Clinical Report: Updated DHHS Breastfeeding Guidelines for HIV in US Practice
Overview
A 2024 national survey of 389 US neonatologists and pediatric infectious disease (PID) specialists revealed that concerns about HIV transmission remain the primary barrier to supporting breastfeeding among individuals with HIV. PID specialists were more likely than neonatologists to offer breastmilk feeding from virally suppressed parents, yet institutional guideline adoption remains low.
Background
Breastfeeding provides significant health benefits for both mother and infant, including immune protection and enhanced bonding. Historically, US guidelines have discouraged breastfeeding by individuals living with HIV due to mother-to-child transmission (MTCT) risks. However, recent evidence from low-resource settings shows low MTCT risk with effective antiretroviral therapy and viral suppression, prompting the 2023 DHHS guideline update emphasizing shared decision-making and patient-centered counseling. Despite this, variability in clinical practice and institutional policies persists in the US.
Data Highlights
Characteristic
PID Specialists (%)
Neonatologists (%)
Respondents
21
79
Support breastmilk feeding from virally suppressed parent
64
42
Centers with feeding guidelines for breastmilk from parent with HIV
35
28
Concern for HIV transmission as barrier
61
63
Key Findings
64% of PID specialists versus 42% of neonatologists support breastmilk feeding from virally suppressed parents with HIV (P < .01).
Only 35% of PID specialists and 28% of neonatologists practice at centers with formal guidelines supporting breastmilk feeding from parents with HIV.
Concern for HIV transmission is the strongest barrier to breastfeeding support, reported by over 60% of both subspecialties.
Neonatologists, physicians with fewer years of experience (0–10 years), and those practicing at nonacademic centers are significantly less likely to offer breastmilk feeding (adjusted odds ratios ranging from 0.35 to 0.49).
Geographical region did not significantly affect breastfeeding support rates.
Clinical Implications
Clinicians should recognize that despite updated DHHS guidelines supporting breastfeeding with viral suppression, persistent concerns about HIV transmission limit guideline adoption. Targeted education and institutional policy development, especially in nonacademic settings and among less experienced providers, are needed to improve breastfeeding support. Emphasizing shared decision-making and patient-centered counseling may facilitate better integration of current recommendations.
Conclusion
Concerns about perinatal HIV transmission remain a major barrier to breastfeeding support in the US, despite updated DHHS guidelines endorsing breastmilk feeding with viral suppression. Focused interventions addressing these concerns are essential to enhance guideline implementation and optimize infant feeding practices among individuals living with HIV.
References
DHHS 2023 -- Updated Guidelines on Infant Feeding for Individuals Living with HIV
Pediatric Infectious Diseases Society Survey 2024 -- Breastfeeding Practices in HIV
American Academy of Pediatrics Section on Neonatal-Perinatal Medicine 2024 -- Neonatologist Survey Data
