Remarks In settings in which health services provide and support lifelong ART, including adherence counselling, and promote and support breastfeeding among women with HIV, the duration of breastfeeding should not be restricted. Furthermore, as for the general population, mothers living with HIV (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter while continuing to breastfeed. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.

WHO-recommended breastfeeding is defined as: (1) initiating breastfeeding within the first hour of life; (2) exclusive breastfeeding for the first six months of life (that is, the infant receives breast milk only without any additional food or drink, not even water); followed by (3) continued breastfeeding for up to two years of age or beyond (with the introduction of appropriate complementary foods at six months); and (4) management of vertical HIV transmission.

Implementation considerations Ministries of Health, together with their partners, need to prioritize efforts to protect, promote and support breastfeeding in all settings in the general population; they also need to create and sustain enabling environments that promote appropriate infant-feeding practices while scaling up interventions to reduce HIV transmission. In all circumstances, it is critical to provide mothers living with HIV and their communities with high-quality, accurate information about HIV transmission and breastfeeding. To help mothers make informed decisions about their infant-feeding choices, free of coercion or intimidation, health care providers need to be trained and equipped to provide clear, concise communication about breastfeeding in the context of maternal HIV. Capacity-building topics for health care providers to support breastfeeding among women with HIV.

Box 4.1 Capacity-building topics for health care providers to support breastfeeding among women with HIV

• Short- and long-term health benefits of breastfeeding as well as its importance for infant growth, development and lifelong health, e.g. importance of breastfeeding in settings where there is an increased risk of malnutrition, diarrhoeal and infectious diseases owing to its effect on reducing morbidity and mortality.
• Health benefits of breastfeeding for mothers.
• Importance of early initiation of ART and maintaining adherence to achieve viral suppression before and during pregnancy and breastfeeding.
• Value of suppressing viral loads to reduce the risk of postnatal HIV transmission.
• Considerations for viral load monitoring throughout breastfeeding in accordance with national guidelines.
• Importance of adhering to infant ARV prophylaxis in accordance with national recommendations.
• Sources of practical support for breastfeeding mothers living with HIV in the event of difficulties. It is important for national programmes to prioritize strategies to scale up HIV testing and retesting, ensure access to antiretrovirals for treatment and prophylaxis, and provide ART adherence support services with optimized viral load monitoring for pregnant and breastfeeding women

Box 4.2 Programme strategies to support breastfeeding among women with HIV Programme strategies to support breastfeeding among women with HIV:

• Integrating HIV and RMNCAH services in all settings to promote access, including breastfeeding counselling and support, ART adherence support and retention in care and linking them with other key health care contacts, e.g. infant feeding review and counselling on infant testing.
• Providing breastfeeding support that is consistent across policies and programmes, health facilities and community activities for all women, including mothers living with HIV, to create an enabling environment for this practice, not only on beginning and during the exclusive breastfeeding period, but also enabling mothers to breastfeed for longer, i.e. until 24 months or beyond.
• Promoting comprehensive person-centred care and support during the postnatal period including addressing postpartum depression and other psychosocial needs.
• Implementing an optimized postnatal prophylaxis approach for infants exposed to HIV based on current recommendations (see Section 4.1 on postnatal prophylaxis).
• Implementing HIV retesting policies for HIV-negative pregnant and breastfeeding mothers at risk of HIV infection with provision of appropriate pre-exposure prophylaxis (PrEP) or early ART in the event of maternal HIV infection.
• Strengthening data collection, monitoring and evaluation of infant feeding practices, breastfeeding duration, infant prophylaxis and infant testing including final diagnosis and maternal viral load results to improve quality of service.
• Safeguarding a supportive environment for mothers who opt to breastfeed, protecting them from coercion, stigmatization, intimidation and criminalization.
• Encouraging community engagement and service delivery approaches to generate support for appropriate infant feeding practices in line with a woman’s rights to make informed choices, to address barriers to breastfeeding and to help community service providers to support breastfeeding more effectively in their communities.
• Developing and strengthening facility- and community-based approaches (including individual and group adherence support, follow-up and peer programmes) and linking them to other services, e.g. legal, social and economic provisions to address barriers to ART retention and adherence, postnatal prophylaxis and recommended infant feeding practices. Programmes ought to establish the most cost-effective approach in order to ensure that the intervention delivery model is sustainable.