Updated Recommendation
A new evidence synthesis was published:2025, WHO updated recommendations on HIV clinical management: recommendations for a public health approach
View latest version (2025)Bibliographic Info
Recommendation
Recommended in favor
Conditional
Certainty of evidence
Moderate
National or subnational health authorities should decide whether health services will principally counsel and support mothers known to be HIV infected to either breastfeed and receive ARV interventions or avoid all breastfeeding. In settings where national authorities have decided that maternal and child health services will principally promote and support breastfeeding and antiretroviral interventions as the strategy that will most likely give infants born to mothers known to be HIV infected the greatest chance of HIV-free survival, mothers known to be infected with HIV should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding should then stop only once a nutritionally adequate and safe diet without breast-milk can be provided
Notes and Remarks
The group identified the following key evidence:
- 1)In the systematic review of the effect of different infant feeding practices, in the absence of ARVs, on HIV-free survival and other mortality (Annex 5), decreased HIV transmission in the first six months of infant life was associated with exclusive breastfeeding (EBF) compared to mixed feeding (10,17,25).
- 2)Exclusive breastfeeding in the first six months of life was also associated with reduced mortality over the first year of life in HIV-exposed infants compared to mixed feeding and replacement feeding in both research and programme settings, especially if inappropriately chosen by mothers (12,26,27).
- 3)The risk of HIV transmission continues for as long as breastfeeding continues (28).
- 4)Despite this, HIV-free survival of HIV exposed infants who breastfeed beyond six months of age was better than, or not statistically different from, infants who were started on replacement feeds (6). Infants given replacement feeds after a period of breastfeeding also suffered increased serious infections, including diarrhoea and pneumonia, growth faltering and death (7–9,13–15,29).
- 5)In South Africa, among infants who were still HIV uninfected and alive at 6 months of age, those who switched from breastfeeding to replacement feeding had a better chance of HIV-free survival at 18 months of age than infants who were breastfed for an extended period (16). However, the social and environmental circumstances of mothers who decided to continue breastfeeding was not included in the analysis. The authors commented that without knowing the circumstances facing mothers when making infant feeding decisions at this time, it is difficult to know whether a change in feeding practices at this age would have been safe for these infants, or whether deaths due to non-HIV infections and malnutrition would have increased.
- 6)In Côte d’Ivoire, infants of HIV-infected mothers who were replacement fed after 6 months of age and who had received counselling and support for safe replacement feeding had equivalent mortality to HIV-exposed infants who were breastfed (19).
Also Featured In
This recommendation also appears in the following guidelines:
Consolidated guidelines on general HIV care and the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach