Breastfeeding in HIV-positive women: What can be recommended?

Breastfeeding remains a common practice in parts of the world where the burden of HIV is highest and the fewest alternative feeding options exist. The impossible dilemma faced by HIV-positive mothers is whether to breastfeed their infants in keeping with cultural norms but in doing so risk transmitting the virus through breast milk, or to pursue formula feeding, which comes with its own set of risks, including a higher rate of infant mortality from diarrheal illnesses, while reducing transmission of HIV. Treatment of mothers and/or their infants with antiretroviral drugs is a strategy that has been employed for several decades to reduce HIV transmission through pregnancy and delivery, but the effect of these agents when taken during breastfeeding is a newer field of study. In this article we evaluate the latest clinical research, from trials that encourage exclusive breastfeeding to trials of antiretroviral therapy (ART) for either the mother or infant, in an attempt to prevent transmission of HIV through breast milk. Additionally, we discuss research that is in progress, with results anticipated in the next few years that will further shape clinical guidelines and practice. Exclusive breastfeeding is much safer than mixed feeding (the supplementation of breastfeeding with other foods), and should be encouraged even in settings where ART for either the mother or infant is not readily available. The research published regarding maternal treatment with highly active antiretroviral therapy (HAART) during pregnancy and the breastfeeding period has all been non-randomized with relatively little statistical power, but suggests maternal HAART can drastically reduce the risk of transmission of HIV. Infant prophylaxis has been intensively studied in several trials and has been shown to be as effective as maternal treatment with antiretrovirals, reducing the transmission rate after 6 weeks to as low as 1.2%. Research that is in progress will provide us with more answers about the relative contribution of maternal treatment and infant prophylaxis in preventing transmission, and the results of such research may be expected as early as this year through 2013. There is hope that perinatal HIV transmission may be greatly reduced in breastfeeding populations worldwide through a combination of behavioral interventions that encourage exclusive breastfeeding and pharmacologic interventions with antiretrovirals for mothers and/or their infants.