Let's Talk About Poz, Undetectable Mothers Who Breastfeed

Currently in the United States, the Centers for Disease Control and Prevention continues to recommend that women living with HIV feed their infants formula instead of nursing them, but more and more women — and their doctors — are questioning that advice.

As the Mayo Clinic notes, breastfeeding has long been recognized as the preferable method of nourishing a newborn baby. Breast milk contains the right balance of nutrients and plays a critical role in the development of a child’s immune system, and the bonding that occurs between a mother and child during breastfeeding can help create a healthy emotional relationship. Despite these well-known advantages, women living with HIV have been warned to avoid breastfeeding out of concern that they could transmit the virus to their child.

Yet, the development of highly effective antiretroviral medications has dramatically reduced rates of vertical transmission (previously called mother-to-child transmission) and in response, the World Health Organization recommends — particularly in low-resource settings where the risk of malnutrition is much higher — that HIV-positive mothers exclusively breastfeed with ongoing antiretroviral therapy.

With the consensus that undetectable equals untransmittable (U=U), proving that if your viral load is suppressed you can’t transmit HIV to others, mothers living with HIV in the U.S. are increasingly questioning the CDC’s anti-breastfeeding recommendations.

The Journal of the International AIDS Society, in an article published in January, examined how health care providers are responding to dual pressures to follow CDC guidelines and to address their patients’ interest in breastfeeding.

Over 75 percent of participating providers reported having a patient with HIV explicitly ask if they could breastfeed their child. The majority of providers (66.7 percent) reported that they discussed infant feeding with their HIV-positive female patients by using open-ended questions.

While sharing the CDC’s recommendations, providers on the whole also tried to understand and address concerns — and continue to support their patients regardless of what choice they made (29 percent reported having a patient who decided to breastfeed despite recommendations against doing so).

The majority of providers (58 percent) reported that their clients’ primary concern was cultural stigma associated with not breastfeeding.

Meanwhile, 70 percent of providers said their primary concern was about their patients adhering to HIV treatment during breastfeeding. (The doctors feared if a patient didn’t adhere, the child could contract HIV.)

Researchers found providers struggled with four main issues: U.S. guidelines that inadequately address the desire to breastfeed among women living with HIV; a need to negotiate patient autonomy amid complex feeding situations; how to create harm reduction approaches to support breastfeeding; and equipping patients to deal with multi-layered stigmatization around breastfeeding (or not) while poz.

Currently, the CDC and the American Academy of Pediatrics advise against breastfeeding while HIV-positive regardless of one’s viral load. The CDC argues online, “The best way to prevent transmission of HIV to an infant through breast milk is to not breastfeed. In the United States, where mothers have access to clean water and affordable replacement feeding, [we] recommend that [HIV-positive] mothers completely avoid breastfeeding their infants, regardless of ART and maternal viral load.”

Although the CDC’s hesitancy to endorse poz women breastfeeding is understandable, breastfeeding has lifelong advantages for children. And it certainly seems that the strict recommendation to not breastfeed when poz is at odds with the latest science around HIV transmission, particularly in association with those who are virally suppressed and undetectable.