CROI 2023: Updated guidelines on infant feeding for people with HIV

Elaine Abrams, MD, from Columbia University moderated a special session at the recent Conference on Retroviruses and Opportunistic Infections in Seattle to update the HIV scientific and provider community on important changes to infant feeding recommendations for parents with HIV. The updated guidance is from the U.S. Department of Health and Human Services.

Dr. Abrams, who co-chairs the perinatal guidelines panel, noted that the changes were informed by decades of research and the needs of mothers and people with HIV and their babies. The HHS pediatric HIV treatment and perinatal infections guidelines panels collaborated on the updated recommendations.

Judy Levison, MD, MPH, a perinatal guideline panel member from Baylor College of Medicine, presented a summary of the updates released Jan. 31, which now support parental choice for infant feeding through shared decision-making between parents with HIV and their providers. She noted that in revising the recommendations, the panel considered the health benefits to infants of breastfeeding and health equity, given that Black women are disproportionately affected by HIV. 

The guidelines now recommend for providers to support individuals with HIV with a sustained undetectable viral load who choose to breastfeed. Dr. Levinson noted that:

• When people with HIV are not on antiretroviral therapy or do not have a suppressed viral load during pregnancy, the guidelines recommend replacing breastfeeding with formula or banked pasteurized donor human milk.
• For infants exposed to HIV, the panel recommends assessing risk in determining the appropriate regimen.
• It is not appropriate to contact Child Protective Services if a parent with HIV chooses to breastfeed. These engagements can be extremely harmful to families and exacerbate the stigma associated with HIV. Parents who identify as Black, indigenous or other people of color have been disproportionately affected by reports to CPS.

Dr. Levinson acknowledged the tension for providers between respecting patient autonomy and paternalism and highlighted the importance of community engagement in the process.   

Providers are encouraged to consult the National Clinical Consultation Center’s Perinatal HIV/AIDS Hotline at 1-888-448-8765 for rapid perinatal HIV consultation. The hotline consultation service is available 24 hours a day, seven days a week. A summary of the updates to the guidelines is available in the What’s New section of the guidelines website.

HIVMA, a sponsor of this blog, in 2020 endorsed the “Expert Consensus Statement on Breastfeeding and HIV in the United States and Canada” calling for informed choice in infant feeding for parents with HIV. The statement was organized by The Well Project and the International Community of Women Living With HIV North America.