Update to Clinical Guidelines for Infant Feeding Supports Shared Decision Making: Clarifying Breastfeeding Guidance for People with HIV

January 31, 2023

HHS HIV clinical practice guidelines now incorporate breastfeeding options for people with HIV on antiretroviral therapy with sustained undetectable viral load (levels of virus in the blood).

People with HIV (PWH) who are considering conception, are pregnant, or in the postpartum period should receive evidence-based counseling to support decision making about infant feeding. The updated guidelines note that:

• The risk of postnatal HIV transmission to an infant is zero with the use of safe replacement feeding. Properly prepared formula or pasteurized human donor milk from a milk bank eliminates risk of HIV transmission to the infant.
• The risk of HIV transmission while breastfeeding is less than 1% (but not zero) for PWH on antiretroviral therapy (ART) with sustained undetectable viral load through pregnancy and postpartum.
• Clinicians should support the choices of people with HIV to breastfeed (if they are virally suppressed) or to formula/replacement feed.
• It is inappropriate to engage Child Protective Services (CPS) or similar services in response to infant feeding choices of PWH.

Due to the potential of HIV transmission in human milk, previous clinical guidelines in the United States did not recommend breastfeeding for individuals with HIV in the United States.

The 2023 guidelines update integrates community input and recent evidence-based data. Together, this information demonstrates increasing interest in breastfeeding among PWH and their providers, quantifies the risk of HIV transmission for PWH who are virally suppressed (<1%), and recognizes that restricting breastfeeding may increase the inequities that already exist for many women with HIV. These inequities include health risks (e.g., obesity, diabetes, reproductive cancers) and/or access to safe water and formula. Research demonstrates maternal and infant health benefits from breastfeeding include bonding, nutritional gains, and immunologic support; breastfeeding is congruent with many community norms and cultural traditions.

Additional updates to the guidelines include revised and reorganized content and some revised section titles. See all updates on the ClinicalInfo.HIV.gov website.

The NIH Office of AIDS Research Advisory Council (OARAC) advises the OAR Director, NIH Director, HHS Secretary and Assistant Secretary for Health. OARAC responsibilities include coordinating five working groups, also known as panels, to develop HIV clinical practice guidelines that are disseminated publicly at CLINICALinfo.hiv.gov

The HHS Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission in the U.S. (“Perinatal Panel”), led by academic and NIH experts, includes approximately 40 voting members with lived experience and expertise in managing the care of pregnant persons with HIV, with specialties in obstetrics, gynecology, infectious diseases, women’s health, community perspectives, maternal pharmacology, and perinatal HIV transmission prevention.

The panel included community input in the development and revision process of the infant feeding guidelines, and specifically reached out to community partners to gather feedback. In collaboration with the HHS Pediatric Antiretroviral Panel, the HHS Perinatal Panel aimed to balance the low risk of transmission with strong community desire to breastfeed, acknowledging community concerns and the desire for bodily autonomy, while promoting a greater focus on shared decision making. The guidelines are structured to address the care of all pregnant individuals with HIV, their infants, and people who are trying to conceive.

Note: The term “breastfeeding” is used to describe feeding a child one’s own milk (either direct feeding or with expressed milk). When counseling individuals with HIV about infant feeding, it is important to assess and use their preferred terminology; some transgender men and gender-diverse individuals may prefer using the term “chestfeeding” rather than “breastfeeding.” We urge providers to consult community-based resources for more information about inclusive, affirming language around gender in health care settings.

For additional information
Click on the following links to view the latest perinatal HIV guidelines , additional resources for clinicians, and additional resources for the general public.
For additional information, call 1-800-HIV-0440 (1-800-448-0440) from 1 p.m. to 4 p.m. ET or email HIVinfo@nih.gov.
For all other inquiries, please email OARinfo@nih.gov.