To help eliminate perinatal HIV transmission, the US Department of Health and
Human Services recommends against breastfeeding for women living with HIV,
regardless of viral load or combined antiretroviral therapy (cART) status.
However, cART radically improves HIV prognosis and virtually eliminates
perinatal transmission, and breastfeeding's health benefits are
well-established. In this setting, pregnancy is increasing among American women
with HIV, and a harm reduction approach to those who breastfeed despite
extensive counseling is suggested. We assess the evidence and ethical
justification for current policy, with attention to pertinent racial and health
disparities. We first review perinatal transmission and breastfeeding data
relevant to US infants. We compare hypothetical risk of HIV transmission from
breastmilk to increased mortality from sudden infant death syndrome, necrotizing
enterocolitis and sepsis from avoiding breastfeeding, finding that benefits may
outweigh risks if mothers maintain undetectable viral load on cART. We then
review maternal health considerations. We conclude that avoidance of
breastfeeding by women living with HIV may not maximize health outcomes and
discuss our recommendation for revising national guidelines in light of
autonomy, harm reduction and health inequities.
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