In Support of Breast/Chest Feeding by People with HIV in High-Income Settings.

Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the United States and other resource rich settings was actively discouraged. Formula feeding was mandated as the only feeding option primarily out of concern for breastmilk transmission of HIV, which occurred in 16-24%1-3 of cases pre-antiretroviral therapy (ART) use. In January 2023, the United States' Department of Health and Human Services (DHHS) Perinatal Guidelines were updated to support shared decision making for infant feeding choices4. Updated data from clinical trials in low- and middle-income settings suggest that the actual rate of HIV transmission through breastmilk in the context of maternal ART or neonatal post-exposure prophylaxis (PEP) is 0.3-1%1-3. High income countries are reporting increasing numbers of people with HIV breastfeeding their infants without cases of HIV transmission to date5-10. Here we will present the reasons for fully embracing breast/chestfeeding as a viable and safe infant feeding option for HIV-exposed infants in high-income settings now, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.