American Academy of Pediatrics Shifts Position on Breastfeeding for People with Human Immunodeficiency Virus

Accumulating evidence shows that it’s rare for HIV to be transmitted via breastmilk to an infant when parent is taking antiretroviral medications 

ITASCA, IL--The AAP has changed its approach to infant feeding among people with human immunodeficiency virus (HIV) for the first time since the start of the HIV epidemic and in accordance with recommendations by the U.S. Department of Health and Human Services Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission, as outlined in an updated report published in the June 2024 Pediatrics. 

The clinical report, “Infant Feeding for Persons Living With and at Risk for HIV in the United States,” published online May 20, is a critical evidence-based update marking a reversal after decades of recommending against breastfeeding or providing breast milk to infants of people with HIV.

“Research now shows that the risk of HIV transmission through breastfeeding is quite low when the lactating parent is on  anti-retroviral treatment and has no detectable viral load,” said Lisa L. Abuogi, MD, MSc, FAAP, lead author of the clinical report, written by the AAP Committee on Pediatric and Adolescent HIV and Section on Breastfeeding. “While avoiding breastfeeding is the only option to guarantee that the virus is not transmitted, pediatricians should be ready to offer family-centered and nonjudgmental  support for people who desire to breastfeed.”

The clinical report includes recommendations for pediatric health care professionals caring for infants of people with HIV that support minimizing perinatal transmission while ensuring the optimal health of parents and infants and promoting health equity.

Policy statements and technical reports created by AAP are written by medical experts, reflect the latest evidence in the field, and go through several rounds of peer review before being approved by the AAP Board of Directors and published in Pediatrics.
Nearly 5,000 people with HIV in the US give birth every year. Without treatment, pregnant people with HIV can pass the virus to their infants during pregnancy, delivery, or breastfeeding. Today, medications are available that, if taken every day, can keep people with HIV healthy and significantly reduce the risk of transmission.
Research finds that the risk of HIV transmission via breastfeeding from a parent who is receiving antiretroviral treatment and is virally suppressed is estimated to be less than 1%. This small risk should be weighed against the numerous health, psychosocial, and financial benefits of breastfeeding. The CDC, which starting in 1985 recommended against breastfeeding for people with HIV, has updated its position and now supports shared decision-making regarding infant feeding for people with HIV who wish to breastfeed. The AAP has strongly supported breastfeeding for decades, and now supports this infant feeding choice in people with HIV who are on successful treatment.

The AAP recommends that pediatric health care professionals:

• Know the HIV status of the pregnant individual to provide appropriate infant feeding counseling and encourage perinatal HIV testing. Those who are known to be living with HIV or who are newly diagnosed should be linked to treatment.
• Be prepared to support people with HIV who want to breastfeed if they meet all of the following criteria: They initiated antiretroviral treatment early in or prior to pregnancy; they maintain viral suppression; have continuous antiretroviral treatment access; and are committed to continuing treatment consistently through breastfeeding.
• Counsel pregnant and postpartum people who are at increased risk of acquiring HIV, including people who inject drugs or who have sexual partners living with HIV who are not virally suppressed, regarding the potential risk of HIV transmission to an infant through human milk if HIV acquisition were to occur while breastfeeding and refer for pre-exposure prophylaxis of HIV (PrEP) medications.

“Healthcare professionals, researchers, and people with HIV have made amazing strides over the past few decades towards eliminating perinatal transmission of HIV in the United States,” Dr. Abuogi said. “We encourage families to share information with their pediatricians about HIV and discuss what will work best for them when it comes to feeding their baby.”

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.