Moving Closer to What Women Want?

A Review of Breastfeeding and Women Living With HIV in the UK and High-Income Countries

N Freeman-Romilly; F Nyatsanza; A Namiba; H Lyall


HIV Medicine. 2020;21(1):1-8. 

In This Article

Reasons for Supporting Women Living With HIV in the UK who Want to Breastfeed

There are many reasons for a woman living with HIV in the UK or other HICs not to breastfeed. And yet some women still want to and some still do.[7–9]

A Harm Reduction Approach

Using a harm reduction model in a health care setting has been defined as: 'interventions aimed at reducing the negative effects of health behaviours without necessarily extinguishing the problematic health behaviours completely'.[20] When a woman living with HIV in the UK would like to breastfeed her baby, health care workers should make it easy for her to share this desire, and then through an open and patient-centred dialogue provide her with information to help make it as safe as possible. Health care workers should continue to encourage women living with HIV in HICs to formula-feed their babies, but also explore if and why a woman wants to breastfeed and, if she does, reinforce the need for ART adherence and monitoring and what to do during situations that can increase the risk of HIV transmission. This harm reduction approach acknowledges that there is a difference between supporting a less safe practice and making it as safe as possible.[20,21]

A Holistic Approach

A woman living with HIV needs to balance the risk of transmitting HIV against other potential harms to her or her child. HIV may not be her only or greatest concern. Some fear stigma from not breastfeeding or that formula-feeding will reveal their HIV status.[7,8] Mothers who intended to breastfeed but were not able to as planned were shown to have an increased risk of postnatal depression, while those who intended to breastfeed and did decreased their risk.[22] The cultural, psychological and social importance of breastfeeding, in some circumstances, may be greater than the felt risk of HIV transmission. Although not breastfeeding eliminates the risk of postnatal vertical HIV transmission, it may be at the expense of the psychological or social wellbeing of the mother, infant and family.

A Practical Necessity

There may be practical underpinnings to a woman's wish to breastfeed. Bottle-feeding with formula milk is more expensive than breastfeeding. Not all women giving birth in the UK will be staying there throughout their child's infancy and breastfeeding will protect the baby if they travel to an area without safe water and reliable formula access.[23,24]

Research and Innovation

Results from the PROMISE trial suggest that the risk of HIV transmission through breastfeeding is lower than previously demonstrated.[10] All data for this study came from women and children living in sub-Saharan Africa and India.[10] We do not know the risk of postnatal vertical HIV transmission in HICs. Research into HIV transmission during breastfeeding may show that the transmission risk for mothers in HICs is lower than currently understood. On-going developments in ART may increasingly facilitate drug adherence and consistent viral suppression. For example, longer acting formulations and alternative drug delivery systems such as patches or injections may reduce or eliminate pill burden. New drug targets, such as glycoprotein 120 (gp120) proteins, capsid assembly inhibitors and broadly neutralizing antibodies, could provide future additional treatment options.[25] Increasing the precision of low-level viraemia monitoring and developing the evidence base for safer breastfeeding guidance may allow more effective support in preventing postnatal vertical transmission of HIV. All of these areas of innovation will allow greater confidence in supporting breastfeeding for women living with HIV in the UK and HICs.

Normalization of HIV Infection

Globally, but particularly in HICs, HIV infection is moving towards becoming a manageable, more normalized chronic condition.[26] Pregnant women with HIV infection in the UK are being managed in the same antenatal clinics as women without HIV infection and see the same leaflets, posters and waiting room videos citing the physiological and psychological benefits of breastfeeding. The 2018 Royal College of Midwives Position Statement on Infant Feeding acknowledges that a woman choosing to formula-feed her baby should not need to give reasons for her decision.[27] However, mainstream postnatal guidance remains heavily in support of breastfeeding. A woman living with HIV may wish to breastfeed her baby because she has been repeatedly told it is 'best' for her and her baby.[7]

Despite the arguments above, and the numerous benefits of breastfeeding that affect all mothers and infants,[28] breastfeeding while living with HIV in the UK could still be felt to be an 'unnecessary risk' with regard to postnatal vertical transmission of HIV.