Infant Feeding and Lactation

The DHHS National Perinatal HIV Guidelines includes recommendations for how to approach breastfeeding using harm-reduction, shared decision-making strategies.

The following guidance is taken directly from the DHHS National Perinatal HIV Guidelines (December 2018):

?If, despite extensive counseling, a woman decides to breastfeed, harm-reduction measures should be taken to reduce the risk of HIV transmission. These include:

• Demonstrating maternal ART adherence and engagement in care both during pregnancy and throughout breastfeeding.
• Documenting consistent viral suppression prior to delivery and throughout breastfeeding. This can be accomplished by monitoring maternal plasma viral loads every 1 to 2 months during breastfeeding. If maternal viral load becomes detectable, consult an expert immediately.
• Breastfeeding exclusively for up to 6 months postpartum, followed by breastfeeding in combination with the introduction of complementary foods.
• Developing a plan for weaning with input from the family and providers. Rapid weaning over a few days is not recommended.
• Infants should receive at least 6 weeks of infant ARV prophylaxis with zidovudine and/or nevirapine. In non-breastfeeding infants, there is high quality evidence that 4 weeks to 6 weeks of infant prophylaxis with zidovudine prevents HIV transmission (see Antiretroviral Management of Newborns with Perinatal HIV Exposure of Perinatal HIV). The most extensively studied infant prophylaxis in breastfeeding infants is daily infant nevirapine, which has been shown to be safe and effective when used for extended prophylaxis in infants whose mothers are not receiving ART.11,14 If the mother is receiving ART, infant ARV prophylaxis can be discontinued after 6 weeks. Some experts in the United States have felt more comfortable with continuing infant ARV prophylaxis through 1 month after cessation of weaning, even when the mother is receiving ART. However, during the HPTN 046 trial, in which the mothers received ART, there was no difference in postnatal transmission when the infant received nevirapine or placebo, suggesting no additive effect.11 
• Monitoring the infant for HIV acquisition during breastfeeding. A reasonable approach to infant monitoring would include virologic HIV testing at the standard time points (see Maternal HIV Testing and Identification of Perinatal HIV Exposure) and then every 3 months throughout breastfeeding, followed by monitoring at 4 to 6 weeks, 3 months, and 6 months after cessation of breastfeeding. 
• In the unlikely case of HIV transmission via breastfeeding, it is important to promptly initiate a full combination ARV treatment regimen for the infant. Resistance testing should be done on the infant viral isolate. If resistance is identified, the treatment regimen can be adjusted appropriately.
• Maternal mastitis and infant thrush should be promptly identified and treated, as both conditions increase the risk of HIV transmission through breastfeeding. Milk from the affected breast should be pumped and discarded until mastitis resolves.? 

Pasteurized Human Milk

The Human Milk Banking Association of North America (HMBANA) is a nonprofit milk bank with a network across the U.S. and Canada. The milk banks prioritize Pasteurized Donor Human Milk (PDHM) for medically fragile infants. PDHM is the only form of donor human milk recommended by all U.S. health authorities. While banked human milk is typically expensive when paid out-of-pocket, some insurance companies and public health benefits cover the cost of human milk for medically fragile infants, including those born to women living with HIV.

While HIVE does not endorse the following infant feeding options, we include resources because we value transparency and shared decision-making. In addition, we understand that patients often find such resources online, and we believe that proactively engaging in conversation with patients ultimately is safer than ignoring what is available online. 

Unpasteurized Donor Human Milk or ?Milk Sharing?

Buying and selling milk is not considered safe for infant feeding, particularly if exchanges are done online, anonymously, or with someone with whom the parent does not have a long-standing trusting relationship and who has not been tested recently for HIV and other infections that may be transmitted via breastmilk. ?The American Academy of Nursing on Policy on Informally Shared Milk. Perinatal Services in BC (Canada) has been a leader in providing information to families about peer-to-peer milk sharing. Eats on Feets (EOF) and Human Milk 4 Human Babies are two of the most well-known social media platforms where people may make offers and requests for human milk that is shared (not bought or sold). They also link to information about safer peer-to-peer milk sharing. EOF offers Four Pillars of Safe Breast Milk Sharing [written by a community midwife; not evidence-based nor officially endorsed by any organization including HIVE]. Mother?s Milk Alliance in WI has another model of community milk sharing, with sample protocols for donor screening. 

Another Person Breastfeeds Baby (?wet nursing?)

A postpartum woman living with HIV may choose to have another person breastfeed her/their baby (i.e. ?wet nurse?). The person who will be breastfeeding should be tested for HIV and other communicable diseases (e.g. HTLV, syphilis, hepatitis B and C) at baseline prior to initiation of breastfeeding as well as be asked about behavior that may be associated with acquisition of communicable diseases during the period of breastfeeding. Given the particularly high risk of HIV transmission to infants in the setting of incident HIV acquisition among breastfeeding women, healthcare providers should encourage and facilitate serial HIV testing of the wet nurse. Alternatively, to ensure a safe milk supply for the baby, those who are providing milk can be screened as milk donors and donate their milk via a licensed milk bank.

Flash Heating to Kill HIV in Expressed Milk

While flash heating of expressed breast milk has been found to be feasible in pilot studies in low-resource settings and appears to kill HIV, HIVE does not endorse this approach given the challenges of women implementing this strategy in the real-world and lack of quality assurance when done outside the structure of a research study.                    

While not endorsed by HIVE, we include information about flash heating to promote transparency and open dialogue. Flash heating of expressed breast milk is one of the 4 Pillars, and parents may wish to flash heat milk they receive from milk sharing. A lactating parent living with HIV can also express their milk and flash heat to kill HIV before storing and feeding by following these instructions from Eats on Feets.

Links from our perinatal providers page:

https://hiveonline.org/a-woman-centered-approach-to-infant-feeding-and-hiv/

https://hiveonline.org/breastfeeding-protocol/

• Booklet on the WHO updated guidance for HIV (updated 2016) (for key audiences such as perinatal  providers. Be mindful the site does not use gender inclusive and affirming language.)
• Link to the World Alliance for Breastfeeding Action 2018 HIV Kit ? this resource does not use gender-inclusive language. It does provide easy to understand guidance, with explanations and information sheets updated in 2018. (for providers)
• BHIVA (U.K. based) guidance on breastfeeding and HIV (for providers)
• BHIVA information sheet for ?women living with HIV? (for patients)
• Breastfeeding and HIV advocacy brief (2018) Global Breastfeeding Collective (general audience/policy)
• AVERT is based in the U.K. and has resources and information for both providers and individuals, might be helpful to click through to see the kind of guidance they include. (both providers and patients, based in the U.K. so guidance may be similar to what would be provided in the U.S.)