In December, the Department of Health and Human Services updated its HIV treatment guidelines for pregnant women and children to reflect recent research. The revision recognizes that mothers on effective antiretroviral therapy with an undetectable viral load have a very low risk of transmitting HIV to their babies during pregnancy, delivery or breastfeeding.

 

Older guidelines advised mothers living with HIV not to breastfeed if safe formula and clean water are available, but HIV-positive women have advocated for more autonomy. The January 2023 update for the first time recommended “evidence-based, patient-centered counseling to support shared decision-making about infant feeding.”

 

The latest guidelines recommend that infants at high risk for HIV acquisition during gestation or delivery—meaning those born to a mother with a viral load of 50 copies or higher during the four weeks prior to delivery—should receive a three-drug antiretroviral regimen starting at birth and continuing for two to six weeks, while those at low risk should receive AZT alone for two weeks. Infants are considered at low risk for HIV acquisition during breastfeeding if the mother is on antiretroviral treatment with sustained viral suppression for at least three months before delivery. The panel members did not reach a consensus about whether such infants should receive extended antiretroviral prophylaxis.

 

The revision includes a discussion about what to do if viral load becomes detectable during breastfeeding. The authors recommend that breastfeeding should be stopped temporarily while viral load is rechecked, causes of viral rebound are assessed and the importance of adherence is reinforced. If viral load goes back to undetectable on repeated tests, a joint decision can be made about whether breastfeeding may safely resume.