Canadian researchers await potential update to breastfeeding guidelines for women with HIV

Researchers are waiting to see if a review by Health Canada will update guidance for mothers living with HIV who wish to breastfeed, noting the department's policy is more restrictive than those of countries such as the United States and Switzerland and runs contrary to a growing body of scientific evidence.
Health Canada currently advises against breastfeeding for women living with HIV because of the risk of transmitting the virus.
Women and parents living with HIV have expressed concerns about the guidance because they say breast milk strengthens a baby's immune system and helps reinforce an emotional connection between mother and child.
They point to research showing that antiretroviral therapy (ART) – a combination of medications to treat HIV – can significantly reduce viral load and lower the risk of HIV transmission, even in cases of individuals living with HIV who choose to breastfeed, though it does not entirely eliminate the risk.
This year, Health Canada expects to complete the initial stage of a broad review of its Nutrition for Healthy Term Infants policy. It is first looking at nutritional policy for infants from birth to six months of age. A second stage will consider nutrition for children six months to 24 months old.
The department says a joint working group is leading the process and it plans to post draft guidelines online for consultation.
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Jason Brophy, who chairs the Canadian Pediatric and Perinatal HIV/AIDS Research Group, said that if Health Canada's guidance is revised, breastfeeding should be recommended only for mothers with long-term viral suppression.
He cautioned, though, that mothers should adhere to treatment and remain in care.
'The baby must be closely monitored by trained health care professionals,' said Dr. Brophy, a pediatric infectious disease specialist at the Children's Hospital of Eastern Ontario.
His research group currently recommends formula feeding exclusively but argues that women with consistently undetectable viral loads who wish to breastfeed should receive appropriate counselling and support. Still, there are calls from within the group to go further.
Mothers or parents with undetectable HIV should have equal access to both breast/chest feeding and formula feeding options, said Logan Kennedy, the research lead at Women's College Hospital in Toronto and a member of the research group.
A 2019 Canadian study published in the Journal of the Pediatric Infectious Disease Society examined the use of combination antiretroviral therapy prophylaxis, a treatment that prevents the virus from replicating. It followed three breastfed infants whose mothers had sustained virologic suppression and received the therapy. All three babies remained HIV-negative.
Sarah Khan, a pediatric infectious disease specialist at McMaster Children's Hospital in Hamilton, said not every baby who breastfeeds from a mother living with HIV will become infected.
'In many low-resource countries, the benefits of breastfeeding outweigh the risks, and several measures can help keep babies safe,' Dr. Khan said.
In the Canadian study, she said, mothers took strict precautions to prevent breast inflammation, a known risk factor for transmission, and their newborns were given HIV medications as an additional layer of protection.
In 2016, the World Health Organization recommended breastfeeding for women living with HIV on ART in low- and middle-income countries where formula may not be affordable or culturally accepted, difficult to use or continue over time or unsafe owing to unclean water. It also said countries that do not promote breastfeeding among mothers living with HIV must ensure access to lifelong ART and consistent adherence counselling.
Three years later, Switzerland advised women on ART to choose either breastfeeding or formula use. In 2023, the U.S. also said mothers living with HIV who are virally suppressed should breastfeed or use formula or donor breast milk.
Dr. Khan said safe breastfeeding is possible when HIV is controlled, breasts are properly cared for and preventative infant prophylaxis treatment is in place.
She hopes health providers will be able to utilize new guidelines and evidence so they can have informed discussions with families affected by HIV to decide on the best approach for a mother and baby.
Dr. Khan is also leading new research called the MILK Study, tracking mothers living with HIV who choose to breastfeed. There are plans to analyze breast milk during high-risk periods, such as when an infant is ill or a mother has inflammation of the breast tissue.