By Pamela Morrison
Part 1 of our update on HIV and infant feeding, by midwife Stefania Mantra, summarises the state of UK policy until 2018, as outlined in the WBTi UK 2016 report.
At the end of 2018, after being under consultation since 2017, the British HIV Association issued two final guidance documents on HIV and infant feeding:
BHIVA 2018, British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018
BHIVA 2018, General information on infant feeding for women living with HIV
While it is often generally understood that women living with HIV in the UK should formula-feed their babies due to the risk of transmission of the virus during breastfeeding, it needs to be acknowledged that in the era of effective antiretroviral treatment, those risks may be exaggerated, while the risks of formula-feeding are being down-played. BHIVA are clear in their latest update that while formula-feeding is the usual advice, it is certainly envisaged that some mothers living with HIV in the UK may want to breastfeed and – if they do – then there are fairly detailed recommendations on how to support them (see box).
HIV and infant feeding in BHIVA guidelines for the management of HIV in pregnancy and postpartum 2018
Section 9.4. Infant feeding ………….. page 84
9.4.1 Breastfeeding advice for women with HIV living in the UK ………………. 84
9.4.2 Supporting women living with HIV to formula feed ………………………… 85
9.4.3 Suppression of lactation ………………………………………… 85
9.4.4 Choosing to breastfeed in the UK ………………………….. 86
9.4.5 Communication with health professionals …………… 87
The BHIVA guidance has been appropriately developed for the population that it aims to protect. Research has shown that approximately three-quarters of HIV+ mothers now living in the UK were born in countries (mostly Eastern and Southern Africa) where breastfeeding is the cultural norm. They want to breastfeed and they may suffer stigma and severe psychological distress if they are counselled not to do so. Bottle-feeding not only identifies them as being HIV-infected, but also goes against cultural beliefs that breastfeeding identifies a woman as a good wife and mother.
In accordance with national recommendations, all pregnant women should be tested for HIV early in pregnancy. Those who identify as having a new HIV infection should receive appropriate antiretroviral therapy (ART), which will reduce their viral load to undetectable. Meticulous adherance to her ART will enable a mother to have a vaginal birth with very little risk of transmission of the virus, and – importantly – to also reduce the risk of HIV transmission during breastfeeding to virtually zero*. I have worked with several HIV+ mothers who wanted to, and with the endorsement and support of their HIV clinicians, obstetric and paediatric teams, succeeded in breastfeeding. The mothers were receiving full antiretroviral treatment, were adherent to their medications, breastfed exclusively for periods ranging from 9 to 26 weeks, (and some of the babies weaned from the breast a little later than that). The mothers were thrilled with their achievement and all the babies have subsequently tested negative for HIV. It is commonly assumed that the only option for HIV+ mothers in the UK is formula-feeding, but that is not the case. Some women want to breastfeed, they do breastfeed, and they are extremely proud of their success.
Mothers’ confidence is increased when they are given consistent information on the safest way to feed and mother their babies. And healthcare providers and infant feeding counsellors can rest assured that the British guidance on HIV and infant feeding is also in line with the WHO/UNICEF Global Breastfeeding Collective Advocacy Brief on Breastfeeding and HIV released for World Aids day in December 2018.
* From the 2018 BHIVA guidance, p 84:
“There are no data on the risk of HIV transmission via breast milk in high-income countries. In low- to middle- income settings, the overall postnatal risk of HIV transmission via breast milk when women are treated with cART has been reported as 1.08% (95% CI 0.32–1.85) at 6 months and 2.93% (95% CI 0.68–5.18) at 12 months, however in these studies women only received cART for 6 months and often breastfed for longer [58]. In the more recent PROMISE trial, women received cART throughout the breastfeeding period, and the transmission rate was 0.3% (95% CI 0.1–0.6) at 6 months and 0.6% (95% CI 0.4–1.1) at 12 months [59].”
Pamela Morrison IBCLC
Pamela was the first IBCLC in Zimbabwe and worked to facilitate training for, and assess, Unicef Baby Friendly Hospitals there since 1992. She is an expert on infant feeding and HIV and the author of numerous articles and toolkits on the topic.
Breastfeeding trends (UK) 
This blog has a headline image, also appearing on WBTI’s tweet of this blog (1), with the text “HIV free breastfeeding model”. This does not seem to accurately reflect the new guidance from BHIVA (2, 3), which notes a transmission risk under cover of cART of 1.08% (95% CI 0.32–1.85) at 6 months and 2.93% (95% CI 0.68–5.18) at 12 months; BHIVA also cites lower values from a more recent trial of 0.3% (95% CI 0.1–0.6) at 6 months and 0.6% (95% CI 0.4–1.1) at 12 months. In the patient leaflets for women living with HIV prepared by BHIVA (3) it is suggested that approximately between 1 and 2 transmissions per 100 breastfeeding women might occur under the safest scenario. The WBTI blog omits to give any of this information on the actual risk of transmission, instead saying the risk is “virtually zero” in the text (and “HIV free” in the header image), which does not seem consistent with what is summarised about the “undetectable=untransmittable” question in the guidelines (2):
“Suppressive maternal cART significantly reduces, but does not eliminate, the risk of vertical transmission of HIV through breastfeeding. The undetectable=untransmissable (U=U) statement applies only to sexual transmission, and we currently lack data to apply this to breastfeeding” (2).
New data from IAS (4), presumably too recent to be included in the guideline, also suggest the possibility of transmission through breastfeeding even when viral load is undetectable.
As I am not an HIV medic nor active scientist (but have done a fair amount of editorial and publishing work with HIV studies) I defer to the clinician-scientists on these aspects. However it seems to me from a lay person’s perspective that this blog is not accurately summarising what the expert clinicians in this field are saying about transmission risks, which ought to be communicated accurately to mothers so they can make informed decisions.
Work aiming to destigmatise and fully support formula feeding for mothers living with HIV in the UK is also not presented in this blog, only ways in which breastfeeding can be supported (which is not the general BHIVA recommendation, rather formula feeding is recommended as generally safest). Support schemes being promoted include clinic funding for formula milk, bottles and sterilisers (2), and other elements around psychosocial support are also noted in the guideline. To be an unbiased presentation of ongoing work to support mothers living with HIV in feeding their babies, these elements should also be pointed out and not just the ways in which breastfeeding can be supported.
Emma Veitch, PhD
Freelance medical editor, London
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(1) https://twitter.com/wbtiuk/status/1081941835273199618
(2) https://www.bhiva.org/file/5bfd30be95deb/BHIVA-guidelines-for-the-management-of-HIV-in-pregnancy.pdf
(3) 2 BHIVA leaflets for patients – https://www.bhiva.org/file/5bfd3080d2027/BF-Leaflet-1.pdf and https://www.bhiva.org/file/5bfd308d5e189/BF-Leaflet-2.pdf
(4) http://www.aidsmap.com/Two-cases-of-HIV-transmission-through-breastfeeding-in-mothers-with-undetectable-viral-load-reported/page/3369097/
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Dear Emma,
Thank you for your thoughtful commentary on our guest blogs on infant feeding guidance for mothers with HIV. The image you refer to was in fact a slide supplied by the author, who is a health professional herself. However I can see that as an illustration and out of the context of the whole article, that title was unsuitable so I have removed it.
Both of these blogs are summarising BHIVA’s own guidance, as there is little awareness among most health professionals and the general public that in fact there is guidance on when it can be appropriate to support a mother’s choice to breastfeed.
You can find the 2016 WBTi UK report on this Indicator 8 (pp48-50) here:
Click to access wbti-uk-report-2016-part-1-14-2-17.pdf
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Thank you for changing the figure, regarding the issue with the accuracy of “hiv free”. I’m pleased to hear this. However, I also noted that the text also says that the transmission risk is “virtually zero” rather than giving actual numbers as the official guidance does, so that healthcare professionals and mothers can make informed decisions together, but I would leave it to experts to judge whether this is appropriate.
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I have added a *note with a direct quote from the BHIVA guidance for clarity on this.
I would also like to point out that the WBTi report, and our guest bloggers on the topic, certainly agree that women who choose to feed their babies formula should be supported to feed their babies safely, and that it can be appropriate for government sources to provide formula free of charge for these infants.
These blogs are specifically about the little-realised fact that it can also be appropriate in certain cases to support women who choose to breastfeed, and in fact in some cases, such as a failed asylum seeker who is sent back to her country of origin with her baby, it can be safer than introducing formula.
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