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:
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 . 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 .”
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.