In January 2023, the Department of Health and Human Services updated its guidelines to recommend that people with HIV should receive “evidence-based, patient-centered counseling to support shared decision-making about infant feeding.” This new approach was discussed during a special session at the Conference on Retroviruses and Opportunistic Infections in February.

Traditionally, women living with HIV in the United States have been advised not to breastfeed due to the risk of mother-to-child transmission. But things have changed in the era of U=U (Undetectable Equals Untransmittable). The viral load threshold for reducing transmission via breastfeeding is unknown, but only a couple of cases of transmission from mothers with a viral load below 50 have been reported.

Women living with HIV have advocated for more autonomy in decisions about infant feeding. While breastfeeding comes with a small risk of transmission, it also confers many benefits, including better infant nutrition, improved health, mother-child bonding, lower cost and reduced stigma.

According to the revised guidelines, maintaining viral suppression during pregnancy and postpartum “decreases breastfeeding transmission risk to less than 1%, but not zero.” Replacement feeding with formula or donor milk is recommended for people who are not on effective treatment or do not have sustained viral suppression.

“Individuals with HIV who are on [antiretroviral therapy] with a sustained undetectable viral load and who choose to breastfeed should be supported in this decision,” the guidelines state, adding that those who choose formula feeding should likewise be supported.