Q&A: New HIV recommendations address infant feeding

SEATTLE — Recently published recommendations for the prevention of pediatric HIV infection say people with HIV should be counseled about infant feeding prior to conception or as early as possible in pregnancy.

The recommendations address replacement feeding and the low risk for HIV transmission through breastfeeding when a person has achieved sustained viral suppression on ART.

We asked Judy Levison, MD, MPH, AAHIVS, professor of obstetrics and gynecology at Baylor College of Medicine in Houston, some questions about the new recommendations.

Levison discussed the recommendations at the Conference on Retroviruses and Opportunistic Infections.

Healio: Why is it important to counsel pregnant and postpartum women with HIV about infant feeding?

Levison: It is important because up until now, we have been very negative about the idea of breastfeeding among people with HIV in high-resource countries, even though, in most of the world, exclusive breastfeeding is what's recommended. We have finally listened to the community.

There are many reasons why people are choosing to breastfeed and/or wanting to at least consider that option. This time we considered the health benefits of breastfeeding both for the infant and for the breastfeeding parents. For example, breastfed infants have a lower risk of developing asthma, obesity, type 1 diabetes, lower respiratory disease, ear infections, sudden infant death syndrome and other infections. The breastfeeding parent has a decreased risk of hypertension, type 2 diabetes and breast and ovarian cancer.

We also paid attention to equity considerations: Black women are disproportionately affected by HIV, and people of color experience a greater burden of many health conditions that may be alleviated by breastfeeding. In addition, there are cultural considerations. We have women for whom not breastfeeding is the equivalent of waving a red flag at their community that they have HIV because in their cultures, the standard is to breastfeed; the stigma associated with the possibility that they have HIV is just too great. And, we recently have had some environmental pressures, such as unsafe water in some cities or formula shortages. So, we're trying to address those health benefits, equity considerations and cultural considerations.

Healio: What is recommended for people with HIV who are not on ART or who do not have a suppressed viral load?

Levison: We recommend that they use replacement feeding, which would generally be formula.

Healio: What about patients who are on ART and have a sustained undetectable viral load?

Levison: It's up to them, after hearing the information, to make the decision based on their particular social, environmental and familial situation.

Healio: You use two phrases in the recommendations to denote someone who is successfully being treated for HIV: “suppressed viral load” and “sustained undetectable viral load.” Did you differentiate between the two?

Levison: They're intended to be the same. “Suppressed” may focus on one point in time. When we say “sustained,” we mean a prolonged undetectable viral load during the third trimester at a minimum.

Healio: What main points should be stressed during counseling?

Levison: One, it needs to be addressed as early as possible, ideally before pregnancy, but at a minimum, early in pregnancy. Two, we've changed our tone: We used to say, “In the U.S. we recommend not breastfeeding. Is that a problem for you, too?” Now, we ask, “What are your thoughts on infant feeding?” We are being more open and really trying to give women the choice. What they need to understand is that providing replacement feeding, which would be formula or donor milk, eliminates the risk of transmitting HIV via breast milk.

However, we now know that if a breastfeeding parent is on ART and has had a sustained, undetectable viral load — what we mean by that is, ideally, at least throughout the third trimester, even better throughout the pregnancy — the risk of transmission is very low — from some of the African studies as low as 0.3%, which is three per 1,000 over 6 months. Among the few babies in those studies who were diagnosed with HIV when their mothers had undetectable viral loads, their mothers would not have met our criteria for sustained viral suppression and would not have been good candidates in our book.

References:

NIH. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/infant-feeding-individuals-hiv-united-states. Published Jan. 31, 2023. Accessed Feb. 20, 2023.