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

Challenges to Supporting Breastfeeding When Done by Women Living With HIV in the UK

Potential Harms to the Child

For a mother living with HIV in the UK, formula-feeding provides a 'zero transmission risk' option. It is safe, accessible and commonly done among mothers in the UK.[29] Until we have replicated data to prove otherwise, we can assume that breastfeeding for 12 months on ART presents the child of a mother living with HIV with a ~1% risk of developing an incurable and life-limiting infection.[10] While the predicted life expectancy for adults diagnosed with HIV infection and on effective ART is now the same as for the HIV-negative population,[30] children diagnosed with HIV infection continue to experience higher comorbidity and mortality from infections even when treated with ART.[31] BHIVA guidelines state that, to safely monitor a breastfed child of a mother living with HIV, the child will require three times the number of appointments and blood tests compared to if he or she had been formula-fed for his or her first 6 months.[11]

Antiretrovirals are passed in breastmilk.[32] The amount that accumulates in the mother's breastmilk varies between drug types; however, there is evidence that a quantitatively important amount of some nucleoside reverse transcriptase inhibitors (NRTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs), including lamivudine, nevirapine and efavirenz, can be passed to an untreated infant through breastmilk.[32] This implies on-going post-natal exposure of the child to potentially harmful drugs. In the rare situation where a child does acquire HIV infection, the on-going exposure via breastmilk to subtherapeutic treatment doses may increase their risk of resistance to that class of ART.[33] This child will then have fewer treatment options for their HIV treatment. They may endure more severe side effects as fewer drug alternatives will be open to them, and more quickly exhaust all HIV treatments.

Breastfeeding Challenges for the Woman Living With HIV

Advice that is appropriate for most women about how to manage breastfeeding difficulties may theoretically increase the risk of vertical HIV transmission if a mother is living with HIV.[19,18,34–36] For example, lactational mastitis affects an estimated 2% to 33% of all breastfeeding women.[37] Efficient and effective milk removal, including encouraging the continuation of breastfeeding, is the mainstay of mastitis treatment.[34] In a breastfeeding mother living with HIV, there is evidence that, when untreated, the viral load of the milk from her affected breast increases during episodes of mastitis.[19,18,35,36] Our understanding comes from studies involving women who were not receiving long-term ART and had detectable HIV viral loads. We do not yet know what happens to breastmilk viral load during an episode of mastitis in a mother living with HIV who is adherent to treatment with an undetectable viral load. However, health care professionals who are unaware either of a mother's HIV infection or of guidance on HIV and 'safer breastfeeding' could inadvertently suggest a management plan that may increase a child's risk of acquiring HIV infection.[19,18,34–36]

Funding for Formula Milk

Supporting breastfeeding for women living with HIV may remove some of the pressure on National Health Service (NHS) England to provide free formula milk for all mothers with HIV infection. Currently, access to subsidized formula milk for mothers living with HIV in the UK is geographically variable, often dependent on the charity sector and vulnerable to funding changes.[38,39] A study of mothers in London living with HIV found that more than half of them, or a family member, went hungry in order to afford baby formula.[40] An HIV clinic in London was able to provide a starter kit of sterilizer, bottles and formula only to the 70% of their pregnant patients who lived in the boroughs funding the scheme.[39] The best solution is to continue campaigning for funded infant formula in parallel with potentially expanding supported breastfeeding. There is a risk that increasing breastfeeding access may dilute attention from the pursuit of providing fully funded infant formula, along with logistical and psychological support, for all new mothers living with HIV.