Postpartum patients with HIV can breastfeed their infants with consistent antiretroviral therapy and support from clinicians, according to updated guidance from the American College of Obstetricians and Gynecologists ( ACOG). 

The change reflects growing evidence that the risk for HIV transmission through breastfeeding is low when patients are treated with antiretroviral therapy and have a controlled viral load. 

“As further evidence emerged related to use of antiretrovirals and viral suppression, we thought that this evidence is provocative enough that the recommendation really needs to be changed,” said Christopher Zahn, MD, chief of clinical practice and health equity and quality at ACOG, who helped draft the guidance. “This should not be a decision made by the clinician for the patient.” 

The updated clinical practice update marks a departure from earlier recommendations to treat HIV as a contraindication to breastfeeding. Instead, clinicians are now encouraged to provide options and support patients’ informed decisions. 

“It’s really an opportunity to have a discussion with our patients about the risk of transmissions and really allow the woman to make an informed decision,” said Maria Luisa Alcaide, MD, professor of infectious diseases and ob/gyn at the University of Miami Miller School of Medicine in Florida, who was not involved in the guidance. 

Monitoring 

The risk for transmission while on antiretroviral therapy is less than 1%. But even with a low risk for transmission, patients with HIV who breastfeed should be more closely monitored for levels of viral load than if they choose formula feeding, Alcaide said. 

To maintain that low risk, clinicians should monitor viral loads every 4 weeks and advise strict adherence to antiretroviral therapy. 

Clinicians should clearly and in neutral terms distinguish between eliminating risk and reducing it, Zahn said. 

“The only way to completely eliminate the risk is to not breastfeed,” he said. But “we should not be qualifying whether that 1% is low, that’s really up to the patient.” 

Should a patient decide to breastfeed, clinicians should also monitor for factors that could increase risk, including lapses in adherence to treatment or development of breast conditions such as mastitis, Alcaide said. 

If a patient develops detectable viral levels while breastfeeding, the update advises temporarily stopping breastfeeding and switching to replacement feeding while reassessing. The infant should also be started on prophylaxis. 

ACOG continues to recommend formula or pasteurized donor milk for patients who are not on antiretroviral therapy or who have not achieved sustained viral suppression during pregnancy or after giving birth. 

Implementation 

While the guidance reflects current evidence, implementation may be challenging as clinicians adapt to a major shift in long-standing thinking. 

“We’re going from ‘don’t do this’ basically to ‘you can do this,’” Zahn said. “It does take time for that to get built into normal day-to-day practice.” 

Zahn added that coordination across specialties will be critical to avoid conflicting advice. 

“It’s really important that the clinician community is all on the same page so that the patients are not getting mixed messages,” he said. 

Some uncertainties remain, including how long breastfeeding can safely continue and how evolving HIV treatments may affect maternal and infant outcomes such as HIV transmission risk, medication exposure through breast milk, and infant growth and development. 

“We should continue monitoring the risk,” especially as more patients choose to breastfeed and longer-term data emerge, Alcaide said. 

Alcaide reported no relevant disclosures. 

Lara Salahi is a health journalist based in Boston.