Effects of fundamental social motives on environmental variation of compliance during pandemics.

In January 2023, U.S. perinatal HIV guidelines were revised to support shared decision-making in infant feeding, affirming that people living with HIV (PLHIV) who meet clinical criteria may be supported in breastfeeding (). This marked a departure from prior guidance that treated breastfeeding as contraindicated for PLHIV. The shift reflects alignment with long-standing scientific data and sustained ethical critique documenting harms of prohibition and conflicts with autonomy, beneficence, and reproductive justice (–). A reproductive justice framework clarifies these harms: beyond limiting choice, prohibition denied a meaningful dimension of parenting to populations already affected by stigma and structural inequity (). In the U.S., HIV disproportionately affects Black individuals, immigrants, and those with low socioeconomic status, groups that also encounter systemic barriers to breastfeeding (–). Implementation of the new guidelines therefore requires more than permission to breastfeed; it requires dismantling the clinical and institutional frameworks that made prohibition permissible. Implementation has been uneven in the three years since U.S. guidelines changed. Surveys of clinicians document variability in uptake of the revised guidelines, inconsistent application of eligibility and monitoring practices, and persistent provider uncertainty about the evidence, ethics, and logistics of the new approach (, ). Patient reports mirror these findings, describing conflicting messages, limited support, and clinical encounters that are unchanged in tone or practice (, ). Together, these findings suggest that the infrastructure of prohibition, including clinical heuristics, EHR defaults, institutional policies, and professional norms, remains largely intact.