Is It Safe to Breastfeed While Living With HIV?

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Deciding how to feed their babies is one of the most crucial choices for expectant and new parents. This decision becomes even more complex when the birthing parent is living with HIV. The information available to mothers and other parents with HIV can be overwhelming, especially for those considering breastfeeding (nursing, body feeding). Feeding a baby milk from another person's body is also referred to as "chestfeeding," a term that accommodates individuals without breasts, whether due to surgery or personal preference for gender-neutral language.

Breast milk is one of the body fluids, alongside blood, semen (“cum”), and vaginal or rectal fluids, that can transmit HIV. Although research hasn't confirmed that the risk is completely zero, similar to sexual transmission, the risk of HIV transmission through breast/chestfeeding when the parent's viral load is undetectable remains 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.

If you're a woman with HIV living in a region where essential resources like clean water, refrigeration, and medical care are scarce, the World Health Organization (WHO) advises that you breastfeed your baby while on HIV medication. They may also suggest that your baby undergoes a course of HIV medication during the breastfeeding period. This recommendation is due to the fact that in such areas (for example, many parts of Africa or India), infants face a higher risk of developing diarrhea and other illnesses, which can be fatal. Breast milk is packed with substances that protect and bolster a child's immune system, even beyond the breastfeeding stage. Therefore, breast milk can play a crucial role in helping children combat these health issues. Additionally, formula feeding might not be a viable option in these regions due to the lack of funds to purchase formula, clean water to mix it if powdered, or refrigeration to keep it safe. Health authorities have concluded that in resource-limited settings, the advantages of breastfeeding outweigh the potential risk of HIV transmission.

If you are a woman with HIV living in a well-resourced area like the US or Europe, you have probably been advised not to breastfeed your baby. Health organizations such as the European AIDS Clinical Society (EACS) and the British HIV Association (BHIVA) recommend that women with HIV refrain from breastfeeding. In these regions, infant formula is usually easy to obtain and safe to prepare (though not always). The likelihood of a baby dying from illnesses that breast milk can help prevent is significantly lower. Consequently, these guidelines are based on the understanding that even the minimal risk of transmitting HIV through breast milk is not justifiable when safe alternatives are available.

A major update took place on January 31, 2023, when the US Department of Health and Human Services (HHS) revised the perinatal HIV clinical guidelines. The new guidelines no longer discourage breastfeeding. Instead, they acknowledge the latest evidence indicating that the risk of HIV transmission via breast milk is very low if the breastfeeding individual is on HIV medication and has an undetectable viral load. Additionally, the guidelines suggest that healthcare providers talk about various infant feeding choices with women and other birthing parents living with HIV.

In recent years, HHS, BHIVA, and EACS HIV treatment guidelines have started to incorporate updates that recognize some women living with HIV wish to breastfeed. They also suggest methods for healthcare providers to assist parents contemplating this option.

For further details on this topic, refer to our fact sheet titled HIV Treatment Guidelines for Pregnant People and Their Infants.

There are numerous significant reasons why parents with HIV in well-resourced regions might want to think about breast/chestfeeding:.

Comprehensive studies have established that breast milk is the ideal nourishment for the majority of infants, safeguarding their health as they develop and meeting every one of their nutritional requirements.
Emotional and cultural factors play a significant role, even if formula is readily available in their location.
Feeling pressure from their families to breastfeed.
Choosing not to breastfeed might lead to the unintended revelation of their HIV status if people in their community start asking why they are using formula.
Parents who have relocated from a country with fewer resources to a more affluent region might find themselves questioning why the guidelines and possible limitations they're receiving in their new location seem different.

In addition, there are various health conditions affecting mothers and infants in the US and other regions that breastfeeding can help protect against. One of these conditions is sudden infant death syndrome (SIDS), responsible for over 1,000 infant deaths annually in the US. Although the exact cause of SIDS remains unknown, evidence suggests that breastfeeding can lower its risk. Women of color, particularly Black women, are disproportionately affected by HIV and also face higher rates and worse outcomes from numerous maternal and infant illnesses, which breastfeeding may help alleviate. Consequently, some healthcare professionals addressing infant feeding and HIV believe that advising against breastfeeding in resource-rich countries could potentially worsen health disparities among women living with HIV.

Grab a copy of this fact sheet in a PDF slide presentation.

Although the possibility of HIV transmission via breast milk significantly diminishes if you are on HIV medication and your viral load is undetectable, there might still be a slight risk. An undetectable viral load in the blood does not necessarily mean it's undetectable in breast milk. Further research is essential to understand how HIV medications impact the cells in breast milk and breastfed babies.

The PROMISE trial, which involved over 2,000 women and their infants in Africa and India, explored the effects of either the breastfeeding mother or the infant taking HIV medication. Findings from both segments of the study showed that the rate of HIV transmission to babies was extremely low, coming in at less than 1 percent one year after birth. Although two infants contracted HIV from their mothers, it is possible that the mothers did not have undetectable viral loads when the transmission occurred.

Breast milk not only nourishes a baby but also provides the mother's antibodies. These antibodies can help shield the infant from common illnesses and allergies. Similarly, any HIV medications a woman takes are also transferred to her baby through breast milk. Studies in areas with limited resources indicate that this transfer of antibodies and HIV drugs may help protect the child from contracting HIV. Despite this, we still lack precise information on how much of these drugs are passed to breastfed infants, whether the amount fluctuates during breastfeeding, or what the long-term effects might be on the child.

A significant portion of our knowledge about HIV and breastfeeding stems from regions with limited resources, where breastfeeding is advised, and older HIV medications are still prevalent. In contrast, women in wealthier countries typically use more modern HIV treatments and have better access to adequate food and clean water. Consequently, the health impact of breastfeeding on both mother and child may differ from that in resource-limited areas. Due to longstanding guidelines in most affluent nations advising against breastfeeding for HIV-positive mothers, there has been a shortage of research on breastfeeding and HIV in these countries.

Breastfeeding and HIV: Don't miss this enlightening conversation between two determined mothers advocating for their right to choose how they feed their children! This episode of A Girl Like Me LIVE, celebrating National Breastfeeding Awareness Month, features host Ci Ci Covin chatting with her companion and fellow advocate Heather O’Connor from the International Community of Women Living With HIV North America. Together, they share their personal journeys and efforts in promoting informed infant feeding choices for parents with HIV. Catch more episodes in the A Girl Like Me LIVE series.

Breastfeeding and HIV: This is a conversation you won’t want to miss! Join us for this powerful episode of A Girl Like Me LIVE, in celebration of National Breastfeeding Awareness Month. Host Ci Ci Covin engages in a heartfelt discussion with her friend and fellow advocate Heather O’Connor from the International Community of Women Living With HIV North America. They dive into their personal stories and the important work they’re doing to support parents with HIV in making informed infant feeding choices.

Check out more episodes in the A Girl Like Me LIVE series.

Adherence challenges for new parents: Caring for a newborn is exhausting. New mothers might forget to take some of their HIV medication and often neglect their own health while tending to their babies. Infants also require frequent visits to healthcare providers. The mother might not have the time to attend all of her baby's appointments as well as her own HIV-related check-ups. Missing doses or healthcare appointments could cause the mother's viral load to increase, heightening the risk of transmitting HIV to her infant.
Inflammation in a baby’s gut: This can occur when an infant experiences vomiting or diarrhea. Research indicates that an irritated gut increases the risk of HIV transmission via breast milk, as the virus can more readily enter the baby’s bloodstream through the inflamed gut lining.
Breast infections: Mastitis, a type of breast infection that frequently occurs in breastfeeding mothers regardless of their HIV status, can lead to an increase in HIV-infected inflammatory cells in the infected area.
Nipple health: It's common for women's nipples to become sore or cracked while breastfeeding, affecting both new mothers and those more experienced with nursing. Cracked nipples can potentially expose the baby to the mother's blood, thereby raising the risk of HIV transmission during feeding.
Breast engorgement: A new mother's breasts can occasionally become painfully overfilled with milk, a condition known as engorgement. This may also lead to a higher viral load in the breast milk, increasing the risk of HIV transmission during breastfeeding.

Profiles of a pregnant person and a person holding an infant with the word “BEEEBAH”.

BEEEBAH (Building Equity, Ethics, and Education on Breastfeeding and HIV) is a thorough, multi-faceted three-year initiative that enhances The Well Project’s mission to broaden awareness and provide information about breast/chestfeeding and HIV. LEARN MORE & CHECK PAGE OFTEN FOR BEEEBAH UPDATES!.

BEEEBAH (Building Equity, Ethics, and Education on Breastfeeding and HIV) is a detailed, multifaceted three-year initiative that enhances The Well Project's mission to broaden awareness and availability of information related to breast/chestfeeding and HIV.

FIND OUT MORE & VISIT THE PAGE REGULARLY FOR BEEEBAH NEWS!

"Undetectable Equals Untransmittable," often abbreviated as "U=U," highlights extensive and increasing research demonstrating that individuals living with HIV who adhere to antiretroviral therapy and achieve an undetectable viral load are unable to transmit the virus to their sexual partners. For further details on this groundbreaking advancement, please see our fact sheet Undetectable Equals Untransmittable: Building Hope and Ending HIV Stigma.

The level of HIV present in a parent's breast milk can vary compared to what's in their blood. We aren't sure if this holds true when the parent's viral load has been undetectable for some time and they are still on HIV medication.

Although the likelihood of HIV transmission via breastfeeding is very low when the parent's viral load is undetectable, studies have yet to confirm that the risk is entirely absent, unlike the scenario with sexual transmission of HIV. As research on this matter progresses, it remains crucial for care providers and other community health professionals to aid parents in making informed decisions using the current information available, and to offer support to those who opt to breastfeed their infants.

Nutrition and protection for baby: Breast milk is the healthiest food for infants and young children. It also contains the parent's antibodies, offering babies protection against numerous illnesses and allergies.
Health beyond infancy: Babies who are breastfed are also less likely to develop diseases like type 2 diabetes and obesity as they grow older.
Cost, availability, and convenience: Breast milk doesn’t cost anything and is always on hand as long as the mother is present. When the mother is away, breast milk can be pumped and given to the baby in a bottle.
For the breastfeeding parent:
Bonding: Nursing can create a sense of closeness between new mothers and their babies.
Mental health: Breastfeeding can also assist new mothers in preventing postpartum depression, which can be severe and challenge the process of caring for a newborn.
Maternal blood loss: Breastfeeding helps reduce the risk of bleeding after childbirth.
Overall maternal health: Evidence suggests that breastfeeding can lower the chances of developing breast and ovarian cancers, as well as high blood pressure and diabetes.

Transmission: HIV can also be passed on through breast milk, meaning that a baby who is born without HIV could get the virus from their parent's milk. Research indicates that the risk of transmission rises with "mixed feeding" (when the baby receives additional forms of nourishment, like solid food, besides breast milk before reaching six months old). This is why the WHO advises that babies in resource-limited countries should be exclusively breastfed for the first six months of their lives. Additionally, breastfeeding can sometimes cause nipples to become sore or cracked, or lead to engorged breasts—conditions that not only cause discomfort for the mother but may also heighten the risk of passing HIV to the infant.
Breastfeeding difficulties: Many mothers face challenges when it comes to breastfeeding, particularly those juggling work, childcare, and household responsibilities, no matter their HIV status. The situation becomes more complicated when factoring in the need to take HIV medications regularly or administer them to their baby on a set schedule, along with additional healthcare appointments. As a result, finding the time and place to breastfeed can become even more challenging.
Legal considerations: In nations where medical guidelines advise against breastfeeding for women with HIV, a mother who opts to breastfeed might end up facing child endangerment authorities or even criminal accusations. The HIV Justice Network reports that women living with HIV have been taken to court for alleged HIV exposure during pregnancy, childbirth, or breastfeeding in various wealthy countries, including the US. The 2023 update to the US perinatal HIV clinical guidelines explicitly cautions against involving Child Protective Services or similar agencies when it comes to questions about breastfeeding while living with HIV.
Disclosure: In societies where breastfeeding is the norm, a mother who opts not to breastfeed may unintentionally reveal that she has HIV, even if she hasn't shared her status. This is particularly apparent when infant formula is given at no cost to mothers with HIV, but not to other new mothers.
Family coercion: Women can sometimes experience pressure from their families to breastfeed. Many women specifically mention feeling urged by their mothers-in-law, the paternal grandmothers of their babies, to breastfeed.
Overall lack of support for breastfeeding: In certain nations, like the US, women face challenges when it comes to breastfeeding, regardless of their HIV status. Breastfeeding in public is often frowned upon, and new mothers are pressured to return to work shortly after giving birth. If "breast is best," it's crucial that breastfeeding women receive the necessary support, whether or not they are HIV-positive.

Navigating the decision on how to feed your infant can be overwhelming for parents living with HIV. The information around breast/chestfeeding can often be confusing for those who want to explore this option. If you decide to breast/chestfeed, it's vital to adhere to your HIV medication regimen and stay consistent with healthcare appointments and viral load tests, exactly as advised by your healthcare provider. Equally crucial is finding a supportive network, including a trustworthy provider and other allies who can offer judgment-free information.

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