Providing opportunities for women to gather information and discuss infant feeding options during pregnancy is ideal, allowing women time to make informed decisions.   

Provision of information on the topic of the mode of feeding in a supportive forum is a complex process.  Nurses and midwives need to have expert knowledge of current evidence and guidelines, skills in collaborative communication and a holistic approach to addressing the WLHIV’s needs (6,9,11). 

In middle- and high-income settings, current guidelines recommend formula feeding to prevent HIV transmission through breast milk.  However, international guidelines and the Australian ASHM guidance document (8) have more recently explored ways in which women LWHIV who do choose to breastfeed may be best supported, whilst minimising the risk of HIV transmission to the infant. 

In the event of a woman choosing to breastfeed, engagement in care is vital.   More frequent virological testing for both her and her infant is required, with a greater emphasis on access and adherence to ART. This is true for the duration of breast/chest feeding and some months after cessation of breastfeeding.  

Infant feeding recommendations in high-income countries such as Australia differ entirely from those in low-resource countries.  For instance, in resource-poor settings where breastfeeding remains the only option, infant PrEP may be used (6).  Differing recommendations can confuse overseas-born women, particularly if they have experienced childbirth and infant feeding before their arrival in Australia. Nurses and midwives can support women in navigating the different approaches to care and explaining the reasons for differences, thus enhancing the therapeutic relationship and engagement in care. 

Specialist nurses have a pivotal role in supporting weaning from the breast and the introduction of solid food in the context of minimising the risk of transmission. Furthermore, midwives and nurses can counsel women on appropriate strategies in the event of mastitis or gastrointestinal upset in the women or infant. Approaches to management of these situations are different to those for people who are not LWHIV (see 6 for more details). It is important to note that should a woman LWHIV not share her HIV diagnosis with a health professional due to lack of trust or fear of stigma, appropriate advice and care may not be provided, and the baby may be at increased risk of HIV transmission through breastfeeding. 

WLWHIV who choose to breastfeed will receive important counselling including the following information (11): 

• The importance of maintaining viral suppression through adherence to ART for the duration of breastfeeding 
• The potential for maternal ART to be excreted in breastmilk and the potential for toxicity to the infant. 
• The potential for increased risk of transmission in the event of: 
• maternal mastitis or cracked or bleeding nipples and how this should be managed 
• gastrointestinal disturbance in the infant, which can lead to gut inflammation, allowing HIV entry to the bloodstream. 
• GI disturbance in the mother, which may reduce ART absorption and efficacy, thereby increasing risk. 
• Mixed feeding i.e. breastmilk and formula or breastmilk and solid food and how this may be managed to minimise risk (6). 
• The need for ongoing blood tests for both infant and mother, which are more frequent than a formula-fed infant and the occasional disparity between maternal serum HIV VL and maternal breastmilk VL.   
• Who to contact and how to contact them should any of these situations arise, preferably provided to the woman in writing and in her chosen language. 

If the woman chooses to formula-feed her infant, nurses and midwives teach safe preparation of formula, sanitising of teats and bottles, storage of formula and choice of formula. Many hospitals follow ‘breastfeeding friendly’ policies (10) which can mean that access to this information is not always readily available.  

At the time of writing, free infant formula is not available to WLWHIV so the woman may require support and funding to access it.