[Table, RECOMMENDATION 1]. - Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV

Strength of the recommendation	Strong
Quality of the evidence	12 months: low 24 months: very low
Justification	The Guideline Development Group unanimously supported removing any restriction on the duration of breastfeeding for mothers living with HIV in the context of full support for ART. All Guideline Development Group members agreed that the likely benefits outweighed the harm even if breastfeeding in the general population has less protective effect against serious morbidity and mortality in the second year of life than in the first 12 months. The Guideline Development Group recognized that, in settings in which health systems support and promote high rates of retention in care and adherence to ART, the risk of postnatal transmission is likely to be low. The Guideline Development Group also recognized that, as programmes become even more robust and efficient in delivering ART services and communities become more aware of the benefits and reliability of ART in protecting against HIV transmission, the balance of risks in favour of prolonged breastfeeding with the provision of ART will be even stronger. In addition, the Guideline Development Group noted the significant benefit of harmonizing guidelines for women living with HIV and the general population. This action will probably decrease the stigmatization associated with infant feeding practices undertaken by mothers living with HIV and also facilitate improved feeding practices in the entire population. There are no comparative data from HIV-exposed children on the overall gains in HIV-free survival that would be associated with prolonged breastfeeding versus shorter durations of breastfeeding, and programmatic and historical data demonstrate small but continued postnatal transmission through the second year of life. The ART adherence rates among the mothers of these children were, however, unknown. Some Guideline Development Group members commented that poor adherence to ART by mothers living with HIV will always constitute a risk factor for postnatal transmission, whether in the first or second year of life. (See the 2013 WHO consolidated guidelines on ARV drugs (WHO, 2013) for interventions to optimize adherence to ART.) The Guideline Development Group noted these concerns and reviewed, on several occasions, the decision to make a strong recommendation. Although some Guideline Development Group members favoured a conditional rather than a strong recommendation in recognition of the diversity of settings in which the recommendation will be implemented, consensus was achieved through discussion and revising how the recommendation should be phrased. The decision to make a strong recommendation was based on agreement on what package of interventions would be best for the individual mother-infant pairs. Where health systems reliably provide and support ART, and mothers retained in care consistently adhere to ART, the Guideline Development Group considered that prolonged breastfeeding to 24 months or beyond by mothers living with HIV is the best option for HIV-exposed infants. The Guideline Development Group also noted that the change in global recommendations on ART for all people living with HIV regardless of CD4 count should result in greater investment and improvement in health services to achieve the quality required to assure high rates of retention and ART adherence. The Guideline Development Group also noted that, in both the past and current recommendations, women living with HIV are not obligated to adopt a single feeding practice even when recommended by the health services. Similar to all women in everyday life, mothers living with HIV ultimately make decisions about infant feeding practices, including the duration of breastfeeding, according to what is appropriate for their circumstances. The 2010 WHO guidelines on HIV and infant feeding highlighted the need for health services to support mothers living with HIV in their chosen feeding practices even when they are inconsistent with the nationally recommended practices. This principle is still endorsed by WHO and remains relevant to these updated recommendations.
Implementation considerations	HIV and maternal and child health programmes need to give priority to integrating ART services, including adherence counselling and support for infant and young child feeding, in all settings. These programmes and partner agencies need to ensure training and developing the capacity of health workers so that they can explain the rationale for the recommendation and to ensure that staff members are able to explain the benefits to mothers living with HIV while emphasizing the value and importance of adherence to ART. These programmes and partner agencies should collect data to monitor the duration of breastfeeding by mothers living with HIV in addition to adherence to ART and the rates of retention in care of mothers and infants. Such data should be used to improve the quality of service delivery at district and local clinics. Investment and action to protect, promote and support breastfeeding in the general population should remain priorities of health ministries, nongovernmental organizations and other partners in all settings.
Research priorities	How does long-term postpartum exposure to low-dose ARV drugs in breast milk affect the early and late health outcomes, especially growth, renal and bone metabolism and neurodevelopment, of HIV-exposed breastfeeding infants and children whose mothers are taking ART?

Strength of the recommendation

Strong

Quality of the evidence

12 months: low

24 months: very low

Justification

The Guideline Development Group unanimously supported removing any restriction on the duration of breastfeeding for mothers living with HIV in the context of full support for ART. All Guideline Development Group members agreed that the likely benefits outweighed the harm even if breastfeeding in the general population has less protective effect against serious morbidity and mortality in the second year of life than in the first 12 months. The Guideline Development Group recognized that, in settings in which health systems support and promote high rates of retention in care and adherence to ART, the risk of postnatal transmission is likely to be low. The Guideline Development Group also recognized that, as programmes become even more robust and efficient in delivering ART services and communities become more aware of the benefits and reliability of ART in protecting against HIV transmission, the balance of risks in favour of prolonged breastfeeding with the provision of ART will be even stronger. In addition, the Guideline Development Group noted the significant benefit of harmonizing guidelines for women living with HIV and the general population. This action will probably decrease the stigmatization associated with infant feeding practices undertaken by mothers living with HIV and also facilitate improved feeding practices in the entire population.

There are no comparative data from HIV-exposed children on the overall gains in HIV-free survival that would be associated with prolonged breastfeeding versus shorter durations of breastfeeding, and programmatic and historical data demonstrate small but continued postnatal transmission through the second year of life. The ART adherence rates among the mothers of these children were, however, unknown. Some Guideline Development Group members commented that poor adherence to ART by mothers living with HIV will always constitute a risk factor for postnatal transmission, whether in the first or second year of life. (See the 2013 WHO consolidated guidelines on ARV drugs (WHO, 2013) for interventions to optimize adherence to ART.)

The Guideline Development Group noted these concerns and reviewed, on several occasions, the decision to make a strong recommendation. Although some Guideline Development Group members favoured a conditional rather than a strong recommendation in recognition of the diversity of settings in which the recommendation will be implemented, consensus was achieved through discussion and revising how the recommendation should be phrased. The decision to make a strong recommendation was based on agreement on what package of interventions would be best for the individual mother-infant pairs. Where health systems reliably provide and support ART, and mothers retained in care consistently adhere to ART, the Guideline Development Group considered that prolonged breastfeeding to 24 months or beyond by mothers living with HIV is the best option for HIV-exposed infants. The Guideline Development Group also noted that the change in global recommendations on ART for all people living with HIV regardless of CD4 count should result in greater investment and improvement in health services to achieve the quality required to assure high rates of retention and ART adherence.

The Guideline Development Group also noted that, in both the past and current recommendations, women living with HIV are not obligated to adopt a single feeding practice even when recommended by the health services. Similar to all women in everyday life, mothers living with HIV ultimately make decisions about infant feeding practices, including the duration of breastfeeding, according to what is appropriate for their circumstances. The 2010 WHO guidelines on HIV and infant feeding highlighted the need for health services to support mothers living with HIV in their chosen feeding practices even when they are inconsistent with the nationally recommended practices. This principle is still endorsed by WHO and remains relevant to these updated recommendations.

Implementation considerations

HIV and maternal and child health programmes need to give priority to integrating ART services, including adherence counselling and support for infant and young child feeding, in all settings.
These programmes and partner agencies need to ensure training and developing the capacity of health workers so that they can explain the rationale for the recommendation and to ensure that staff members are able to explain the benefits to mothers living with HIV while emphasizing the value and importance of adherence to ART.
These programmes and partner agencies should collect data to monitor the duration of breastfeeding by mothers living with HIV in addition to adherence to ART and the rates of retention in care of mothers and infants. Such data should be used to improve the quality of service delivery at district and local clinics.
Investment and action to protect, promote and support breastfeeding in the general population should remain priorities of health ministries, nongovernmental organizations and other partners in all settings.

Research priorities

How does long-term postpartum exposure to low-dose ARV drugs in breast milk affect the early and late health outcomes, especially growth, renal and bone metabolism and neurodevelopment, of HIV-exposed breastfeeding infants and children whose mothers are taking ART?

From: Evidence and recommendations

Cover of Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV

Guideline: Updates on HIV and Infant Feeding: The Duration of Breastfeeding, and Support from Health Services to Improve Feeding Practices Among Mothers Living with HIV.

Geneva: World Health Organization; 2016.

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