Interventions to support breastfeeding among mothers living with HIV: a systematic review and meta-analysis of randomized controlled trials

Background. Breastfeeding improves infant survival, especially in low-resource settings. Although the risk of postnatal transmission is below 1% among virologically suppressed mothers living with HIV, exclusive breastfeeding (EBF) rates and retention in HIV care remain suboptimal. This review evaluated the effect of non-pharmacological interventions aimed at supporting breastfeeding among people living with HIV (PLWH). Methods. We searched PubMed, Embase, and Cochrane Library up to Jan 1, 2025, for randomized controlled trials (RCTs) assessing facility- and community- based interventions. Outcomes included any breastfeeding, EBF, maternal-infant retention, and maternal viral suppression. Risk of bias was assessed using the Cochrane RoB2 tool. Data were pooled using a random-effects meta-analysis, and evidence certainty was rated using GRADE. The study adhered to PRISMA statements and was registered with PROSPERO, https://www.crd.york.ac.uk/PROSPERO/view/CRD42025636327. Findings. Eight RCTs (n=3,715) from South Africa, Uganda, Kenya, and India were included. Healthcare support was associated with a borderline increase in maternal viral suppression (RR 1.21, 95% CI 1.00–1.47), corresponding to 140 more per 1,000 mothers. Pooled interventions improved EBF uptake (RR 1.38, 95% CI 1.06–1.80), corresponding to 92 more per 1,000 mothers. Certainty of evidence was low to very low. Conclusions. Facility- and community-based interventions may increase EBF among PLWH. The main limitation of the included RCT was the absence of blinding. No publication bias was detected. More context-specific trials are needed to assess their impact on HIV-related outcomes.