Navigating guidelines and realities: informed free choice in infant feeding for people living with HIV

Recent shifts in U.S. and global HIV perinatal guidelines have reopened long-constrained conversations about infant feeding for people living with HIV (PLWH), including the option of breast/chestfeeding under conditions of viral suppression. While these changes represent meaningful progress, they unfold within a historical and contemporary landscape shaped by medical racism, gender-based oppression, criminalization, and persistent HIV stigma - forces that continue to constrain autonomy and trust in care. In this Perspective, we propose the Informed Free Choice model, a reproductive justice informed framework that moves beyond conventional shared decision-making to explicitly address structural inequities, power dynamics, and the lived realities of families affected by HIV. Drawing on interdisciplinary clinical practice, community advocacy, and participatory training and organizing with women living with HIV, we situate infant feeding decisions within multilevel systems of care and governance. We argue that Informed Free Choice requires not only accurate risk-benefit counseling, but also meaningful involvement of people living with HIV (MIPA), interdisciplinary care teams, trauma-informed and culturally responsive practices, and policy alignment that protects families from coercion, surveillance, and punishment. We conclude by outlining implications for clinical practice, guideline development, and future research, positioning Informed Free Choice as a necessary evolution in perinatal HIV care that aligns scientific advances with reproductive justice and health equity.