Can HIV-positive Mothers Breastfeed Their Babby?

Breastfeeding has a vital role in children's development and growth, especially in areas where diarrhea, pneumonia, and malnutrition are still the leading causes of death in children. For this reason, it is strongly recommended that exclusive breastfeeding be given during the first 6 months of life, followed by continued breastfeeding and appropriate complementary foods up to the age of 2 years or more.

On November 30, 2009, for the first time, WHO recommended the use of antiretroviral drugs (ARVs) to prevent postnatal HIV transmission during breastfeeding until the baby is 12 months old. According to a WHO study, the consumption of antiretroviral drugs combination during pregnancy, childbirth, and breastfeeding in HIV-positive mothers reduces the risk of transmission to their babies by 42%.

The WHO Recommendations Regarding Breastfeeding for HIV-positive Mothers

According to the WHO recommendations in 2016, Guidelines for HIV and Infant Feeding, HIV-positive Mothers should be given long-term ARV or prophylactic ARVs to reduce the risk of transmission due to breastfeeding. In this guideline, several key recommendations made by WHO are:

1. Duration of breastfeeding: For HIV-positive Mothers and the baby's HIV status uninfected or unknown, exclusive breastfeeding is recommended for 6 months and can be continued for up to 12 months or more. After that, breastfeeding can be stopped by ensuring a safe and adequate source of nutrition is available.

2. Mixed feeding: If the mother does not exclusively breastfeed the baby, this guideline states that ARVs can reduce the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, mixed feeding does not need to be a reason for a mother to stop breastfeeding if she has taken ARVs.

3. Breastfeeding duration is shorter than 12 months: In this guideline, WHO states that breastfeeding duration shorter than 12 months is safer and better than no breastfeeding at all.

4. If ARVs are not immediately available when the baby is born: Breastfeeding while waiting for the availability of ARVs is highly recommended because breastfeeding still provides a high likelihood that the child is not infected with HIV.

5. If the baby is HIV positive, mothers are advised to breastfeed exclusively for 6 months and continue until at least 2 years of age with recommendations according to the general population.

What is meant by the WHO recommendations for exclusive breastfeeding is breastfeeding from newborn until the age of 6 months in which infants only receive breast milk without additional food or drinks, including plenty of water. It is recommended to continue breastfeeding for at least 24 months. Breastfeeding is done on-demand or every baby's needs, both day and night.

How if Mother with HIV-positive Decides to Stop Breastfeeding?

If an HIV-positive mother decides to stop breastfeeding, make sure that the replacement food is safe and adequate to support the baby's normal growth and development.

Termination of breastfeeding must be done gradually in 1 month. Prophylactic ARVs continue until 1 week after breastfeeding is stopped. Stopping breastfeeding suddenly is not recommended.

Food Replacement Criteria for Breast Milk

The most appropriate baby feeding options for HIV-infected mothers are also seen based on the mother's condition, including health status and local situation. The election must also consider the availability of health services, counseling, and surrounding support.

For babies under the age of 6 months, an alternative can be given in commercial formula milk or warmed breast milk. Processed animal milk is not recommended.

For children over 6 months, commercial formula milk, dairy foods, milk combinations, and other foods can be given 4-5 times a day.

Warmed breast milk can be an option, with conditions:
a. Babies born with low birth weight or babies who are very ill during the neonatal period,
b. When the mother's health is interrupted and temporarily unable to breastfeed directly, the mother has temporary breast disorders such as mastitis
c. The mother will gradually stop breastfeeding her baby
d. If a temporary ARV drug is not yet available.

HIV-positive mothers are advised to only give commercial formula milk as a substitute food for babies with HIV negative or unknown status if the following conditions are met:
a. Clean drinking water is available, and sanitation is maintained around the residence.
b. Mothers or baby sitters can provide formula milk needs until healthy child growth and development is achieved according to age.
c. Mothers or baby sitters can prepare formula milk cleanly and according to the administration schedule to avoid the occurrence of diarrhea
d. Mother or babysitter can give formula milk for at least 6 months.
e. The family supports formula feeding.
f. Mothers or baby sitters can easily access the health center if the baby needs it.

This requirement is often referred to as AFASS (acceptable, feasible, affordable, sustainable, and safe).

Patient Education
The recommendation from WHO for all mothers regardless of HIV status is exclusive breastfeeding, which means no fluids or other foods besides breast milk is given during the first 6 months of life. After the baby is 6 months old, start giving complementary foods. The purpose of feeding babies in the context of HIV is not only to prevent HIV transmission but to ensure the health and survival of the baby.

Exclusive breastfeeding significantly reduces malnutrition and other serious infectious diseases (such as diarrhea and pneumonia), especially those that occur in the first year of life.

Writer: dr.Nenvy Gracia Wantouw, Pediatricians

1. Frank NM, Lynch KF, Uusitalo U, Yang J, Lonnrot M, Virtanen SM, et al. The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children. BMC Pediatr. 2019; 19: 339.
2. WHO. Breast is always best, even for HIV-positive mothers. Volume 88(1) : 1-80. 2010.
3. Kesho Bora study group. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomized controlled trial. The Lancet. 2011; 11: 171-80.
4. WHO. Guideline Updates on HIV and Infant Feeding. 2016.;jsessionid=2B554BB26D511600AA20A02F502322F8?sequence=1
5. WHO guidelines on HIV and infant feeding 2010. Geneva, WHO, 2010.
6. Kagaayi J, Gray RH, Brahmbhatt H, Kigozi G, Nalugoda F, Wabwere-Mangen F et al. Survival of infants born to HIV-positive mothers, by feeding modality, in Rakai, Uganda. PLoS One. 2008; 3:e3877.
7. Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S et al. Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015; 104:114–34.
8. WHO. Guidelines on antiretroviral drugs for treating pregnant women and preventing HIV infections in infants: Recommendations for a public health approach, Geneva, WHO, 2010.