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Breastfeeding and HIV Around the World

Choosing a method for feeding their babies is one of the most important decisions expectant and new parents make. This decision can be even more complicated when the birthing parent is living with HIV. The information available to mothers and other parents living with HIV can be confusing for those who may want to explore the option of breastfeeding (nursing, body feeding). The practice of feeding milk to a baby from another person’s body is also sometimes called “chestfeeding” (a term that is inclusive of those who do not have breasts due to surgery or otherwise, or who may prefer language that is gender neutral).

Breast milk is one of the body fluids—along with blood, semen (“cum”), vaginal or rectal fluids—that can transmit HIV. While research has not yet shown that the risk is zero, as is the case with sexual transmission, the risk of HIV transmission through breast/chestfeeding when the parent’s viral load is undetectable is low (less than 1 percent). For more information on how to nourish a baby beyond breast/chestfeeding, please see our fact sheet Overview of Infant Feeding Options for Parents Living with HIV.

Not breastfeeding may become a matter of unwanted disclosure of their HIV status if members of their community question why they are using formula.

If you are a woman living with HIV in an area of the world where access to resources such as clean water, refrigeration, and medical care is limited, the World Health Organization (WHO) recommends that you breastfeed if you are taking HIV drugs. A course of HIV drugs may also be recommended for the baby during breastfeeding. One reason for this recommendation is that in such settings (for instance, many areas of Africa or India), infants are more likely to develop diarrhea and other illnesses, and may die from these. Breast milk contains substances that protect and strengthen a child’s immune system, even after they stop breastfeeding. Because of this, breast milk may help children to survive these health conditions. Furthermore, formula feeding may not be an option in these areas because of lack of money to buy it, clean water to mix it with (if the formula is powdered), or refrigeration to keep it fresh. Health authorities have determined that the benefits of breastfeeding outweigh the risk of HIV transmission in areas where resources are limited.

If you are a woman living with HIV in a resource-rich region of the world, such as the US or Europe, you have likely been told not to breastfeed your babies. HIV treatment guidelines written by health organizations such as the European AIDS Clinical Society (EACS) and the British HIV Association (BHIVA) currently recommend that women living with HIV avoid breastfeeding. Infant formula tends to be readily available and safe to prepare (though that is not always the case in these areas). The chance of a baby dying from illnesses for which breast milk can provide protection is much lower. Therefore, these guidelines are based on the belief that even the low risk of a baby getting HIV from breast milk is not justified when parents can access alternatives.

A significant change occurred on January 31, 2023, when the US perinatal HIV clinical guidelines, issued by the US Department of Health and Human Services (HHS), were updated to remove language discouraging breastfeeding. They now reflect current knowledge about low likelihood of HIV transmission through breast milk when the breastfeeding person is taking HIV drugs and has an undetectable viral load; and recommend that healthcare providers discuss a range of infant feeding options with women and other birthing parents living with HIV.

In previous years, HHS, BHIVA, and EACS HIV treatment guidelines had begun to include updates acknowledging the desire of some women living with HIV to breastfeed and suggesting ways for providers to support parents considering this option.

For more information on this guidance, please see our fact sheet HIV Treatment Guidelines for Pregnant People and Their Infants.

Breast/Chestfeeding Considerations

There are many important reasons why parents living with HIV in resource-rich areas might consider breast/chestfeeding:

  • Extensive research showing that breast milk is the best food for most babies, protecting a growing baby’s health while satisfying all of their nutritional needs
  • Emotional and cultural reasons, even if they live in an area where formula is easily accessible
  • Pressure from their families to breastfeed
  • Not breastfeeding may become a matter of unwanted disclosure of their HIV status if members of their community question why they are using formula
  • Parents who have moved from a resource-limited country to a resource-rich area may wonder why they are being given a different set of instructions and potential restrictions in their new country

Furthermore, there are many health conditions in mothers and infants in the US and elsewhere that breastfeeding may provide protection against. This includes sudden infant death syndrome (SIDS), which causes death in more than 1,000 babies in the US each year (the cause of SIDS is unclear, but data show that breastfeeding can reduce the risk). Black women and other women of color are disproportionately impacted by HIV. They also experience higher rates and worse outcomes from many of the causes of maternal and infant illness or death that breastfeeding may reduce. Therefore, some healthcare providers working on the issue of infant feeding and HIV believe that recommending against breastfeeding in resource-rich countries may actually increase health inequities among women living with HIV.

Recommending against breastfeeding in resource-rich countries may actually increase health inequities among women living with HIV.

Click above to view or download this fact sheet as a PDF slide presentation

HIV Transmission and Breastfeeding: What Do We Know (and Not Know)?

While the risk of transmission through breast milk drops dramatically if you are taking HIV drugs and your viral load is undetectable, there may still be some risk. Having an undetectable viral load in blood may not guarantee an undetectable viral load in breast milk. More research is needed into how HIV drugs affect the cells in breast milk, as well as in breastfed infants.

Breast milk also transfers the mother’s antibodies to her baby. This can protect an infant against common illnesses and allergies.

A study among more than 2,000 women and their infants in Africa and India, called the PROMISE trial, compared results when either a breastfeeding mother or her infant took HIV drugs. In both parts of the study, HIV transmission rates to babies were found to be very low—less than 1 percent a year after birth. Two infants in this study did acquire HIV from their mothers, though there may be reason to believe the mothers did not have undetectable viral loads at the time of transmission.

Breast milk also transfers the mother’s antibodies to her baby. This can protect an infant against common illnesses and allergies. Like other medications, the HIV drugs a woman takes are passed on to her baby through breast milk. However, we do not know how much of the HIV drugs is passed on to breastfed infants, whether that amount changes during the time they are breastfeeding, or what long-term effects HIV drugs may have on the child.

Much of the information we have on HIV and breastfeeding comes from resource-limited settings, where breastfeeding is recommended, and older HIV drugs are common. Women in resource-rich countries usually take newer HIV drugs and are more likely to have access to enough food and clean water. Therefore, breastfeeding may affect the health of both mother and child differently than in resource-limited settings. Because HIV guidelines in most resource-rich countries have recommended against breastfeeding for many years, studies on breastfeeding and HIV have been limited in such countries.

Breastfeeding and HIV: You do not want to miss this informative discussion between two mothers fighting for the right to feed their children as they choose! In this episode of A Girl Like Me LIVE in honor of National Breastfeeding Awareness Month, host Ci Ci Covin talks with her friend and sister advocate Heather O’Connor of International Community of Women Living With HIV North America about their personal experiences and work around informed infant feeding decisions for parents with HIV.

View other episodes in the A Girl Like Me LIVE series​

What Factors Can Affect HIV Transmission Risk During Breastfeeding?

  • Adherence challenges for new parents: Taking care of a newborn is exhausting work. New mothers may forget to take some of their HIV drugs, and often forego their own care as they care for their new babies. Infants also need to see a healthcare provider often. The mother may not have time to get the baby to all their appointments and go to all of her own HIV-related appointments. Not taking all drugs as prescribed or forgetting a healthcare appointment may lead to the mother’s viral load going up, increasing the risk for passing HIV on to her baby.
  • Inflammation in a baby’s gut: This can happen when the baby is vomiting or has diarrhea. Gut irritation has been shown to be a risk factor for HIV transmission through breast milk because the virus can more easily pass into the baby’s bloodstream through an irritated gut.
  • Breast infections: A breast infection called mastitis—which is common among breastfeeding mothers whether or not they are living with HIV—can increase HIV-infected inflammatory cells in the area of the infection.
  • Nipple health: Many women’s nipples become sore or cracked during breastfeeding, whether they are new to parenthood or experienced with breastfeeding. Cracked nipples may expose the baby to some of their mother’s blood, again increasing the risk for transmitting HIV during feeding.
  • Breast engorgement: A new mother’s breasts can sometimes become engorged (painfully overfilled with milk), which may also increase the viral load in breast milk and the risk of transmitting HIV during feeding. 

Is U Equals U True for Breastfeeding?

“Undetectable Equals Untransmittable,” or “U=U,” refers to the large and growing body of research that has shown that a person living with HIV who takes HIV drugs and whose viral load is undetectable cannot pass the virus on to their sexual partners. For more information on this exciting development, please see our fact sheet Undetectable Equals Untransmittable: Building Hope and Ending HIV Stigma.

The amount of HIV in a parent’s breast milk can be different from the amount in their blood. We do not know whether that is also true if the parent’s viral load has been undetectable for a while and they continue to take HIV drugs.

While the risk of HIV transmission through breastfeeding is low when the parent’s viral load is undetectable, studies have not shown the level of risk to be zero as is the case with sexual transmission of HIV. While research into this issue continues, it is important for care providers and other community health professionals to help parents make informed choices based on the information we have today, and to provide support to those who choose to breastfeed their babies.

What Are the Benefits and Challenges of Breastfeeding?

Benefits:

  • Nutrition and protection for baby: Breast milk is the most nutritious food for babies and young children. It also carries the parent’s antibodies, which protect babies from many illnesses and allergies.
  • Health beyond infancy: Breastfed babies also have lower risk of diseases such as type 2 diabetes and obesity later in life.
  • Cost, availability, and convenience: Breast milk is free and readily available whenever the mother is with the baby. It can be expressed (pumped) and fed to the baby in a bottle when the mother is not nearby.
  • For the breastfeeding parent:
    • Bonding: Breastfeeding may help new mothers feel close to their infants.
    • Mental health: Breastfeeding can also help new mothers avoid postpartum depression, which can be serious and make it harder to care for a new baby.
    • Maternal blood loss: Breastfeeding lowers the risk of blood loss after delivery.
    • Overall maternal health: Breastfeeding has also been shown to reduce risk of breast and ovarian cancers, high blood pressure, and diabetes.

Potential risks and challenges:

  • Transmission: HIV can be transmitted through breast milk, which could mean that a baby born HIV-negative acquires the virus from their parent’s milk. There is some research showing that risk increases with “mixed feeding” (baby is given other forms of nourishment, such as solid food, in addition to breast milk before six months of age). That is why the WHO recommends that, for the first six months of their lives, babies in resource-limited countries only be fed breast milk. Breastfeeding also sometimes leaves nipples sore or cracked, or breasts can become engorged—which are not only uncomfortable conditions for the mother but may increase the risk of transmitting HIV to the infant.
  • Breastfeeding difficulties: Numerous mothers, regardless of their HIV status, struggle with breastfeeding while they work outside the home or take care of other children and a household. Add to this HIV drugs that must be taken on a schedule—or given to the baby on a schedule—and additional appointments with healthcare providers, and finding the time and space to breastfeed may become even more difficult.
  • Legal considerations: In countries where clinical recommendations discourage women living with HIV from breastfeeding, a woman who chooses to breastfeed her child may be forced to face child endangerment authorities, or even criminal charges. According to the HIV Justice Network, women living with HIV have been charged in court for alleged HIV exposure through pregnancy, birth, or breastfeeding in several high-income countries, including the US. The US perinatal HIV clinical guidelines specifically warn against engaging Child Protective Services or similar agencies in response to inquiries about breastfeeding while living with HIV.
  • Disclosure: In communities where everyone breastfeeds, choosing not to do so may signal to others that a mother is living with HIV, even though she has not disclosed her status (told others that she is living with the virus). This is especially true if infant formula is provided for free to women living with HIV, but not to other new mothers.
  • Family coercion: Women may also face pressure from their families to breastfeed. In particular, women have reported being pushed to breastfeed their babies by their mothers-in-law—the paternal grandmothers of their babies.
  • Overall lack of support for breastfeeding: In some countries, such as the US, women find it difficult to breastfeed, independent of HIV status. Breastfeeding in public places is stigmatized and new mothers are expected to return to work outside the home soon after birth. If “breast is best,” women who breastfeed must get the support they need, whether or not they are living with HIV.

The Bottom Line

The process of deciding how to feed your infant can be overwhelming for parents who are living with HIV. For those who wish to explore breast/chestfeeding, the information available can be confusing. If you choose to breast/chestfeed, it is important to take your HIV drugs, and keep up with healthcare visits and viral load testing, exactly as prescribed and recommended by your provider. It is also very important to find a support network, including a provider—and other allies—whom you trust, and who can be good sources for information without judgment.

Special thanks to Shannon Weber, MSW from HIVE and Lena Serghides, PhD from University of Toronto for their special consultation on the initial version of this fact sheet.

The Well Project is a non-profit organization whose mission is to change the course of the HIV/AIDS pandemic through a unique and comprehensive focus on women and girls across the gender spectrum. Visit their website, https://www.thewellproject.org/, to access fact sheets (English and Spanish), blogs, and advocacy tools, and to join a global community of women living with HIV.