If an HIV-infected woman chooses to breastfeed

The decision to avoid breastfeeding may be a very difficult one. The Department of Health's guidelines HIV and Infant Feeding ¹ recognise that: “In communities where breastfeeding is the cultural norm, this decision may be particularly difficult, because a woman’s decision not to breastfeed may be viewed negatively…women’s concerns about this decision should be recognised and discussed”.

The BHIVA/CHIVA guidelines make it clear that, for women living in the UK, it is safest to avoid breastfeeding altogether. The Department of Health’s guidelines outline the support that should be offered to a woman who feels under pressure to breastfeed, including financial and practical help with managing formula feeding and support with dealing with the expectation that she should breastfeed.

In specific circumstances, breastfeeding may need to be considered, for example if a woman will not be remaining in the UK but is likely to return to a country where formula feeding is not a viable or safe option.

WHO’s HIV Transmission through Breastfeeding ² makes three recommendations:

• The most appropriate infant feeding option for an HIV-infected mother continues to depend on her individual circumstances, including her health status and local situation but should take greater consideration of the health services available and the counselling and support she is likely to receive.
• Exclusive breastfeeding is recommended for infants born to HIV-infected women for the first six months of life, unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), as it usually is in the UK, and
• When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommended.

While breastfeeding will continue to carry a risk of transmission, this will be reduced by:

• The woman and child being on antiretroviral therapy.
• The woman breastfeeding exclusively. In African settings, there is evidence that mixed feeding (some formula feeding or introducing solids) results in a higher transmission risk than breastfeeding alone. It is suggested that mixed feeding may have exposed babies to both allergens, causing inflammation and damage to gut mucosal barriers, and HIV, which in turn led to a higher infection rate.³
• Minimising the duration of breastfeeding – switching to formula feeding if before six months or solid food if after six months.
• Ensuring the woman is given early, skilled help with positioning and attachment of the baby at the breast, to avoid problems such as cracked nipples and inflammatory or bacterial conditions (such as mastitis).
• Treating promptly any inflammation of the mucous membranes, such as oral thrush, in the baby’s mouth.