A woman living with HIV can pass HIV to her child during pregnancy, delivery, or breastfeeding. Treatment can greatly reduce the chances of this.

Lifelong antiretroviral therapy (ART) is recommended for all adults and children from the time their HIV-positive status is known. A woman who started ART before pregnancy or when tested during pregnancy greatly reduces the chances that her baby will be infected in the uterus or during delivery. ART for the mother also greatly reduces the chances of passing HIV to her infant through breast milk.

Also, the newborns of mothers living with HIV should receive 2 antiretroviral drugs (ARVs) for the first 6 weeks of life. This further reduces the chances of HIV passing from mother to child in the period around birth.

How can family planning providers help prevent mother-to-child transmission of HIV?

• Help women—and men—avoid HIV infection (see Chapter 22 – Sexually Transmitted Infections, Including HIV, Avoiding STIs). Women and men at high risk of HIV infection can take PrEP, pre-exposure prophylaxis, a daily oral treatment with ARVs.
• Prevent unintended pregnancies: Help women who do not want a child to choose a contraceptive method that they can use effectively.
• Offer HIV counseling and testing: In all settings offer counseling and testing in family planning facilities to all pregnant women and to the partners of women living with HIV. Where HIV is common, offer testing to all women. Testing in family planning facilities can be helpful because a woman’s HIV status might affect her choice of a family planning method. If testing in family planning facilities is not possible, refer clients to an HIV testing service or offer self-testing so that they can learn their HIV status.
• Refer for prevention of HIV transmission: Refer women living with HIV who are pregnant, or who want to become pregnant, to services for prevention of mother-to-child transmission, if available. If a couple wants to have a child, and one partner has HIV while the other does not, they can take steps to reduce the chances of passing HIV while trying for conception (see Chapter 22 – Sexually Transmitted Infections, Including HIV, Safer Conception for HIV Serodiscordant Couples).
• Promote and support appropriate infant feeding: In each country national authorities decide which of 2 infant feeding practices should be promoted to pregnant women and mothers living with HIV and that all health facilities should support. The 2 practices are either (1) breastfeeding while mothers receive ART or (2) avoiding all breastfeeding (while mothers still receive ART). Countries decide which practice will lead to more children surviving free of HIV, depending on conditions in the country.

• Where national authorities have decided to promote and support breastfeeding and ART for mothers living with HIV:
  • Counsel all women, including women living with HIV, that breastfeeding, and especially early and exclusive breastfeeding, is the best way to promote the child’s survival.
  • Mothers living with HIV and their infants should receive appropriate ART, and mothers should exclusively breastfeed their infants for the first 6 months of life, then introduce appropriate complementary foods and continue breastfeeding. All children need complementary foods from 6 months of age.
  • Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or more (like other women) while being fully supported to keep taking ART.
  • Breastfeeding should stop only when a nutritionally adequate and safe diet without breast milk can be provided.
  • When mothers decide to stop breastfeeding, they should stop gradually within one month, and infants should be given safe and adequate replacement feeds to enable normal growth and development. Stopping breastfeeding abruptly is not advised.
  • Even when ART is not available, breastfeeding (exclusive breastfeeding in the first 6 months of life and continued breastfeeding for the first 12 months of life) may still give infants born to mothers living with HIV a greater chance of survival while avoiding HIV infection than not breastfeeding at all.
  • If a woman is temporarily unable to breastfeed—for example, she or the infant is sick, she is weaning, or her supply of ARVs has run out—she may express and heat-treat breast milk to destroy the HIV before feeding it to the infant. Milk should be heated to the boiling point in a small pot and then cooled by letting the milk stand or by placing the pot in a container of cool water. This approach should be used only short-term, not throughout breastfeeding.
  • Women living with HIV who are breastfeeding need support to maintain their own nutritional status and keep their breasts healthy. Infection of the milk ducts in the breast (mastitis), a pocket of pus under the skin (breast abscess), and cracked nipples increase the risk of HIV transmission. If a problem does occur, prompt and appropriate care is important (see “Sore or cracked nipples”).

• Where national authorities have decided to recommend that mothers living with HIV should avoid all breastfeeding even where ART is provided:
• Mothers living with HIV should receive skilled counseling to ensure that they provide a replacement food that is safe and adequate and is safely prepared, stored, and given to their infant.
  • For infants less than 6 months of age, the recommended alternative to breastfeeding is commercial infant formula, as long as home conditions outlined below are met. Home-modified animal milk is not recommended as a replacement food in the first 6 months of life.
  • For infants more than 6 months of age, alternatives to breastfeeding include:
    • Commercial infant formula milk, as long as home conditions outlined below are met
    • Animal milk (boiled for infants under 12 months), as part of a diet providing adequate micronutrients. Children should be fed meals, including milk-only feeds, other foods, and combination of milk feeds and other foods, 4 or 5 times per day.
• All children need complementary foods from 6 months of age.
• Mothers living with HIV should consider replacement feeding only if all the following conditions are met:
  • safe water and sanitation are ensured in the household and community; and
  • the mother or caregiver can reliably provide sufficient infant formula to support the infant’s normal growth and development; and
  • the mother or caregiver can prepare it cleanly and frequently enough so that it is safe enough and carries a low risk of diarrhea and malnutrition; and
  • the mother or caregiver can give the replacement feeding exclusively in the first 6 months; and
  • the family supports this practice; and
  • the mother or caregiver can obtain comprehensive child health services.
• If infants and young children are known to be living with HIV, mothers should be strongly encouraged to exclusively breastfeed for the first 6 months of life and continue breastfeeding up to 2 years or beyond.