Anti-racism in postgraduate medical curricula: A review of curricula.

Over half the global population of people with HIV are women and an estimated 1.3million people with HIV become pregnant each year (, ). Vertical transmission rates are low because of routine antenatal HIV testing, antiretroviral therapy (ART) during and after pregnancy, appropriate management of delivery and the neonatal period—and in high income settings recommendations to avoid breastfeeding and use formula milk instead (, ). The vertical transmission rate of HIV in England fell from 2.9% in 2000 to 0.3% in 2021 (). With consistent access to ART and appropriate healthcare, people with HIV have a similar life expectancy as someone without HIV (). If a person with HIV is on effective ART and has an HIV viral load less than 200 copies/mL, they cannot pass HIV during sex, referred to as Undetectable = Untransmittable (U = U) (, ). However, U = U does not apply to HIV transmission through breastmilk. Without ART, the risk of HIV transmission through breastmilk is estimated between 16% to 20% (). When the feeding parent is virally suppressed on ART this risk is reduced to less than 1%, but it is not zero (, ). However, almost all data on the risk of HIV transmission through breastfeeding with ART come from studies conducted in low- and middle- income countries (LMICs) (, ). These data may not be generalisable to high-income countries (HICs) where healthcare is often more accessible and individuals may have been on long term suppressive ART prior to pregnancy with access to resistance testing, routine HIV viral load monitoring and potentially a wider range of treatment options. In the UK between 2017 and 2023, ∼90% of new mothers and birth parents with HIV were aware of their HIV diagnosis prior to pregnancy, 95% of whom were on ART prior to conception (). In comparison, routinely collected data across three sub-Saharan African countries (January to December 2018) found only about half of pregnant women were aware of their HIV before pregnancy, although varying between countries and age groups (). The World Health Organization advises that “Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breast feeding” (). This is a harm reduction approach for when access to clean water and formula milk is inconsistent. In the UK and similar HICs, national HIV guidance continues to advise avoidance of breastfeeding completely stating “feeding your baby with formula milk in a bottle is the only way to make sure the risk of passing on HIV to your baby is zero” (). Guidance for parents with HIV living in HICs generally assumes consistent access to safe water and infant formula. It is based on a combination of the LMIC-based research demonstrating residual transmission risk from breastfeeding in the context of lower infant morbidity and mortality secondary to gastrointestinal and respiratory infections—making formula feeding the ideal way to avoid all risk of HIV transmission (). This discrepancy in advice, however, causes parents anguish and confusion ().