7.1.3 ARV drugs and duration of breastfeeding
Consolidated ARV guidelines, June 2013
The primary aim of WHO recommendations regarding HIV and infant feeding is to improve the HIV-free survival of HIV-exposed infants. This includes reducing the risk of HIV transmission through breast-milk, primarily by providing ARV drugs, while avoiding malnutrition and the increased risk of serious infections in infants and children through unsafe feeding practices.
In 2010, WHO recommended that ARV drugs be provided either to the mother or the infant throughout breastfeeding to reduce the risk of postnatal HIV transmission (82, 99). In countries that recommended breastfeeding with ARV drugs, it was recommended that women with HIV should “continue breastfeeding for the first 12 months of life” and “only stop once a nutritionally adequate and safe diet without breast-milk can be provided” (99).
This recommendation was based on evidence that the maximum benefit of breastfeeding in preventing mortality from diarrhoea, pneumonia and malnutrition is in the first 12 months of life and that the risk of transmitting HIV to infants through breastfeeding is low in the presence of ARV drugs (100,101). At that time, there was uncertainty about the mothers’ adherence to ARV drugs as prophylaxis and their ability to give ARV drugs to their breastfeeding infants over longer periods of time up to 18 or 24 months of age. Consequently, there was uncertainty about the level of protection against HIV transmission for children breastfeeding beyond 12 months. Finally, there were limited data on potential adverse events among infants exposed to prolonged – though low-dose – ARV drugs through breast-milk (102–104).
Since 2010, country-level recommendations on the appropriate duration of breastfeeding for women with HIV and their infants (where breastfeeding is recommended) have varied from 12 to 24 months; in some cases, the duration is not specified. Data on ARV drug coverage and adherence during breastfeeding and effective postpartum follow-up of mother–infant pairs remain limited. With increasing antenatal coverage of ARV drugs in PMTCT programmes, the relative proportion of infants infected during breastfeeding may be increasing because of inadequate ARV drug coverage during breastfeeding, emphasizing the importance of an effective postpartum prevention strategy.
The option of providing lifelong ART to all pregnant women with HIV, regardless of CD4 count or clinical stage (section 7.1.2: When to start ART in pregnant and breastfeeding women), raises the question of whether these mothers need to limit the duration of breastfeeding.
The Guidelines Development Group therefore considered whether, in the context of pregnant women with HIV receiving lifelong ART regardless of CD4 count or clinical stage, to maintain the recommendation on the duration of breastfeeding as continued breastfeeding for the first 12 months of life or whether to recommend unrestricted duration of breastfeeding. The Guidelines Development Group considered a revision because of the potential operational advantages of extending the breastfeeding period, including:
- harmonizing and simplifying recommendations for mothers with HIV and their infants with those for mothers without HIV would likely simplify public health messaging and improve infant-feeding practices in the entire community; and
- decreasing stigma and possible increasing acceptability by mothers and communities.
Ultimately, the Guidelines Development Group decided not to change the 2010 recommendations on HIV and infant feeding.