Supporting infant feeding by parents living with HIV in Canada

For parents living with HIV, the decision about whether to breast/chest feed can be difficult, and it can be even more challenging if a family surveillance system is involved. In this blog post, we discuss family surveillance and the current guidelines on breast/chest feeding and HIV, and we offer practical steps that community and healthcare workers can take to provide families with compassionate, evidence-based support that honours and uplifts parental autonomy.

Family surveillance, sometimes referred to as family policing, refers to systems that are often framed as child protection or child welfare but can monitor families in ways that impact their feelings of safety, trust and autonomy. Research shows that parents living with HIV are disproportionately subject to family surveillance, particularly those who are Black, Indigenous or face other systemic barriers. Family surveillance systems are rooted in intergenerational and intersecting realities of racism, classism, sexism and other social determinants of health. The 2023 report Understanding the Over-Representation of Black Children in Ontario Child Welfare Services shows that while 7% of the children in Ontario in 2016 were Black, 13.9% of the children involved in family surveillance investigations were Black. Of the nearly 30% of families living with HIV who had interactions with family surveillance systems, 32% were Black and 14% were Indigenous.

HIV transmission and infant feeding

Parents living with HIV in Canada have historically been discouraged from breast/chest feeding their babies. With advances in HIV treatment and care, though, transmission of HIV to a fetus or baby during pregnancy, birth or breast/chest feeding has become rare. For parents on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during and after pregnancy, the risk of transmission through breast/chest feeding is less than 1%. Today, breast/chest feeding can be a safe and supported option for parents living with HIV. With these advancements, parents have choices between formula and breast/chest feeding and should be supported to explore these options to see what works best for them.

Infant feeding: A particular area of surveillance and judgment

Parents living with HIV face surveillance and judgment about their decisions to formula feed or breast/chest feed. For example, many parents have experienced discrimination or judgment from service providers, community or family about their decision to breast/chest or formula feed, which can result in mistrust of others. This mistrust can be exacerbated when community and healthcare professionals or community and family, who want to provide advice about infant feeding, interact with parents in a way that the parents perceive as showing a lack of trust in their ability to make good decisions for themselves and their families. Intersecting factors such as classism, racism, sexism, education level, judgments about HIV and substance use can contribute to pervasive moral judgments and barriers to supportive care.

Recent guideline updates: Breast/chest feeding as a supported option

People living with HIV in Canada were discouraged from breast/chest feeding in the past, but current guidelines recognize that families should be supported to make the decisions about breast/chest feeding that are best for them. In 2025, a commentary published in the Canadian Medical Association Journal (CMAJ) affirmed that breast/chest feeding can be a safe and supported option for parents living with HIV who are on ART, have a sustained undetectable viral load and are engaged in clinical care. For these parents, the risk of HIV transmission is very low. The guidelines also indicate that “parents should be supported to make the best choice for themselves and their infants.”

Despite these updated guidelines, many families continue to experience surveillance and intervention related to their choices about infant feeding. It’s important for community and healthcare workers to keep their knowledge up to date and support families in a way that is consistent with the latest evidence. These workers are uniquely positioned to help families to thrive by offering evidence-based information about infant feeding and compassionate guidance so parents can make the best decisions for their family.

Tips to support parents in their infant feeding choices

Addressing HIV requires a collective, community-centred response, and community and healthcare workers play a crucial role in these efforts. They are present when families most need support, offering guidance and care. Community and healthcare workers should ensure families have access to evidence-based information about their infant feeding options, resources and supports. Here are some tips:

1. Gather information: Give the family clear, unbiased and evidence-based information from the updated guidelines. This may include providing information about the risks and benefits of breast/chest feeding and formula feeding and discussing resources and supports for both options. It could also include providing objective, non-judgmental support in the decision-making process. This might involve connecting the family with healthcare providers who are informed about the guidelines and experienced at supporting parents living with HIV. Teresa Group has helpful information including case management, advocacy, education and support about infant feeding options. Staff are well informed about the guidelines and able to support parents with whatever choice is best for them.
2. Foster well-being: Support the family’s needs to foster their well-being during pregnancy and infant feeding. Plan ahead and document the plan. Often poverty, racism, discrimination, stigma, isolation and lack of resources increase the stress levels of the family during this time, which can lead to a family surveillance system becoming involved in their lives.
3. Build a network of care: Foster the family’s involvement in a range of supportive, non-judgmental communities of care and support. Encourage them to attend and help at shared meal programs, attend health appointments, attend parenting workshops, volunteer at a local community health centre or engage with their community in another way. These involvements will help families to develop networks of connections that can support them if stressors arise.
4. Create a “what if” plan: Help the parent(s) map out indicators of stress and strategies to build support if needed. This plan can help foster the family’s situational awareness and autonomy and to discreetly determine what they would find useful.
5. Support family leadership and autonomy: If the family needs additional support, consider collaborating with the parents to jointly call child protective services or other family support programs. You can respect the parents’ autonomy by encouraging them to lead this process, clearly indicate what supports they would find helpful and share about the supports they already have in place. This can also help to foster a trusting relationship between the parents and community and healthcare providers.
6. Document your work: Document the work you did with the family to reach an informed decision, including any work related to the tips listed here. One way to do this is to create a mind map visual diagram with the family at the centre and their various supports or community involvements surrounding it, which demonstrates their circle of support. Review the map regularly to ensure its details are current. This documentation can help to demonstrate the range of supports in place for the family if they are referred to a family surveillance system.

These tips can help to create a supportive, positive pregnancy and infant feeding experience for parents living with HIV and can help to provide support in instances of family surveillance system referrals or other experiences of discrimination.

Molly Bannerman is the provincial director of Women and HIV/AIDS Initiative (WHAI). 

Mercy Majachani is the evaluation and knowledge translation lead at Women and HIV/AIDS Initiative (WHAI). 

WHAI builds community capacity to support women and gender-diverse people living with or facing systemic risk of contracting HIV.

Claudia Medina is a program manager at Teresa Group.

Rajesh Pisharody is the executive director of the Teresa Group.

The Teresa Group is Canada’s oldest community-based charitable organization specifically serving children affected by HIV and AIDS and their families.