Current Canadian guidelines recommend formula feeding for all infants of birthing parents with HIV, but research shows the risk of a breast or chest feeding parent transmitting HIV to their child is very low when the parent is receiving antiretroviral therapy (ART), virally suppressed and under the care of a clinician.
A new commentary in CMAJ, authored by Dr. Mona Loutfy, clinician-scientist and founder of the Women HIV and Health Research Program at Women’s College Hospital (WCH) and Logan Kennedy, a registered nurse and research lead in the program, suggests that Canadian guidance should present formula feeding and breastfeeding as equivalent options for parents with suppressed HIV.
“For years, Canada advised against breastfeeding due to HIV transmission risk. But between 2010 and 2020, research showed that the risk was much lower for those on ART,” says Kennedy.
In November 22, guidance on supporting parents who choose to breast- or chest-feed was formally published. However, Canada’s recommendation for birthing parents with HIV to formula feed their babies remained unchanged.
“The key takeaway from the CMAJ opinion piece is that this recommendation should be updated to align with current evidence, including community-level practices. Families are opting to breast- or chest-feed, aware of the minimal risk and recognizing that other countries have revised their recommendations to offer both options,” explains Kennedy.
Loutfy and Kennedy reviewed case reports from high-income countries and found that, as of October 2024, 431 parents living with HIV on ART with suppressed viral loads breastfed their infants. Of these, 392 infants tested negative for HIV, with no confirmed cases of transmission. This suggests that the transmission risk is possibly zero for parents with sustained viral suppression before conception and throughout breastfeeding.
Countries like the US, the UK, Switzerland, and Germany – countries with resources similar to Canada – have reassessed their guidelines in recent years. Many have begun presenting breast- or chest-feeding as a recommended option for people living with HIV, recognizing factors like the benefits of breast milk alongside the low transmission risk when the parent is on ART and has a fully suppressed viral load. This shift highlights the importance of reproductive rights and supports the autonomy of individuals in making informed decisions about their health and parenting choices.
This proposed approach shifts responsibility from the person with HIV to advocate for their reproductive rights. Instead, both options are presented, allowing the parent to make an informed decision about infant feeding.
“There’s still a lot of stigma around HIV and the general public still fears it. There’s also a lot of taboo around discussing it,” says Loutfy. “We wrote this piece to address a specific stigma that often goes unnoticed: the HIV stigma from healthcare providers. When clinicians focus on the risk of HIV transmission, even when it’s essentially zero, it reflects an illogical fear and stigma.”
“Our goal with this commentary is to confront that stigma and encourage clinicians to reflect on their own attitudes,” Loutfy continues. “We hope to start discussions about how they approach HIV care and help them recognize the need for a more informed, supportive perspective.”
“Broadly speaking, healthcare providers may not be familiar with this important aspect of HIV care” says Kennedy. “This paper provides an opportunity for broader dialogue – especially among influential groups, like those writing guidelines and providing frontline care. It’s a chance to hear different perspectives and spark conversations that may not have happened otherwise.”
“It’s incredible to see how far HIV treatment has come,” says Loutfy. “People living with HIV can lead normal lives, and this is a powerful message we need to spread. Unfortunately, many people still don’t know this, and that’s the kind of information we need to get across—to normalize HIV and show how much progress has been made.”
To read their paper, click here.