U=U Principles Now Includes Breast Feeding

By: Ranier Simons, ADAP Blog Guest Contributor

The phrase ‘undetectable equals untransmittable’, commonly referred to as U=U, originated from the efforts of the Prevention Access Campaign in 2016.[1] This phrase explains the current scientific consensus that a person living with HIV (PLWHA) who has undetectable levels of the virus in their blood does not pose an infection risk and will not sexually pass the virus on to their partners.[2] Medical research is proving that U=U extends past sexual activities. A recent May 2024 clinical report released by the American Academy of Pediatrics (AAP) indicates evidence shows it is acceptable for HIV-positive mothers to breastfeed.[3] This is a reversal of previous guidance banning the activity.

Photo Source: CNN.com

Recommendations against breastfeeding by PLWHA date as far back as 1985, following the start of the HIV pandemic. This was well before the advent of modern antiretrovirals (ART). Before ART, about 30 percent of maternal-to-infant HIV transmission occurred during breastfeeding. In the early 1990s, there were about 2000 breastmilk-related transmissions annually in the US. Presently, the risk of maternal-to-infant HIV transmission from a parent who is on ART and is virally suppressed is less than one percent.[3]

The recently updated guidelines from the AAP follow 2023 updated recommendations by an advisory panel to the U.S. Department of Health and Human Services (HHS). That panel recommendation stated, “People with HIV should receive evidence-based, patient-centered counseling to support shared decision-making about infant feeding…individuals with HIV who are on ART with a sustained undetectable viral load and who choose to breastfeed should be supported in this decision”.[4] In order to allow PLWHA to breastfeed safely, the AAP updated guidance lists specific requirements. ART must be initiated early in or before the pregnancy, sustained viral suppression must be maintained along with consistent access to ART, and infant prophylactic medication must be administered.[3] The guidelines also recommend regular monitoring of the parent’s viral load. Additionally, research indicates that if PLWHA are going to breastfeed, they must exclusively breastfeed for the first six months of the infant’s life without switching back and forth to formula.[3] Switching could increase transmission risk due to interruptions in the infants’ gut environment.

About 5,000 PLWHA give birth annually.[5] The new guidelines end the history of denying PLWHA the bond created between parent and child with breastfeeding. 

Photo Source: The Well Project

Bruce Richman, the Executive Director of the Prevention Access Campaign, explains, “This is incredible news for the rights, choice, and autonomy of people living with HIV and the joy and intimacy of parenthood! Too many people living with HIV faced criminalization and having their infants removed by child protective services if they chose to breastfeed or chestfeed despite this being a safe method when undetectable." 

Richman further stated the updates to guidance for pediatricians complement the recent HHS and Centers for Disease Control & Prevention [CDC] guidelines updates and further support people living with HIV in making healthy reproductive choices for themselves and their infants.” 

Breastfeeding has health-related benefits for both parent and infant in addition to the familial bond. Breastmilk provides optimal infant nutrition and protection from morbidity and mortality from infectious diseases, allergic conditions, obesity, diabetes, autoimmunity, and sudden infant death syndrome.[3] Breastfeeding protects the parent from breast and ovarian cancer, hypertension, and type 2 diabetes.[3]

Pediatricians and physicians receive their clinical guidance from groups such as the CDC, HHS, and AAP. It is crucial that these new guidelines be widespread and utilized to change the current paradigm of many medical professionals. Unfortunately, many clinicians still hold outdated attitudes regarding HIV as well as they are not up to date on evidence-based science. The new AAP guidelines will enable clinicians to support PLWHA in their decision to breastfeed and empower them to be partners in their care instead of just being told what they can and cannot do with their bodies and infants. The AAP plans to have webinars for clinicians concerning the new guidelines in hopes of effecting widespread adoption of the latest evidence-based recommendations.

Photo Source: American Academy of Pediatrics

Not only is U=U positively affecting breastfeeding, but it is enabling freedoms for PLWHA concerning conception. In the United Kingdom, laws are changing that will now allow heterosexual and same-sex couples with non-transmissible HIV to become parents.[6,7] Amendments to the Human Fertilization and Embryology Act will allow PLWHA with undetectable viral status to donate eggs or sperm to their partners. 

Current IVF law only allows male PLWHA to donate sperm to their female partners exclusively. This means that before the law changed, they could not donate to family or friends. Additionally, the law amendment will allow female same-sex couples undergoing shared motherhood IVF treatment to conceive. In the shared IVF treatment, one partner of the sero-discordant couple provides the egg, and the other carries the embryo.[6] The stipulations for PLWHA wishing to donate under the new law are: they have to have a sustained undetectable viral load, have to prove they have been on ART for at least six months prior to donation, and the person receiving the gamete consents and is aware of the donor’s HIV status.[6]

Not only have medical advancements changed an HIV diagnosis from a death sentence to a matter of chronic disease management, but they are continually taking the shackles off PLWHA's ability to live their lives. HIV stigma still exists. However, the more the understanding of U=U spreads, the easier the lives of PLWHA will become. Moreover, as medical advancements continue, U=U and future achievements will allow PLWHA to live as wholly integrated members of society defined by their humanity and not their disease.

[1] Third Amended Class Action Complaint. (2023, October 24) ). Retrieved from https://consumerwatchdog.org/wp-content/uploads/2023/11/2023-10-24-241_Third-Amended-Complaint.pdf

[2] John Doe One et al. v. CVS Pharmacy Ruling. (2024, April 18). Retrieved from https://www.courthousenews.com/cvs-medication-program-discriminates-against-hiv-aids-patients-judge-says/john-doe-one-et-al-v-cvs-pharmacy-et-al-mtd-ruling/

[3] Doe One et al. v. CVS Health Corporation et al. (2018, March 21). Retrieved from https://dockets.justia.com/docket/ohio/ohsdce/2:2018cv00238/211764

[4] Faul, A. (2018, March 29). CVS Health unintentionally revealed HIV status of 6,000 customers: Lawsuit. Retrieved fromhttps://abcnews.go.com/Health/cvs-health-unintentionally-revealed-hiv-status-6000-customers/story?id=54095674

[5] Schladen, M. (2018, June 29). State, CVS sued over HIV mailing. Retrieved from https://www.dispatch.com/story/news/politics/elections/2018/06/29/state-cvs-sued-over-hiv/11624806007/

[6] AIMED Alliance. (2020, May 15). CVS Health to Settle Lawsuit for Revealing HIV Status of Over 4,500 Patients. Retrieved fromhttps://aimedalliance.org/cvs-health-to-settle-lawsuit-for-revealing-hiv-status-of-over-4500-patients/

[7] Accetta, L. (2021). Expanding therapies, indications and implications for payors: Pipeline trends that will drive change in 2022. Retrieved from https://business.caremark.com/insights/2021/expanding-therapies-indications-and-implications-payors.html   

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.