are not compliant with their medications. She is not promoting breastfeeding among the HIV+ women she works with for this reason. I was really disappointed to hear this from her since our rates of HIV+ in young women is really high in my area of the country (Southeast).
Hello dear moms, I wish to thank the administrators of this forum. I appreciate the information exchange so much.I am hiv positive and 5 months pregnant. I have an undetetable viral load with a cd4 count of about 500. My ARVs are Kaletra and Truvada which i have no problem taking. I live in Berlin Germany and my Gyn is specialised in infectious diseases. She has advised me to think of breastfeeding my baby but im so worried because she said at the moment she has 4 moms breastfeeding and she has no first hand information from personal experience yet to give me. I have to give her my final decision by month end and im so worried! She says i have to chose between a period of 2months or maximum 4 months for exclusive breastfeeding, after which formular feeding. The conditions to breastfeed are be religious in taking my medication and secondly respect the monthly blood controls to check the viral load and the babys blood. I have a 7 year old boy but i didnt breastfeed him. Im excited yet so confused and to an extent afraid! Please I need some advice. I beg moms in this forum to tell me how their babies are doing health wise. This will help me make a calm decision and with certainty.Theory we know is often far from reality!! Please help!!
With the AAP recommending only formula feeding for moms with HIV
(http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3543), I am wondering if anyone is seeing U.S. moms deciding to breastfeed anyway…
Pamela, according to the research cited in this document, the transmission rate for infants of HIV-positive mothers on ART breastfeeding for twelve months is 2.2%. That is not ‘virtually zero’. That is a rate of 1 in 50. If the evidence cited is correct, then one in fifty of the HIV-positive mothers following your advice here will infect her baby as a result.
The advice to breastfeed regardless is aimed at mothers in resource-poor settings where formula feeding carries such a horrific mortality rate that that 2.2% transmission rate is the lesser of two evils. In developed countries, where the risks of formula feeding are a small fraction of what they are in the developing world, that no longer applies. WABA are deliberately blurring that distinction in their paper to make it look as though breastfeeding is now seen as a feasible and appropriate option for HIV-positive mothers in developed countries as well, and that just isn’t so.
I can’t begin to put into words the sense of fury, grief, and betrayal I would feel if a health professional recommended a course of action to me with regard to my child and assured me it had ‘virtually zero’ risk, when in fact it carried a 1 in 50 chance of infecting my child with an incurable and potentially serious and life-threatening disease. I’m appalled that you, as an IBCLC, are taking this line and advising others to do the same.
I am an hiv positive mum, I have breastfeed for 6 months, I am now trying to wean my baby off breast, and introduce formula. Can I give her formula during the day and breatmilk at night only? Or is the risk to high? She is on Neverapine
I am also trying to wean after 6 months of breastfeeding alone. How do I go about doing this? Do i give formula during the day and breastmilk at night?
Thanks for checking in with your breastfeeding question. We’re not able to answer specific breastfeeding questions here on our site. We encourage you to seek out support from your healthcare provider. You can also reach out to an IBCLC in your community. You can find an IBCLC at http://www.ilca.org/i4a/pages/index.cfm?pageid=3432
Other options for finding breastfeeding support include mother-to-mother organizations. Depending on your community, you might find a local La Leche League group, Breastfeeding USA (in the US), or other peer support group.
Best wishes on your parenting journey!
I’m a mother of 2weeks baby boy. I’m positive also on treatment (atripla) and I’m using S-26 to feed him…..he is on nevarapine I would love to breastfeed him,,,,how safe it is for him not to be affected?
I recently gave birth and wanted to breast feed my baby but the milk would not come out, so I had to give him formula. Its been two days now and to my surprise the breast are now coming out milk. Can I stop the formula and breast feed him, is it recommended that I should stop formula and start breast feeding. My viral load is not detectable and iam taking the Atrioza pill. Please help.
Susan, congratulations on the birth of your baby boy. All the research suggests that the risk of transmission of HIV through breastfeeding is higher with “mixed feeding” (breastfeeding and formula-feeding given together). Consequently it would probably be safer for you to feed your baby your own flash-heated expressed breastmilk for 2-3 weeks, as an interim measure, rather than going straight from formula-feeding to breastfeeding direct. To flash heat: place 50 – 150ml expressed breastmilk in a clean jar or bottle. Place the container in a small cooking pot containing approximately 450ml of cold water, and ensure that the level of water is two finger-widths higher than the level of the milk in the jar. Bring the water to the boil on the stove. When the water reaches a rolling boil, take the pan off the stove, and remove the container of milk. Cool the milk to room temperature before feeding it to the baby. You can find more information about home-heating your own milk in Section 4, pages 8 – 11 of the WABA Comprehensive Resource on HIV and infant feeding at http://www.hivbreastfeeding.org Best wishes to you and your baby. Pamela
Thank you Pamela for your advise but how safe it is to mix expressed milk and formula, what are the chances of infecting the baby? Can I use a breast pump to express the milk?
Susan, yes it is safe to mix heat-treated expressed breastmilk with formula. The reason that mixed feeding (with formula and direct breastfeeding together) is not recommended is because it is thought that formula (made from cow’s milk – a foreign protein) damages the infant gut to allow any virus in the breastmilk to enter the baby’s bloodstream through small sites of inflammation. However, when expressed breastmilk is heat-treated, it inactivates the virus, making mixed feeding safe. You should continue to use heat-treated expressed breastmilk for at least 2 weeks after you no longer feed the baby any formula. This should allow enough time for the baby’s gut to heal from the previous exposure to the formula, and then you should be able to more safely carry on with exclusive breastfeeding direct at the breast.
And yes, it is perfectly fine to use a breast pump to express the milk. You should pump or express often enough to keep your breasts soft and comfortable (at least every three hours, and more often if you’re making a lot of milk, or if you need more milk to exclusively breastmilk-feed your baby). The WABA resource also tells you how much milk your baby will need, depending on his age and his weight. Best wishes. Pamela.
l love this because its very true have also been working with these mothers and indeed its true
How do the mothers you are working with wean their babies? If mixed feeding is not recommended how can you continue breastfeeding for 12 months without mixing with some food.
Hi I’m 22 and hiv+ and my viral load is undetectable and I want to breast feed what should I do so I can … With out giving my son HIV… He is 2 days old… And we live in North Carolina… Plz help
Thanks for checking in with your breastfeeding question. We’re not able to answer specific breastfeeding questions here on our site. We encourage you to seek out support from your healthcare provider. You can also reach out to an IBCLC in your community. You can find an IBCLC at http://www.ilca.org/i4a/pages/index.cfm?pageid=3432
Makeba, thank you for your query. Although the ILCA folks are not able to answer your question, as the author of the piece, I would like to respond. And if you would like to communicate with me privately, you can reach me at . In the meantime, I wonder if you have seen American Academy of Pediatrics, Committee on Pediatric AIDS, Infant feeding and transmission of HIV in the United States, COMMITTEE ON PEDIATRIC AIDS, Pediatrics 2013; 131:2 391-396; January 28, 2013, doi:10.1542/peds.2012-3543, Available at http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3543.full.pdf+html ?
This document gives the following information. “An HIV-infected woman receiving effective antiretroviral therapy with repeatedly undetectable HIV viral loads in rare circumstances may choose to breastfeed despite intensive counseling. 20 This rare circumstance (an HIV-infected mother on effective treatment and fully suppressed who chooses to breastfeed) generally does not constitute grounds for an automatic referral to Child Protective Services agencies. Although this approach is not recommended, a pediatric HIV expert should be consulted on how to minimize transmission risk, including exclusive breastfeeding. Communication with the mother’s HIV specialist is important to ensure careful monitoring of maternal viral load, adherence to maternal therapy, and prompt administration of antimicrobial agents in instances of clinical mastitis. Infant HIV infection status should be monitored by nucleic acid (plasma HIV RNA or DNA) amplification testing throughout lactation and at 4 to 6 weeks and 3 and 6 months after weaning.”
It’s good to hear that your viral load is undetectable. However, if your son has been having infant formula for the first two days of his life, a further option might be to feed him your home-pasteurized expressed breast milk, at least for now, and for 2-3 weeks in order to avoid the risk of transmission of HIV which is thought to occur with mixed breast and bottle-feeding, after which your wish to (exclusively) breastfeed him might be more safely realized. However, you should consult with your HIV specialist doctors and take their advice. Best wishes. Pamela Morrison IBCLC, Rustington, England.
My email address seems to have vanished from the post above…. It is pamelamorrisonibclc@gmail.com Best wishes.
I am pregnant and hiv positive I am very happy to know that my baby will receive his benefit of breastmilk like other children my viral load is unditected I cant wait to breastfeed my baby
Best wishes to you and your baby, Ndumi!
Hi, my viral load is undetectable and I am already 25 weeks pregnant. I am strongly advised not to breast feed even your site says its fairly safe if my viral load is undetectable. But can I still pump my breast milk even if I am not feeding it to my child, its to avoid taking more medication to stop breast milk from producing and side effects after that? Please advise…
Hello Wendy, yes of course you can pump your breastmilk after your baby is born as a way of comfortably and safely suppressing lactation and as a way to do this without taking drugs to stop the milk. My quick-and-easy tips for doing this would be as follows: The easiest way to suppress lactation quickly is to simply express a little milk whenever the breasts feel a little overfull, and tuck fresh, raw, cabbage leaves around the breasts in between expressing sessions. From Days 4 – 9 after the birth, as the milk comes in, the mother may need to express very often. She should express to comfort – taking off no more milk and no less than she needs to avoid feeling tight and overfull. Down-regulation of milk production will be well underway within 4 days, and the mother will usually find that she can lengthen the intervals between needing to express, from about every 3 hours to every 4 or 5 or 6. Within a week or ten days she may only need to express 2-3 times in 24 hours. By the end of 2 weeks she may not need to express again at all.
This is a safer way to stop breastmilk production (especially important for a mom with HIV, to avoid a breast infection, than to leave the breasts uncomfortably full and tight. Not only is this painful, it’s also bad for you! The above way is a little slower – about 2 weeks – but much safer. Hope this is the info you wanted. Best wishes. Pamela.
Thank very much Pamela… Appreciate much for your kind advise… I will follow the given steps… 🙂
im an hiv positive mother who formula feeds during the day nd breastfeeds @ night. im on treatment nd so is my baby. is it safe to continue
Hello Portia, It’s good to hear that you’re on treatment. If your baby is under 6 months it would be recommended that you either breastfeed only, or formula-feed only, to avoid mixed feeding. However, if your baby is over 6 months, then the research suggests that the baby’s gut would have had time to mature, and mixed feeding would pose only a very tiny risk when the mother continues to take her antiretroviral medication. Hope this answers your question. Best wishes.
In honour of World Aids Day on December 1st, GOLD Conferences has teamed up with The Mother and Child Health and Education Trust in order to globally share a recording of a GOLD Lactation Conference 2013 presentation on the subject of HIV & Breastfeeding. GOLD Lactation Speaker Pamela Morrison, IBCLC offers us invaluable insight on this topic with her presentation titled “Back to the Future on HIV and Breastfeeding: The findings that transformed policy” .
http://www.goldlactation.com/news-promotion/conference-news/item/143-back-to-the-future-on-hiv-and-breastfeeding-free-presentation
I have a question. . I’m breastfeeding my baby and he is six weeks now but u want to stop and start giving him formula milk. . is it okay? and which milk can I use for my baby?
i’m hiv positive mother who breastfeeding my 2weeks baby boy and i’m also on ARV’s for so some years now,so its not risky for my baby because i want whats best for him
and what about giving him water or other. medications while u’r still breastfeeding b’cs sometimes he took 4days without poop and was having a flu so what risky 4 all those that i’v been mentioned?
Angie, it sounds as if you’ve already had medical advice about deciding to breastfeed your baby boy. It’s very important in the context of HIV that the baby receives no other foods and liquids, except for your milk – not even water, The recommendation does include prescribed medicines, so if you doctor has prescribed a medication for your baby for the flu then that would not be considered to interfere with exclusive breastfeeding. He would probably also be receiving prophylactic antiretroviral medications for his first 4-6 weeks of life? The other point you raise though is that it’s unusual for a 2 week old baby to go 4 days without stools. When they are getting enough breastmilk, babies up to 6-8 weeks usually produce about 6 wet nappies/diapers with clear urine and 3-5 yellow seedy stools in each 24 hour period. Perhaps you could check his weight to make sure he is taking enough breastmilk? Healthy babies usually lose a little weight, not more than 7% in the first 3 days of life, and then gain at the rate of about 30g per day for the first 3 months. And this normal weight gain usually means that the baby produces enough wet and dirty nappies, as explained above. I hope this gives you enough information to go on. Best wishes.
I am 29 with undetectable HIV. I had 2 children before hiv that I exclusively breastfeed for over a year. I want to conceive soon and exclusively breastfeed. In California I am told absolutely no breastfeeding. I am moving back to Hawaii in a couple months and after establishing with a doctor we are going to try to conceive. What do you do when the doctor says “no breastfeeding”? I will have to have a scheduled c section because my previous births were also cesarean. Which puts me in a hospital for a couple days. Even before hiv when in the hospital it was a fight to keep formula away from my children.