Expert View
Rafael Pérez-Escamilla, PhD, a professor of public health and director of the Maternal and Child Health Program at Yale University in New Haven, Connecticut and a member of the National Academy of Medicine, recently coauthored a review published in Advances in Nutrition. The review highlighted significant shifts in breastfeeding guidelines for women with HIV since the introduction of more effective ART in 2010.
Speaking to Medscape Spanish, Pérez-Escamilla emphasized that changing health guidelines that have been established over decades is a slow and complex process. “It requires political will, a transparent process, and the active involvement of scientists, public health professionals, program implementers, and women living with HIV,” he stated.
The review examined policy analyses and recommendations from 19 Latin American countries and found a widespread lag in the adoption of WHO guidelines. Although Argentina, Trinidad, and Tobago have made some updates, most countries in the region continue to prohibit breastfeeding of women with HIV.
Furthermore, the review found no documented experience of how this new breastfeeding approach for women with HIV has been implemented in Latin America.
Nevertheless, Pérez-Escamilla pointed out signs of progress. “Some countries are considering formal revision processes and have published updated technical reports explaining how to support safe breastfeeding,” he said.
Emphasizing the challenge ahead, he added, “The real challenge is translating updated guidelines into practice effectively, equitably, and with respect for human rights.”
Leda Guzzi, MD, an infectious disease specialist at Maternidad Santa Rosa and Clínica Olivos in Vicente López, Buenos Aires, Argentina, highlighted the delicate balance between risk and benefit. “When women are on effective ART with sustained viral suppression, especially before pregnancy, the risk of HIV transmission through breastfeeding is less than 1%. At the same time, the benefits are significant,” she noted.
Breastfeeding offers infants ideal nutrition and immune protection, thereby reducing the risk for infection and allergies. For mothers, breastfeeding lowers the risk for breast and ovarian cancers, obesity, and postpartum depression while strengthening the mother-infant bond.
“Therefore, in my opinion and that of many colleagues, we are facing a clinical balance between the minimal risk of HIV transmission in favorable virological scenarios and the unquestionable benefits of breastfeeding,” said Guzzi.
She added that Latin America is only beginning to explore this possibility. “We could say that there is a time lag compared to other countries. I believe this is explained by the region’s socioeconomic and cultural complexities, as well as the need for health strategies that provide both security and access across all social sectors,” Guzzi said.
Until 2023, the United States maintained a formal prohibition against breastfeeding for women with HIV. However, growing scientific evidence, expert consensus, and advocacy from affected women led the Department of Health and Human Services to reverse the ban.
The updated guidelines now support evidence-based counseling, allowing women with HIV to make informed and shared decisions regarding infant feeding.
Canada and several European countries have moved in this direction, where HIV transmission through breastfeeding is rare when mothers maintain undetectable viral loads.
However, Latin America lags in terms of policy changes. Guzzi explained, “There is a status quo in infant feeding policies. The evidence is strong, and society is calling for change. However, given the region’s social and economic complexities, its implementation is challenging. For now, each case must be assessed individually.”
She underscored that maintaining high adherence to ART is critical and depends on psychological, social, cultural, and economic factors. The postpartum period is particularly vulnerable, making medical and social support essential for mothers.
“Implementation should be progressive and individualized,” she said, stressing the importance of a multidisciplinary care team.
For Pérez-Escamilla, breastfeeding transcends public health and is a human right that is fundamental to the health of individuals and the development of nations. “It is not justifiable that outdated recommendations continue to deny support to women with HIV who want to breastfeed,” he said.
He urged governments to ensure universal access to HIV screening, effective ART, and breastfeeding counseling, along with increased investment in implementation research to coordinate health and social systems.
Guzzi echoed this call for action, emphasizing the need for greater involvement of health authorities, scientific societies, and women living with HIV.
She pointed to the Argentine Society of Infectious Diseases, which updated its guidelines in 2023 and reinforced them in 2024, as a regional example.
Guzzi noted that there is a strong and well-founded demand from civil society, especially from groups of women living with HIV who feel that their reproductive rights have been violated.
They see it as inequitable that in many middle- and high-income‑ countries, feeding practices for infants born to mothers with HIV are restricted to formula feeding. For this reason, she explained that there are urgent calls to reopen the discussion and establish new breastfeeding guidelines.
This demand is also driving regional efforts by professionals from multiple sectors to seek more flexible practices. “We owe this to our patients. The HIV community is constantly fighting stigma and discrimination, and the fact that breastfeeding cannot even be considered places them in a situation of inequality,” Guzzi concluded.
By Fernando Fuentes, MD
