“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

Abstract

IntroductionCurrently, the United States (U.S.) recommends that infants born to women living with HIV (WLHIV) be fed formula, whereas many low‐resource settings follow the World Health Organization's recommendation to exclusively breastfeed with ongoing antiretroviral therapy. Evidence on infant feeding among WLHIV in high‐resource countries suggest that these contrasting recommendations create challenges for providers and patients. Our study used multiple methods to understand providers’ infant feeding perspectives on caring for their pregnant and post‐partum WLHIV in the U.S.MethodsWe sent a survey (n = 93) to providers across the U.S. who have cared for WLHIV. A subset of survey participants opted into a follow‐up qualitative interview (n = 21). These methods allowed us to capture a broad understanding of provider attitudes via the survey and more nuanced qualitative interviews. The study was completed prior to an updated breastfeeding section of the U.S. Perinatal Guidelines.ResultsThe majority of providers (66.7%) discussed infant feeding intent with their patients using open‐ended questions. Many also discussed alternative feeding methods (37.6%) and disclosure avoidance strategies (34.4%). Over 75% (95% confidence interval (CI): 65.1 to 84.2) of participants reported that a WLHIV asked if she could breastfeed her child, and 29% (95% CI 20 to 40.3) reported caring for a patient who breastfed despite recommendations against breastfeeding. Providers reported that their patients’ primary concern was stigma associated with not breastfeeding (58%), while providers were primarily concerned about medication adherence during breastfeeding (70%). Through qualitative analysis, four overarching categories emerged that reflect providers’ sentiments, including (1) U.S. guidelines inadequately addressing WLHIV's desire to breastfeed; (2) negotiating patient autonomy amidst complex feeding situations; (3) harm reduction approaches to supporting WLHIV in breastfeeding; and (4) providers anticipating multilayered patient stigmatization.ConclusionsThe majority of provider respondents cared for a WLHIV who desired to breastfeed, and a third had WLHIV who breastfed despite recommendations against it. Providers found that the status of U.S. guidelines and their incongruity with WHO guidelines left them without adequate resources to support WLHIV's infant feeding decisions. Our findings provide important insight to inform professional associations’ discussions about public health policy as they consider future directions for infant feeding guidelines among WLHIV.

Moving closer to what women want? A review of breastfeeding and women living with HIV in the UK and high‐income countries

“…However, mainstream postnatal guidance remains heavily in support of breastfeeding. A woman living with HIV may wish to breastfeed her baby because she has been repeatedly told it is ‘best’ for her and her baby .…”

“…However, mainstream postnatal guidance remains heavily in support of breastfeeding. A woman living with HIV may wish to breastfeed her baby because she has been repeatedly told it is 'best' for her and her baby [7]. Despite the arguments above, and the numerous benefits of breastfeeding that affect all mothers and infants [28], breastfeeding while living with HIV in the UK could still be felt to be an 'unnecessary risk' with regard to postnatal vertical transmission of HIV.…”

“…Until recently, guidelines in high-income countries (HICs) [4] advised women living with HIV not to breastfeed, and only use formula milk or other infant feeding alternatives [5,6]. Despite this, a significant minority continued to breastfeed [7][8][9]. Recent evidence showed that the risk of HIV transmission through breastmilk is lower than previously thought [10].…”

Infant feeding guideline awareness among mothers living with HIV in North America and Nigeria

“…Health workers who do not understand the rationale or intent of infant feeding guidelines may jeopardize the level of awareness they create for mothers living with HIV. In the US, 29% of mothers living with HIV breastfed despite health workers' recommendations against breastfeeding [8]. African American women are less likely than other ethno-racial groups to adhere to policies advocating breastfeeding [9][10][11].…”

The COVID‐19 liquid gold rush: Critical perspectives of human milk and SARS‐CoV‐2 infection

“…As illustrated above, much of human milk science remains firmly grounded in these ideologies and, wittingly or not, reproduces them. The fact is that simply isolating virus in human milk neither leads to more straightforward infant feeding recommendations (Tomori et al, 2020) nor does it necessarily lead to the desired behavioral outcomes (Tuthill, Tomori, Natta, & Coleman, 2019;Van Hollen, 2011).…”