US clinicians propose breastfeeding protocol for women living with HIV in high-income countries

A multidisciplinary team in Colorado has developed a protocol to address infant feeding among women living with HIV (WLWH) in the U.S. They recommend early counseling, frequent viral load monitoring, and infant prophylaxis for women with undetectable viral loads who want to breastfeed. A chart review also identified the characteristics of WLWH who wanted to breastfeed.

About This Study

“Development and implementation of an interdisciplinary model for the management of breastfeeding in women with HIV in the United States: experience from the Children’s Hospital Colorado Immunodeficiency Program” was published online on April 27, 2023, in Journal of Acquired Immune Deficiency Syndromes. The lead authors are Lisa Abuogi, M.D., and Christiana Smith, M.D., of the Department of Pediatrics at the University of Colorado in Aurora.

Key Research Findings

Many high-income countries (including the U.S., albeit recently) have acknowledged that living with HIV is not a barrier to breastfeeding/chestfeeding a child. Despite this, the study authors stated that detailed recommendations on how to implement a program supporting these individuals were not available. Their single-site study describes a protocol for supporting WLWH in the U.S. who choose to breastfeed.

Developed by an interdisciplinary group of providers in Colorado, the protocol emphasizes the need for coordination among the healthcare team that cares for the birthing parent and the infant. In addition, a small, retrospective chart review of cisgender females described the characteristics of those who wished to breastfeed.

Infant feeding is addressed early during prenatal care and an undetectable viral load (≥20 copies/ml) is a prerequisite for safely breastfeeding. The infant is given zidovudine or nevirapine beginning by 6 hours after delivery until four weeks after being weaned. Both lactating parent and infant are frequently tested for HIV until six months after weaning.

Mixing breast and formula feeding is discouraged. To facilitate weaning, lactating parents are encouraged to feed the infant both directly from the breast and using a bottle with pumped breastmilk. If a lactating parent’s viral load rises to ≥20 copies/ml and <200 copies/ml, the maternal viral load is repeated as soon as possible, breastfeeding is stopped, and stored breast milk from before viremia or donor milk is used. The infant is given a three-drug antiretroviral regimen until the parent’s viral load returns to undetectable. If the repeat maternal viral load is undetectable, breastfeeding is resumed. If the lactating parent’s viral load rises ≥200 copies/ml, breastfeeding is permanently discontinued.

The chart review indicated that between 2015 and 2022, 10 WLWH breastfed 13 infants for a median of 62 days, with 4 women weaning within the first month. Two women experienced low-level viremia, and 6 infants had laboratory abnormalities related to prophylaxis. One participant had a viral blip and the other one weaned their infant. All infant adverse events resolved, mostly spontaneously.

Discussion Highlights and Implications for Practice

This group’s protocol has changed over time and is updated at least annually. Lactation consultation and educational materials are provided. The authors recommend that parents introduce expressed breastmilk early and they offer support for breast pumps, to facilitate weaning.

Study authors also recommend qualitative research into lactating parents’ experiences with breastfeeding, as well as further research into mixed feeding when the lactating parent’s viral load is undetectable.

Because programs all vary in approaches, national guidelines are needed, the authors stated. Until then, they offered that this program protocol lays out practical guidance and tools for providers to support people living with HIV to breastfeed/chestfeed.

By Barbara Jungwirth