There may be social or financial pressures on women to breastfeed, and support of formula feeding is important. The NSHPC report on perinatal HIV transmission in the UK [2] noted adverse social factors as a frequent factor in HIV transmission. A recent House of Lords report recommends the provision of free infant formula milk to HIV-positive mothers who have no recourse to public funds [68]. 8.4.2 In very rare instances where a mother who is on effective HAART with a repeatedly undetectable VL chooses to breastfeed, this should not constitute grounds for automatic referral

to child protection teams. Maternal HAART should be carefully monitored and continued until 1 week after all breastfeeding has ceased. Breastfeeding, except during the weaning period, should be exclusive and all breastfeeding, including the weaning period, PF-562271 concentration should have been completed by the end of 6 months. Grading: CX-5461 chemical structure 1B Breastfeeding while not on HAART, or with detectable viraemia on HAART does constitute a potential child protection concern. Because the risk of HIV transmission by breastfeeding is entirely avoidable, maternal breastfeeding

against medical advice has previously been considered a child protection concern warranting referral to social services and, where necessary, legal intervention. The efficacy of ART in reducing HIV transmission by breastfeeding in the UK has not been measured. However, while the African data do not warrant a change in the recommendation not to breastfeed in these UK guidelines, they do make it likely that the risk of transmission is low enough that breastfeeding by a woman with HIV and fully suppressed virus on ART should no longer automatically constitute grounds for a child safeguarding referral. It is

considered safer for women to be engaging with medical services while breastfeeding than for them to be breastfeeding without disclosing this. Data from Africa, in women not on HAART, show that mixed feeding carries a higher risk of HIV transmission than exclusive breastfeeding [69]. It is recommended that breastfeeding be stopped as soon as is acceptable to the mother, but in any case Methocarbamol by 6 months. A short period of mixed feeding may be necessary while ending breastfeeding. 8.4.3 Prolonged infant prophylaxis during the breastfeeding period, as opposed to maternal HAART, is not recommended. Grading: 1D Studies in Africa have included both ART given to the mother and ART given as prophylaxis to the infant during breastfeeding. While serious adverse events were not reported in the infants given nevirapine for up to 6 months [61], there are currently insufficient safety data to advocate this approach given the particular safety concerns regarding the use of nevirapine in adults uninfected by HIV. The use of nevirapine for longer than the 2–4 weeks currently recommended for PEP is not advised [70]. 8.4.