AAP updates breastfeeding guidelines for individuals with HIV

Yesterday, May 20, 2024, the American Academy of Pediatrics (AAP) issued a clinical report in Pediatrics outlining guidelines for infant feeding by persons living with or at risk for human immunodeficiency virus (HIV). The updated guidelines acknowledge that the risk of transmitting HIV through breastfeeding is minimal, less than 1%, if patients are taking the appropriate antiretroviral medications.

The report analyzes the risk of HIV transmission through breastfeeding, noting that the global incidence of HIV transmission through breastfeeding is roughly 30%. However, the report notes that transmission primarily comes from individuals who are not being treated with antiretroviral therapy or those who are on the drugs but have not achieved viral suppression.

More insight into HIV transmission and its association with breastfeeding notes that the risk of HIV transmission to the infant is most significant during the first 4–6 weeks of life, with the risk varying from 5% to 6%. With each month of breastfeeding, the risk declines by 0.9%.

The AAP emphasizes that antiretroviral drugs are essential for minimizing the risk of HIV transmission when breastfeeding. According to the report, those on antiretroviral therapy only have a 5% chance of passing the virus through breastfeeding. Furthermore, those on the appropriate HIV treatment regimen who have achieved viral suppression have a less than 1% chance of transmitting HIV through breastfeeding.

In addition, the researchers note that antiretroviral drugs have not caused any long-term toxicity or sequelae in infants based on the millions of infants who have been exposed in utero or during breastfeeding.

Despite the data presented in the report, the AAP acknowledges that the only way to eliminate the risk of HIV transmission from breastfeeding is to avoid it altogether.

“The AAP recommends that for people with HIV in the United States, replacement feeding (with formula or certified, banked donor human milk) is the only option that is 100% certain to prevent postnatal transmission of HIV. However, pediatric healthcare professionals should be prepared to provide infant feeding counseling and a family-centered, culturally sensitive, harm reduction approach for people with HIV on ART with sustained viral suppression who desire to breastfeed,” concluded the report.