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

How to Support Women Living With HIV in Clinical Practice

The 'zero risk' way for a mother living with HIV to feed her baby in the UK, and other HICs, remains formula or other forms of infant replacement feeding. For some mothers it is necessary to provide a 'managed risk' option. This is the position of current UK and US guidelines on women living with HIV who wish to breastfeed. Our clinical work has shown us that new mothers with HIV infection want clear information on how to feed their baby, including Dos and Don'ts and troubleshooting advice. Our safer breastfeeding rules (Table 2) and 'safer triangle' (Figure 1) summarize information that may lower the risk of HIV transmission through breastfeeding in formats that can be shared with health care colleagues and patients.

Figure 1.

The 'safer triangle'.

The Future

We need to better understand what women want and what underlies their choices. The Positive Attitudes Concerning Infant Feeding (PACIFY) study recently investigated the infant feeding choices made by women living with HIV in the UK who were pregnant or had children up to 3 months old. The study found that more than one-third of the 94 participants wanted to breastfeed and that a small number did breastfeed after they were aware of their HIV diagnosis. They also found that the large majority of women had discussed breastfeeding with a health care professional, but half wanted to understand more. These findings show the persistent need to understand how to minimize the risk of HIV transmission through breastfeeding – and then communicate this effectively to new mothers living with HIV.[41]

HICs will struggle to offer guidelines with an unequivocally positive position on women living with HIV and breastfeeding until there is dedicated quantitative research on HIV transmission through breastmilk from women living in these countries. Questions still to be answered include: What is the HIV transmission risk through breastmilk for women living with HIV in HICs? Is it the same as in middle- and low-income countries? Does long-term viral suppression affect transmission through breastmilk compared with short-term suppression or ART started in pregnancy? What causes postnatal vertical transmission in the context of an undetectable maternal plasma viral load? What is the optimal monitoring frequency? What is the best way to manage breastfeeding difficulties in the mother living with HIV and what else can be done to maximize safety? We now know that 'undetectable = untransmittable' for sexual transmission of HIV – but what is needed to make this also true for breastfeeding?[42–45]