For decades, global recommendations for HIV and breastfeeding have differed than for those in the United States. Families in the United States have historically been counseled not to breastfeed due to the risk of HIV transmission. On January 31, 2023, new perinatal HIV guidelines were released from the United States Department of Health and Human Services that were revised and retitled to provide more comprehensive guidance on feeding infants born to individuals with HIV (Infant Feeding for Individuals with HIV in the United States, 2023). The major change in these guidelines is to now support parental choice in infant feeding through shared decision-making, not a specific infant feeding method.

This change in language represents an important step forward in caring for childbearing families living with HIV. Health benefits of human milk and breastfeeding for the child and lactating parent are significant (Meek et al., 2022). Thus, families should be able to make an informed feeding choice based on all available evidence and personal preferences. There are important health equity considerations, as Black women are disproportionately affected by HIV (Infant Feeding for Individuals with HIV in the United States, 2023). People of color experience a greater burden of health-related conditions (diabetes, hypertension, reproductive cancers) that may be mitigated through use of human milk and through lactation (Meek et al., 2022).

People with HIV should receive patient-centered counseling that supports a shared decision-making process (Infant Feeding for Individuals with HIV in the United States, 2023). Ideally, counseling would occur prior to conception; however, if this is not possible, it should be as early in pregnancy as possible. Although replacement feeding with properly prepared formula or access to pasteurized donor human milk (PDHM) would eliminate all risk of postnatal HIV transmission to the infant, these options may not be preferrable or feasible to all families. For example, PDHM distribution is mostly prioritized to hospitalized infants and gaining access to it in the community setting may be difficult or cost prohibitive.

If a mother does not have access to antiretroviral therapy (ART) or infant antiretroviral prophylaxis, risk of an infant acquiring HIV through breastfeeding is 15% to 20% over 2 years (Infant Feeding for Individuals with HIV in the United States, 2023). However, if the lactating person can achieve and maintain viral suppression through ART during pregnancy and postpartum, transmission risk is less than 1% (Infant Feeding for Individuals with HIV in the United States, 2023). Clinicians recommend infant prophylaxis with Zidovudine for the first 4 to 6 weeks of life, as well as daily Nevirapine until 1 month after the cessation of breastfeeding. If a detectable viral load is noted, temporary cessation of breastfeeding is recommended. During this time, the infant can receive previously stored expressed milk, PDHM, or formula. Repeat screening for viral load is recommended and if still detectable, breastfeeding should be discontinued (Infant Feeding for Individuals with HIV in the United States, 2023).

Historically, families living with HIV in the United States have struggled to navigate infant feeding in the absence of more guidance. Research with health care providers demonstrated that clinicians perceived White patients with HIV faced fewer barriers to breastfeeding than patients with other racial identities (Lai et al., 2023). Lai et al. (2023) found providers had a range of management styles from patients making informed feeding choices to paternalism. As nurses, we have an important role in educating and advocating for families living with HIV, so they can make informed infant feeding choices.

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