Advice on
infant feeding has been updated in the 2018 guidelines to address the
uncertainties surrounding HIV transmission through breast milk when viral load
is undetectable on antiretroviral treatment.

“The undetectable=untransmissable (U=U) statement applies only to
sexual transmission, and we currently lack data to apply this to
breastfeeding,” the guidelines state. Nevertheless, the guidelines also
recognise that some women on antiretroviral treatment will choose to breastfeed.

“Women who are virologically suppressed on cART with good adherence
and who choose to breastfeed should be supported to do so, but should be
informed about the low risk of transmission of HIV through breastfeeding in
this situation and the requirement for extra maternal and infant clinical
monitoring.

 “When a woman decides to breastfeed, she and her infant should be
reviewed monthly in clinic for HIV RNA
viral load testing during and for 2 months after stopping breastfeeding.”

They should be supported in their decision, if they fulfil the
following criteria:

  • A fully suppressed HIV viral load (for as long a period as possible,
    but certainly during the last trimester of pregnancy);
  • A good adherence history;
  • Strong engagement with the perinatal multidisciplinary team (MDT);
  • Prepared to attend for monthly clinic review and blood HIV viral load
    tests for themselves and their infant while breastfeeding and for 2 months after stopping.

Maternal antiretroviral therapy (rather than infant pre-exposure prophylaxis (PrEP)) is
advised to minimise HIV transmission
through breastfeeding and safeguard the woman’s health.

BHIVA continues to recommend formula feeding as the safest way for a mother with HIV to feed her baby, recognising that it may
come at an emotional cost to some mothers.

The guidelines also emphasise the importance of considering the
financial costs of formula feeding for women, especially women with an
irregular immigration status and no recourse to public funds, and women on low
incomes.

“The provision of free formula milk, and the appropriate equipment to
use it, alleviates any financial burden attached to this key prevention tool.
This ensures that women can make decisions on how to feed their infant without
being influenced by cost.”

“We advise discussing infant feeding intentions early in pregnancy so
that appropriate information and support can be provided.”