Tilting the Scale: Current Provider Perspectives and Practices on Breastfeeding with HIV in the United States

Abstract

The risk of vertical transmission from breastfeeding with HIV (BFHIV) has been found to be very low in optimal scenarios with sustained maternal viral suppression during pregnancy and postpartum. Medical providers must account for the risk of this serious adverse event alongside parental autonomy, breastfeeding benefits, and patient values. To assess provider practices, comfort, and challenges with BFHIV, an online mixed-method survey was sent to breastfeeding and HIV provider listservs from June to July 2021. The target population was US medical professionals from diverse practice settings with experience in clinical issues associated with BFHIV, including physicians, advanced practice providers, nurses, and lactation consultants. Data analysis utilized nonparametric hypothesis testing, ordinal regression, and reflexive thematic analysis. Most providers reported counseling pregnant people with HIV on infant feeding choices, but fewer specifically endorsed counseling about breastfeeding. Of 84 unique institutions identified by 100 included respondents, 10% had an institutional protocol supporting BFHIV. Institutional protocols were associated with higher degrees of provider comfort with BFHIV in optimal scenario clinical vignettes. Providers perceived that White patients faced fewer BFHIV barriers than patients with other racial identities. Discomfort balancing the goals to protect infants from infection risk and support the parent's role in infant feeding decisions was a key theme in free text responses; this manifested in a spectrum of management styles ranging from patient's informed choice to paternalism. This study highlights the tension providers navigate regarding BFHIV discussions, calling for patient care guidelines and protocols grounded in risk reduction and respect of patient autonomy.

Importance of human milk for infants in the clinical setting: Updates and mechanistic links

“…For example, although maternal human immunodeficiency virus (HIV) infection has long been considered a contraindication to BF, the World Health Organization recommends antiretroviral therapy, which greatly reduces postnatal transmission of HIV through maternal HM, and supports BF as long as desired. 26 Additionally, few medications are fully incompatible with BF, and infant age and health status, lactational stage, dosage, and timing of medication may alter the risk profile for an individual infant; the InfantRisk Center at Texas Tech University Health Sciences Center (https://infantrisk.com/) provides individualized, up-to-date guidance. Provision of maternal HM to infants whose parents engage in substance use is highly variable, and we would refer providers to the Academy of Breastfeeding Medicine's protocol on managing BF in the case of substance use disorder.…”

“…To best support BF parents, including those of vulnerable infants most in need of HM, clinicians should familiarize themselves with up‐to‐date guidance from the Centers for Disease Control and Prevention and the American Academy of Pediatrics on contraindications for providing maternal HM, 7,24,25 which may vary based on available resources and circumstances. For example, although maternal human immunodeficiency virus (HIV) infection has long been considered a contraindication to BF, the World Health Organization recommends antiretroviral therapy, which greatly reduces postnatal transmission of HIV through maternal HM, and supports BF as long as desired 26 . Additionally, few medications are fully incompatible with BF, and infant age and health status, lactational stage, dosage, and timing of medication may alter the risk profile for an individual infant; the InfantRisk Center at Texas Tech University Health Sciences Center (https://infantrisk.com/) provides individualized, up‐to‐date guidance.…”

Guidance for Breastfeeding and HIV

“…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.…”

“…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.…”