Breastfeeding in Women Living With HIV in the ART Era: Toward Risk-Adapted Clinical Care.

IntroductionBreastfeeding in women living with HIV remains controversial despite effective antiretroviral therapy (ART), as a small residual transmission risk persists even with viral suppression, leading to divergent global recommendations.MethodsWe performed a narrative review and policy analysis of randomized trials, international guidelines, and national recommendations (2010-2025), focusing on breastfeeding policies, maternal ART, infant prophylaxis, and monitoring strategies across settings.ResultsEvidence from resource-limited settings shows maternal ART during breastfeeding reduces transmission and improves HIV-free survival, supporting WHO recommendations for breastfeeding with ART and infant prophylaxis. In high-income countries, breastfeeding is often discouraged due to safe alternatives, though some guidelines now allow it under strict viral suppression and close monitoring. Observational studies suggest transmission is rare when suppression is maintained.ConclusionsDifferences in guidance mainly reflect risk tolerance and ethics rather than evidence. Breastfeeding may be considered a conditional option within structured clinical pathways.