Breastfeeding Uncommon Among HIV-Positive Women in North America

Breastfeeding was uncommon among HIV-positive mothers in North America, and variation in institutional breastfeeding policies and infant and maternal HIV testing schedules indicate the need for further research to identify best care practices.

Breastfeeding is not commonly practiced among women with HIV infection in North America, suggesting the need for multisite studies to identify best care practices. These study results were published in Clinical Infectious Diseases.

National guidelines recommend HIV-positive mothers to use formula over breastmilk due to the risk for HIV transmission. These recommendations are in contrast with data from resource-limited settings suggesting that the risk for HIV transmission from mother to infant is less than 1% among women who are virologically suppressed.

This study was designed to evaluate trends in breastfeeding practices among HIV-positive women in high-resource settings. Researchers sourced data from 8 sites in the United States and 3 in Canada on HIV-positive women who breastfed between 2014 and 2022. Study participants who breastfed (N=72) were retrospectively evaluated for characteristics and trends in care.

Among participants included in the analysis, the median age was 34 (IQR, 29-37) years, 62.5% were diagnosed with HIV more than 5 years before index pregnancy, 86.1% were receiving antiretroviral therapy (ART) prior to pregnancy, 52.8% used ART during pregnancy, and 22.2% used a modified ART regimen post partum.

At delivery, 90.3% of participants had a viral load of less than 40 copies/mL. At 12-months post partum, 31.9% of participants had a viral load of less than 40 copies/mL; however, 58.3% did not undergo laboratory analysis within the 12 months following delivery.

Most women were multiparous (80.6%) and entered prenatal care within 14 weeks of pregnancy (51.4%). Participants indicated attendance at a median of 7 (IQR, 4-10) prenatal visits.

In the first 12 months following delivery, 22.2% and 50.0% of participants indicated no attendance at obstetrics or HIV primary care appointments, respectively. Participants reported attendance at a median of 6 (IQR, 4-8) pediatric infectious disease appointments in the first 12 months following delivery.

The majority of participants reported receipt of counseling on infant feeding from an obstetrician (72.2%), followed by a pediatrician (34.7%) or adult HIV specialist (22.2%).

The most common motivations for breastfeeding included mother-infant bonding (23.6%), health benefits for the infant (22.2%), and community expectations or fear of HIV status disclosure (18.1%).

[S]tandardized recommendations may help expand infant feeding options to all locations where parents living with HIV and their infants receive care.

Participants breastfed for a median of 24 weeks (range, 1 day-72 weeks), and the most commonly reported challenge with breastfeeding was low supply (20.8%).

The most commonly used neonatal ART regimens included triple therapy until after breastfeeding cessation (n=22); zidovudine for 4 to 6 weeks (n=12); zidovudine plus or followed by nevirapine for 6 weeks until or after weaning (n=12); full triple therapy for 6 weeks followed by nevirapine monotherapy until weaning (n=10); and nevirapine monotherapy for 6 weeks or until weaning (n=7).

In an analysis of the study sites, 63.6% had a policy regarding breastfeeding in the setting of HIV, with most (72.7%) developed in coordination with obstetricians (72.7%), pediatric infectious disease specialists (72.7%), and lactation specialists (54.5%). The yearly volume of deliveries among women with HIV was low overall, with only 27.2% of sites indicating more than 40 deliveries occurring among women with HIV infection per year.

Limitations of this study include its retrospective design, the inclusion of only data from participants who disclosed their feeding status, and potentially underestimated care retention rates among both mother and infants.

According to the researchers, “[S]tandardized recommendations may help expand infant feeding options to all locations where parents living with HIV and their infants receive care.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Levison J, McKinney J, Duque A, et al. Breastfeeding among people with HIV in North America: a multisite study. Clin Infect Dis. Published online April 20, 2023. doi:10.1093/cid/ciad235